Hajj is the regular grand Islamic annual event where more than two million Muslims gather in Mecca and its surrounding sacred locations, including Mina, Muzdalifah, Arafat, and Aljamarat. They perform the required rituals in a timely manner to complete the Hajj rituals in a sequence of mass movements of the pilgrims. The Hajj poses several challenges to the Saudi government and its ministries in ensuring the safety and protection of all pilgrims from many risks. These include, among others, health risks of communicable infectious diseases of various kinds, such as respiratory tract infections, meningococcal diseases, pneumonia, blood-borne diseases, diarrheal diseases, cholera, and the recent global pandemics such as coronavirus disease 2019 and severe acute respiratory syndrome. Also, noncommunicable diseases, such as cardiovascular diseases, are a common cause (43%) of death during the Hajj.1 The extreme congestion of people during Hajj time in a confined area of 12km (where crowds reach seven persons per meter) significantly increases the health risks, such as those related to infectious diseases, which vary each year.2 These challenges could be a nightmare for health planners, but with the full support of the leadership and the determination of motivated health staff, they could successfully address these challenges through cost-effective policies. It is remarkable that all health services provided to pilgrims are rendered freely. Cholera, an acute bacterial enteric disease caused by Vibrio cholera, accounted for several outbreaks after the Hajj in 1984 to 1986. According to the Saudi Ministry of Health, cholera has been reported in Hajj areas and has caused epidemics recorded as far back as 1846.3 Improved water supply and sewage systems have eliminated cholera outbreaks. However, sporadic cases of cholera have still been diagnosed in Saudi Arabia. Examples of preventive measures for communicable diseases, such as cholera, include social distancing, hand hygiene, and contact avoidance. We review both communicable and noncommunicable hazards that pilgrims face.4 Despite all the challenges and disasters that occurred in the past, resulting in unnecessary deaths and injuries, the Saudi government kept actively improving the Hajj services every year making use of the lessons learned in many directions. In 2012, there were 25 hospitals with 4427 beds and 141 health centers with 20,000 qualified specialized personnel in service.5 The services included measures to prevent deaths from fire, following the devastating fire that occurred in 1997 in the Mina area, where there were 343 deaths and more than 1500 estimated casualties.6 Since then, all makeshift tents have been replaced by permanent fiberglass installations, which are fireproofed material. Also, Saudi government has made significant improvements in crowd control and prevention of deaths during stoning of the pillars at Jamarat and in the tunnel leading to the holy sites. In the past, many deaths and catastrophes occurred between the years of 1990 and 2006 that lead to death of many pilgrims.7 Methods used to mitigate the outcomes of large crowd disasters included crowd simulation models, grouping and scheduling of pilgrims, crowd management and control, luggage management, video monitoring, and changes in the construction of transport system. After implementing these measures, there have been no stampedes since 2006.8 During Hajj time, Teflon-coated awnings are added, and the aluminum frames remain in place the rest of the year. No pilgrim is permitted to set up their own tent. Additionally, pilgrims are not allowed to cook food at Mina. Smoking is forbidden by an Islamic Fatwa (Ruling), thus reducing the risk of a naked flame and the risks that affect negative smokers. Continuous public education is being undertaken successfully to further reduce fire and other risks. With each Hajj, authorities refine the management of Hajj health rituals. In the Jamarat area, where crowds surge around the pillars, is particularly dangerous for stampedes.4 To reduce this crowding, the cylindrical columns have been replaced with elliptical ones, increasing the surface area available for stoning and dissipating the intense crowd pressure surrounding each column. After the 2006 Hajj, a four-level Jamarat bridge was built with a capacity of five million pilgrims over 6 hours. Currently, all the improvements are in effect with a remarkable reduction in deaths among pilgrims. The Kingdom of Saudi Arabia has successful comprehensive plans updated annually to ensure that this great event is conducted safely. Methods used to mitigate the consequences of large crowd disasters included crowd simulation models, grouping and scheduling pilgrims, crowd management and control, video monitoring, and changes in the construction of the transport system for the event. After implementing these measures, there have been no stampedes since 2006. To sustain the remarkable achievements, Saudi authorities are aware of all the challenges they face. Their vigilance, monitoring, and coordination need to continue. During the last few decades, the health of the Saudi people has significantly improved. This is a factor in the development and improvement in getting excellent results with the health of the pilgrims. The need for research in all health issues related to Hajj is well appreciated by the authorities, and a Hajj research institute was established.9 Research could be an excellent tool to determine priorities and provide solutions for complex challenges. The Hajj research institute can accommodate residents’ training on Hajj health problems. It can also encourage residents to do their research projects in addressing health issues related to Hajj. Some universities have made it mandatory for family and community medicine residents to rotate at the institute. Another important institution, Global Center for Mass Gathering Medicine, was established.10
Eltahir et al. (Fri,) studied this question.