A lurch, a screech, my driver’s arm out the window banging on metal, a barrage of angry honks: I counted four near-misses and two streetside fights from the backseat of the taxi on my abnormally congested commute to work in Amman this morning. It is, not coincidentally, the first day of Ramadan. Sitting at 99 degrees Fahrenheit before noon, it’s no wonder frustrations were running high amongst those forsaking water during daytime hours in the desert.
As a religious and cultural phenomenon, Ramadan tends to dominate other standard obligations: work schedules may be shortened, and caregivers may switch to a nocturnal schedule to both prepare meals in a timely manner and to avoid hunger pains during daylight hours. What are the consequences of this month of fasting? About what you would expect:irritability skyrockets, psychomotor abilities deteriorate, and perceptual sensitivity is cut significantly. These effects are most often considered on the individual level — challenges of fasting to be overcome by faith and discipline — but they have dire health ramifications at the population level as well.
Rituals, both religious and cultural, are impossible to disentangle from the health of a community. Nowhere is this more evident at the moment than in West Africa, where the practice of washing bodies of the deceased prior to burial has not exempted victims of Ebola, helping to fuel an epidemic of unprecedented proportion. As a long-standing religious obligation, Ramadan isn’t exempt: just as with bubbly celebrations on New Year’s Eve on US roads or female genital mutilation across the globe, the holiday poses a number of health risks that ought to be confronted by health authorities in the region.
Cataloging the Burden
Traffic fatalities and reckless drivers rank among the consequences. In Oman, for example, 20% of all traffic accidents in 2011 took place during this single month (versus the 8.3% that might be expected from an equal distribution). Anecdotal accounts corroborate these reports.* This 64% reduction in risk exceeds that from Abu Dhabi’s 2011 Blackberry outage.
Fasting during pregnancy is associated with a dramatic increase in birth defects. It’s most harmful during the first few weeks of gestation, when a woman may not know she is pregnant. Children born nine months after the end of Ramadan have significantly lower birth weights on average, are 20% more likely to be disabled as adults, and more likely to be born female in regions where rights and opportunities for women may be relatively limited (this study sampled patients in Iraq and Uganda). Children overlapping with Ramadan at any period of gestation are more likely to be born prematurely, which comes with its own set of health risks.
Hospitals in less developed regions tell of mothers who stop lactating while fasting, presenting babies with symptoms of malnutrition at critical stages of development. While lactating and pregnant women are exempt from fasting as outlined in the Quran, impoverished or illiterate women are not necessarily aware of these exceptions, or may live in more conservative communities where it is customary to persevere regardless.
All of this leaves out the impact of diseases associated with the reduced immunity that occurs with extended fasting, such as the common cold — easily transmittable to non-observers.
If the human costs do not prompt sufficient concern, perhaps financial considerations will. In Riyadh, 79.1% of patients who missed medical appointments attributed the absence to Ramadan. A study based in England showed that failed clinic appointments were significantly higher among Muslim patients as compared to non-Muslim patients, with the brunt of this disparity created during Ramadan. These missed appointments cost the British healthcare system over $4.8 billion. With these costs at hand, it is no wonder that a majority-Muslim health system might face significant financial pressure to scale back hours and staff during this month. No studies have comprehensively examined financial losses in healthcare productivity in the Middle East, but it’s not hard to imagine that these would dwarf those in a Muslim-minority country. These are costs that many health systems here, strained by floods of refugees and a relatively lack of health aid, cannot afford.
So, What to Do?
Clinical protocols could be modified to include forms of combined health and religious counseling for pregnant mothers or those of young children prior to Ramadan. These could spread awareness about the health risks of fasting while pregnant, lactating, or menstruating, while simultaneously providing clarity regarding religions exemptions. Clinic hours could be shifted later in the day, to align with the hazy late-afternoon when people stir from their fasting slumbers and to reduce wasted staffing costs during the empty early mornings.
Motor vehicle accidents pose a greater challenge: unlike alcohol on New Year’s Eve, where the risk factor of relevance is easily testable and legally enforced, thresholds for time spent driving without eating are obviously preposterous and unverifiable. Increased enforcement of reckless driving ticketing is also extremely unlikely in countries where lanes are already suggestions, and where fasting traffic officers are less predisposed than usual to monitor ill-behavior. The UAE has experimented with public educational campaigns, though these have not yet been evaluated rigorously.
And for those choosing to fast, I would implore you to consider the safety of those around you as you observe— perhaps the child in the first few weeks of gestation, the driver in the next lane who might fall victim to your fatigue, or your child who may go unvaccinated while your sleeping schedule does not align with clinic hours. If your career is one in which the public is affected by your performance (you ferry people across the sky in pressurized aluminium tubes, perhaps, or command armies or perform surgeries), bear in mind the impact fasting may have on those you have elected to serve.
As an secular person working in public health, I know I’m fiercely outnumbered — many aid organizations and those who work for them, Islamic and Christian alike, have been inspired to this work by their faith. But religious and cultural determinants of public health are real, with real lives at stake, and failing to confront some aspects of these determinants because they’re uncomfortable is irresponsible not just for health practitioners, but for societies as a whole.