Health and Environmental Issues at the Hajj | Middle East And North Africa

HAJJ HEALTH ISSUES

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Hajj quality control
At one time the Hajj was ravaged by epidemics of small pox, cholera and malaria spread by the crowded and unsanitary conditions. To combat contagious disease the Saudi Government installed mobile hospitals and portable toilets, and made sure there was an abundant supply of pure water. Over the last couple of decades most of the hajj's problems have been caused by the massive numbers of people.

At the Hajj, it is a common sight to see people pushing their elderly parents around on wheelchairs in order to help them complete the Hajj. Some people are quite sick and old and frail, and it is one of their last wishes before they die to do the Hajj. As there are generally around 2 million people at the Hajj it is not unexpected for a hundred or so people to die during the two-week event.

But sometimes there are health-related tragedies, often related to the weather. In 1974, 460 Indonesians died of exposure from camping outside during the cold Saudi winter. The days when those kinds of things happened are largely over. Still, every year dozens of pilgrims die from natural causes, diseases and heat stroke and in car accidents or other incidents. The Hajj morgue has space in its coolers for 920 bodies. Out back there a cemetery for burying them. One man who lost his daughter in a stampede told the New York Times, “She is dead now but at least she will be buried in this holy place.”

Websites and Resources: Islam IslamOnline islamonline.net ; Institute for Social Policy and Understanding ispu.org; Islam.com islam.com ; Islamic City islamicity.com ; BBC article bbc.co.uk/religion/religions/islam ; University of Southern California Compendium of Muslim Texts web.archive.org ; Encyclopædia Britannica article on Islam britannica.com ; Islam at Project Gutenberg gutenberg.org ; Muslims: PBS Frontline documentary pbs.org frontline

Hajj Medical Services

The area outside the Grand Mosque is dotted with ambulances, mobile clinics and fire trucks during the Hajj. Thousands of paramedics are on standby inside the Grand Mosque. Saudi authorities said in 2023 more than 32,000 health workers were on hand to treat cases of heatstroke, dehydration and exhaustion. More hospital beds have been made available, according to Al Jazeera. [Source: Haitham El-Tabei, AFP,, June 25, 2023]

According to the Saudi Arabian government: The Ministry of Health has established 21 hospitals with 7,000-bed capacity to serve and provide health care to pilgrims. There are hospitals, ambulances and other centers specializing in the treatment of sunstrokes and heat exhaustion in Makkah Al-Mukarramah, Al-Madinah Al-Munawwarah and the Holy Shrines. Makkah Al-Mukarramah has seven hospitals with a total capacity of 3,173 beds. There are several hospitals in the Holy Shrines containing specialized outpatient clinics, ambulance units and operations and admittance rooms in addition to special arrangements for treating sunstroke and heat exhaustion.

These hospitals include: 1) The 800-bed Arafat General Hospital, 24 beds for sunstroke patients, 130 beds for heat exhaustion patients; 2) The 30-bed Jabal Al Rahmah Hospital, 4 beds for sunstroke patients, 150 beds for heat exhaustion patients; 3) Arafat's Mobile Hospital (100) beds at the heat exhaustion center, 8 cooling units, 50 beds for admittance; 4) Mina General Hospital (350 beds); 5) King Abdul Aziz Bridge Hospital in Mina (120 beds); 6) The 370- beds Namera Hospital, 8 beds for sunstroke and 71 beds for heat exhaustion; 7) The 130-beds Mina Al Wadi Hospital, 10 beds for Intensive Care Unit; The following hospitals serve pilgrims in Al-Madinah

Al-Munawwarah: 1) King Fahd Hospital (500 beds); 2) The Obstetrics and Paediatrics Hospital (500 beds); 3) Badr Charitable Hospital (216 beds); 4) Chest Diseases Hospital (120 beds); 5) Isolation Hospital (57 beds); 6) Common Diseases Hospital (200 beds).

Plagues and Cholera Outbreaks at the Hajj

Ken Chitwood wrote in Quartz: “There are reports that the first time an epidemic of any kind caused hajj to be canceled was an outbreak of plague in A.D. 967. And drought and famine caused the Fatimid ruler to cancel overland hajj routes in A.D. 1048. [Source: Ken Chitwood, Quartz, June 26, 2020]

“Cholera outbreaks in multiple years throughout the 19th century claimed thousands of pilgrims’ lives during the hajj. One cholera outbreak in the holy cities of Mecca and Medina in 1858 forced thousands of Egyptians to flee to Egypt’s Red Sea border, where they were quarantined before being allowed back in. Indeed, for much of the 19th century and the beginning of the 20th century, cholera remained a “perennial threat” and caused frequent disruption to the annual hajj. An outbreak of cholera in India in 1831 claimed thousands of pilgrims’ lives on their way to perform hajj.

According to humanappeal.org: The deadly plague in 967 ended up killing thousands of people and also led to Hajj being cancelled. In 1831, a horrific plague from India made its way to Mecca by the pilgrims themselves. Three-fourths of the pilgrims died as a result of the plague and Hajj had to be immediately suspended to prevent future deaths. [Source: humanappeal.org, July 23, 2020]

Between 1837-1858, the Hajj was cancelled for a total of seven years, pilgrims could not go to Mecca. In 1837, Mecca was hit by another plague and Hajj was cancelled for three years. In 1846, Mecca was hit by a cholera outbreak that persisted until 1850, which killed more than 15,000 people. In 1858, another cholera outbreak hit Mecca, and many pilgrims fled to Egyptian shores where they were quarantined.

Meningitis, Flues and MERS at the Hajj

In 1997, Saudi Arabia limited the number of Nigerians participating in the Hajj because of an outbreak of meningitis in Nigeria. In 2006, the Saudi government purchased $6.7 million on Tamiflu to be ready if there was a bird flu outbreak. At that time the disease had killed people in the Muslim countries of Turkey and Indonesia.

In 2009, at least five died of the so-called swine flu (H1N1/A flu), a relatively small number considering the size of the event. Authorities recorded 73 cases of the disease and said only 10 of the 2.5 million pilgrims at the Hajj had been vaccinated. Health officials circulated among the tent camps in Mina and conducted swab tests. The also placed hand sanitizers by the wells in camps, near public bathrooms and at ritual sites. Pilgrims arriving at the airport were scanned with a thermal cameras and offered the vaccine.

On the eve of the Hajj in 2014, health officials in Saudi Arabia said they were doing all they can to avoid an outbreak of the deadly Middle East Respiratory Syndrome (MERS) coronavirus at the annual Hajj. By that time hundreds had died of the disease, many on the Middle East, and the World Health Organization (WHO) said it considered MERS a "public health concern". MERS is a coronavirus from the same family of viruses as SARS which killed almost 800 people in China and Southeast Asia in 2003 and related to Covid-19. There is no known cure or vaccine, however MERS is not as contagious as SARS and Covid-19. The disease originated with camels and has a death rate of 40 percent. [Source: BBC, 15 September 2014]

Hajj During the Coronavirus Pandemic

In 2019, more than 2.4 million pilgrims participated in the Hajj. In 2020, the first year of the Covid-19 pandemic, fewer than 10,000 did amid worldwide coronavirus lockdowns and Saudi Arabia limiting the pilgrimage to a few thousand Saudi citizens and local residents. Around 60,000 did it in 2021 — all of them residents of Saudi Arabia since pilgrims were forbidden to come from abroad. In 2022, just under 900,000 attended as Saudi Arabia allowed limited numbers of pilgrims from abroad.

Aya Batrawy of Associated Press wrote: For the first time in Saudi history, the government barred Muslims from entering the kingdom from abroad to perform the hajj in order to limit exposure of coronavirus. Instead, as few as 1,000 people already residing in Saudi Arabia were selected to take part in the hajj this year. Two-thirds are foreign residents from among the 160 different nationalities that would have normally been represented at the hajj. One-third are Saudi security personnel and medical staff. [Source: Aya Batrawy, Associated Press, July 29, 2020]

“The Saudi government waited until just five weeks before the hajj to announce its decision. The timing indicates the sensitivity around major decisions concerning the hajj that affect Muslims around the world. “This is a very sensitive operation and we are working with experts at the Health Ministry,” Benten said, stressing the importance of protecting the lives and health of pilgrims. As part of the curbs, Saudi officials said that no one over the age of 65 will be allowed to perform the hajj and that all pilgrims and those serving the pilgrims this year will be quarantined both before and after the pilgrimage. [Source: Aya Batrawy, Associated Press, June 23, 2020]

Measures Taken at the 2020 Hajj During the Coronavirus Pandemic

Describing the Hajj in 2020, Aya Batrawy of Associated Press wrote: Rather than standing and praying shoulder-to-shoulder in a sea of people from different walks of life, pilgrims this year are social distancing — standing apart and moving in small groups of 20 to limit exposure and the potential transmission of coronavirus....Pilgrims are eating prepackaged meals alone in their hotel rooms and praying at a distance from one another. The Saudi government is covering all the pilgrims’ expenses of travel, accommodation, meals and healthcare. Sites visited by pilgrims were thoroughly cleaned ahead of their arrival. [Source: Aya Batrawy, Associated Press, July 29, 2020]

“The pilgrims, who were selected after applying through an online portal, were required to be between the ages of 20 and 50, with no terminal illnesses and showing no symptoms of the virus. Preference was given to those who have not performed the hajj before. Pilgrims were tested for coronavirus, given wristbands that connect to their phones and monitor their movement and were required to quarantine at home and in their hotel rooms in Mecca ahead of the start of the hajj. They will also be required to quarantine for a week after the hajj concludes on Sunday. Mecca was sealed off for months ahead of the hajj, and the smaller year-round Umrah pilgrimage was suspended earlier this year, with pilgrims already in the city at that time flown back home.

Workers disinfected the ground inside and outside the Grand Mosque, According to the Los Angeles Times: Authorities used tracking bracelets linked to a smartphone app, while giving pilgrims a “smart card” loaded with their personal information and a bar code to regulate movement. Saudi Arabia's Ministry of Islamic Affairs said it debuted a robot connecting pilgrims to scholars through video-conferencing for religious counseling. [Source: Nabih Bulos, Los Angeles Times, August 1, 2020]

AFP reported: “Even the pebbles they use to symbolically "stone the devil" have been sanitised, as part of elaborate amenity kits provided by authorities that include disinfectant and masks. “Everything is clean and there are only a few municipal workers collecting the small amounts of garbage," Azim Allah Farha, a pilgrim from Afghanistan who has performed the hajj several times before, said at Mount Arafat, the site of one of the main rituals. [Source: AFP, August 1, 2020]

Hajj in 2021 — the Second Year of Covid-19 Pandemic

Around 60,000 pilgrims did the Hajj in 2021 — all of them residents of Saudi Arabia since pilgrims were forbidden to come from abroad. Reuters reported: “Clad in white and carrying umbrellas against the blistering summer, Saudi citizens and residents performed the rite. With the coronavirus the main concern this year, authorities have restricted access to pilgrims aged 18 to 65 who have been fully vaccinated or immunised against the virus and do not suffer from chronic diseases. “"I ask God to end the coronavirus, it made us very scared and made the situation very difficult," said Palestinian pilgrim Hassan Jabari. [Source: Reuters, July 18, 2021]

Small groups of pilgrims wearing masks have been circling the Kaaba as health professionals monitor their movements. Robots are being used to disinfect the Grand Mosque in Mecca and its courtyard and also to distribute bottles of zamzam water, pumped from a holy well in Mecca, to reduce human interaction and ensure physical distancing. Thermal cameras at entrances to the Grand Mosque monitor people's temperatures. Around 3,000 electric carts have been provided for pilgrims, who also wear electronic identification bracelets connected to GPS. Around 500 health volunteers are available to offer medical assistance and 62 screens were installed to broadcast awareness messages in different languages.

Associated Press reported: “Robots have been deployed to spray sanitizing disinfectant around the cube-shaped Kaaba's busiest walkways. Cleaners are sanitizing the vast white marble spaces of the Grand Mosque that houses the Kaaba several times a day. ““We are sanitizing the floor and using disinfection liquids while cleaning it two or three times during (each) shift,” said Olis Gul, a cleaner who said he has been working in Mecca for 20 years. [Source: Amr Nabil and Aya Batrawy, Associated Press, July 18, 2021]

Saudi Arabia is also testing a smart bracelet in collaboration with the government’s artificial intelligence authority. The touchscreen bracelet resembles the Apple Watch and includes information on the hajj, the pilgrim’s oxygen levels and vaccine data and has an emergency feature to call for help. Like 2020 pilgrims drank water from the holy Zamzam well in packaged plastic bottles. Pilgrims also carried their own prayer rugs, were provided with umbrellas to shield them from the sun and had to follow a strict schedule via a mobile app that informs them of when they can be in certain areas to avoid crowding. “I hope this is a successful hajj season," said Egyptian pilgrim Aly Aboulnaga, a university lecturer in Saudi Arabia. “We ask God to accept everyone’s hajj and for the area to be open to greater numbers of pilgrims and for a return to an even better situation than before.”

At Mt. Arafat, according to Reuters, thousands of face-masked pilgrims gathered to atone for their sins, expressing hopes for peace and an end to the COVID-19 pandemic."It is an indescribable feeling that I got selected among millions of people to attend the haj. I pray for God to put an end to these hard times the whole world has gone through under the coronavirus," said Um Ahmed, a Palestinian pilgrim who lives in the Saudi capital Riyadh and who said she lost four family members to the virus. This year pilgrims had to observe social distancing and wear face masks on Mount Arafat, the hill where Islam holds God tested Abraham's faith by commanding him to sacrifice his son Ismail. [Source: Reuters, July 19, 2021]

Heat Issues at the Summertime Hajj in 2023

In 2023, when the Hajj was held in June, more than 8,400 people were treated for heat stroke or exhaustion, according to data compiled by the Saudi Gazette. The temperature regularly topped 44°C (111°F) weather data from Saudi Arabia’s National Center for Meteorology showed. Time magazine reported: To tackle the issue, the kingdom has put in place some measures to minimize the chances of heat stroke and other ailments. Worshippers at the Grand Mosque are being sprayed with water via automatic cooling systems, and free bottles and umbrellas are being distributed. As climate change heats up an already scorching region, making sure all goes well for the Hajj pilgrims could prove to be even more challenging. [Source: Armani Syed, Time, June 30, 2023]

Associated Press reported:During the rituals, pilgrims often walk for hours outside, scale a desert hill known as the Mountain of Mercy, where the prophet is said to have delivered his last sermon, and cast stones at pillars representing the devil in a desert plain. They pack into the Grand Mosque in Mecca to circumambulate the Kaaba. On top of the exertions, the Hajj population skews to the elderly, who are more vulnerable to heat. On an evening this week around sunset in Mecca, temperatures hovered around 37 degrees Celsius (98 degrees Fahrenheit). The crowds made it feel hotter, stifling any airflow. In a bustling basement supermarket near the Grand Mosque, pilgrims bought handheld fans that spray water on the face and every kind of umbrella. [Source: Riazat Butt, Associated Press, June 22, 2023]

Many pilgrims suffered in the heat during the hajj in 2023 when temperatures soared to 48 degrees Celsius (118 degrees Fahrenheit). AFP reported:Saudi officials said about 1,700 heat stress cases were recorded on Thursday alone — as huge numbers of pilgrims remain at the holy sites, a day after the main rituals finished — added to the 287 reported earlier. Officials did not provide a death toll but at least 230 people — many from Indonesia — died during the pilgrimage, according to numbers announced by various countries which did not list causes of death. According to the consul general of Indonesia, the world's largest Muslim country, at least 209 Indonesians died during the hajj. "It is inaccurate to say that a lot of Indonesian pilgrims died because of heat strokes," said Eko Hartono, adding that causes of death were mostly due to heart and respiratory ailments. [Source: AFP, June 30, 2023]

But he did acknowledge that some pilgrims had "fainted" during the days-long pilgrimage "because of the heat". Iran's oldest pilgrim this year, aged 114, died of a heart attack, the semi-official Fars news agency said, reporting 10 Iranian deaths. Eight Algerians and four Moroccans died, officials said, while an Egyptian pro-government media outlet said eight pilgrims from the country had passed away. Hundreds of people were treated for heart problems, including one 78-year-old Filipino man who had successful open-heart surgery in Mecca, the health ministry said. The real figure for heat stress — which includes heatstroke, exhaustion, cramps and rashes — is probably far higher, as many sufferers were not admitted to hospitals or clinics.

People struggling in the heat was a common sight, especially after the day-long outdoor prayers at Mount Arafat where overheating phones shut down and shade was hard to find. In Mina, soldiers sprayed pilgrims with water to cool them down in the heat in the desert plain, where there is little respite from the blazing sun. The Gulf climate is so harsh that in 2021, the United Nations' Intergovernmental Panel on Climate Change warned parts of it could become uninhabitable by the end of the century due to global warming. Maximum summer temperatures of 50 degrees Celsius (122 degrees Fahrenheit) could become an annual occurrence by the end of the century, experts say.

Hajj and Climate Change

Riazat Butt of Associated Press wrote: Experts have found that the Hajj both contributes to climate change and will be affected by it in the coming decades as one of the hottest places on Earth gets even warmer. A study of the 2018 Hajj by experts from Victoria University in Melbourne estimated that the five-day pilgrimage produced over 1.8 million tons of greenhouse gases, roughly the amount New York City emits every two weeks. The biggest contributor was aviation, accounting for 87 percent of emissions. [Source: Riazat Butt, Associated Press, June 22, 2023]

Abdullah Abonomi, a Saudi researcher and one of the authors of the study, said Saudi authorities have embraced sustainability as part of Vision 2030, which calls for preserving natural resources in order to attract pilgrims, tourists and businesses. “Everything has changed,” he said, pointing to the establishment of national centers to coordinate sustainable policies, the creation of an environmental police force to crack down on violations and the integration of sustainability into university courses on tourism. “If you ask four years ago about sustainability ... no one understands what sustainability is,” he said. “But today, everything is going to be better. And I know we are late, but better late than never.”

A 2019 study by experts at the Massachusetts Institute of Technology found that even if the world succeeds in mitigating the worst effects of climate change, the Hajj would be held in temperatures exceeding an “extreme danger threshold” from 2047 to 2052 and from 2079 to 2086.

Addressing the Environmental Challenges of Hajj

According to Associated Press: In the past cars and buses packed with pilgrims filled the streets around Mecca, belching exhaust into the air, but expansion of the Grand Mosque has led to bigger courtyards and increased pedestrianisation in most of the routes leading to the holy site. Still, human bottlenecks have replaced traffic, and garbage swirls in clouds of heat. For travel around Mina and Arafat, two crucial Hajj locations, cars and buses remain the two most widespread forms of transport. The journey by foot, in sweltering temperatures, is arduous but can prove faster than four wheels [Source: Riazat Butt, Associated Press, June 22, 2023].

In recent years, Saudi authorities have installed large awnings and misters around holy sites to cool pilgrims. As temperatures climb, authorities will likely need to step up such measures or introduce new strategies like limiting pilgrim numbers in higher-heat years, the heat stress study concluded.“People who want to do Hajj should get the opportunity to do it,” said Elfatih Eltahir, one of the study's authors. “Global warming is going to make it a little bit more difficult — for some years, for some individuals.”

Muslim activists have launched grassroots initiatives aimed at a “green Hajj,” encouraging pilgrims to only make the journey once, to avoid single-use plastics and to offset carbon emissions by planting trees. The Hajj “can be green and sustainable if there are smart policies and technology to lower the ecological footprint,” said Odeh Jayyousi, a professor at the Arabian Gulf University in Bahrain who researches sustainability and innovation.

The use of biodegradable plastics, reusable tents, and renewable energy would cut down on greenhouse gases, he said. Artificial intelligence could be brought to bear on logistics, streamlining travel and ensuring that planes and busses are full and do not spend too much time idling. “The young generation are mindful of the trade-offs and the need to change consumption patterns,” Jayyousi said. “Hajj can offer a platform for displaying the best green practices to global audiences.”

Image Sources: Al-Jazeera English, Wikimedia Commons

Text Sources: Internet Islamic History Sourcebook: sourcebooks.fordham.edu ; Arab News, Jeddah; “Islam, a Short History” by Karen Armstrong; “A History of the Arab Peoples” by Albert Hourani (Faber and Faber, 1991); “World Religions” edited by Geoffrey Parrinder (Facts on File Publications, New York); “Encyclopedia of the World’s Religions” edited by R.C. Zaehner (Barnes & Noble Books, 1959); Metropolitan Museum of Art, Encyclopedia.com, National Geographic, BBC, New York Times, Washington Post, Los Angeles Times, Smithsonian magazine, The Guardian, Al Jazeera, The New Yorker, Time, Newsweek, Reuters, Associated Press, AFP, Library of Congress and various books and other publications.

Last updated April 2024