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Paper delivered by Professor Dr Omar Hasan Kasule Sr. MB ChB (MUK), MPH & DrPH (Harvard) WEB: http://omarkasule.tripod.com/ at the Winter Camp in the Tropics organized by IIUM and PPIM and FIMA under the theme ‘Recuperating Muslim Strength: Success Beyond the Horizon’ 0n 13th January 2005
INTRODUCTION
Islamic Law has guidelines on healthy living that are adequate and comprehensive to ensure individual and community health. If Muslims lived according to the dictates of the law they would be the healthiest individuals and communities. In our quest to rebuild our civilization, we tend to go for big issues and forget the apparently small but major one like hygiene. This paper summarizes Islamic teachings that should form the basis of health education on hygiene in Muslim communities. Similar guidelines are available for nutrition, physical exercise, mental health, and control of addictions (alcohol, gambling, sexual promiscuity).
CONCEPTS OF NAJS
Islamic Law has defined what is najs and what is not. In general najs comprises material that is potentially either toxic or are infectious. Najs refers to: feces, al ghait/al buraaz; human urine, bawl; spilled blood, ddam masfuuh (arterial or venous); menstrual discharge, dam al haidh; pus/discharge of infected wounds, qaih; vomitus, qay'i; intoxicants, khamr; saliva of some animals; suur al hayawaan (dog saliva, su ur al kalb, pig saliva, su ur al khanzir; prostatic fluid, wadi; and urethral fluid, madhi; animals not slaughtered according to Law; dead animals, maitat, or dead tissues and organs from living animals; milk of inedible animals; and hair of inedible animals.
The Law has also defined things that are not najs. The saliva and urine of edible animals is not najs. The whole body of the dog is najs[1]. The dog is a carrier of many parasites that cause disease in humans. Smoke from burning of a najs material is also najs. Blood that remains in the vessels or tissues of a slaughtered animal is not najs. It becomes najs when exposed to the toxic and infectious elements of the atmosphere. Two types of blood are not najs and are edible: the liver and the spleen[2]. Prayer is allowed with a wound that has human blood[3] because fresh blood is not yet exposed to infection. In general solids are not najs because when touched nothing is transferred, al jaf bi al jaaf tahirun bila khilaaf. When impurities are dry they can be touched without making the person impure, al yaabis la yanjis. The human; dead or alive, believer or non-believer; is not najs but can be contaminated with najs especially if he does not follow the Islamic hygienic code[4].
The following human emissions are not considered najs: saliva; nasal discharge; throat clearings; sweat, 'irq; tears, dummu'u; fresh blood; fresh internal body fluids (cerebro-spinal, peritoneal, pericardial, pleural, and amniotic fluids); and the normal vaginal discharge, rutuubat al mar at[5]. Human sexual discharges, the male seminal fluid and the female sexual discharge are not najs but have to be washed away.
The saliva of a dog is considered dirty and has to be washed with water 7 times one of them with soil[6]. On the other hand cat saliva[7] and camel saliva[8] are not considered najs. The saliva of domestic animals is not najs if their meat is eligible to be eaten.
A distinction must be made between najs which invalidates acts of ‘ibadat and must always be cleaned and other causes of dirt such as sweat that have to be washed away anyway. Thus not everything that has to be washed is considered najs. Non-najs material that could encourage infection should not be left unwashed on the argument that it was not specifically mentioned as najs. Both najs and non-najs material must be cleaned away; the difference is that the former nullifies wudhu but the latter does not. The term najs, like taharat, has both a physical and moral dimension. The discussion above refers to the physical najs, najs hissiyat.
FECAL HYGIENE
Islamic Law has taught proper ways of excrete disposal, qadhau al haajat. Relieving one-self of body wastes is a physiological necessity. It however must be done in such a way that infection and toxic material will not pollute the environment or cause harm to humans and other living things. Proper excreta disposal also has a social purpose of making sure there are no bad smells when the waste products putrefy. Proper excreta disposal also has an aesthetic dimension to make sure that the environment is clean and is pleasing to look at.
Istinjah refers to cleansing oneself of all traces of the excreta. Cleansing is needed for stool and urine but not for flatus. In case of flatus, no physical cleaning is necessary in the anal area; only the wudhu is repeated. Istinjah is the process of cleansing oneself of filth and its details have been given by Islam to make sure that there is personal hygiene that prevents infection. Ritual ablution for prayer cannot be valid before istinjah[9]. Water and solid cleansers are used. The solids may be paper; stones, istijmar[10]; or other plant material. Human bones and material known to be najs are not allowed[11]. It is preferred to use a solid followed by water[12].
Water is the universal and best cleanser or purifier. Water being a universal cleanser is preferred[13]. Water may appear pure but cannot be used for purification because of pollutants like filth, microorganisms, and other hazardous solids and liquids. Seawater is generally taken to be purifying[14] because of its abundance and consequently low levels of contaminant concentration. Water is purifying unless contamination is beyond a reasonable limit such as when the color, smell, or taste of the water change[15]. A big amount of water is generally considered purifying because the concentration of pollutants is low. Ancient jurists had opined that 2 qullatain of water (216 liters) cannot be polluted[16]. With present-day sewage and industrial discharges into water, even amounts beyond 2 qullatain can be made impure. Polluted stagnant water is not purifying while running water may be. There are limits of microbiological and hazardous material contamination beyond which water should not be used for purification. Water that has been used already in wudhu or cleaning najs, mau musta'mal, is not usable in istinjah because it could transfer infection. Water that has any filth dumped into it cannot be used for cleansing if it is less than 216 liters. This is on the basis that a lot of water does not become najs, al mau al kathiir la yanjis. It is not usable if there are easily visible signs of pollution such as change of color, taste or smell even if it is more than 216 liters. We can extrapolate and say that water that appears normal and is more than 216 liters should not be used if bacterial assays indicate that it has more than the allowable coliform content. Recycles water can be used for cleansing.
Islam has emphasized toilet hygiene and treats it a religious duty. The Prophet took great care to teach his followers the main principles of hygiene. All books of fiqh start with the chapter on cleansing, taharat. Islam has taught toilet etiquette to protect both human dignity and also prevent infection. To prevent entry of airborne pathogens, the Law forbids conversation in the toilet[17], and giving returning greetings, salaam. The Law also forbids using containers belonging to persons whose hygienic standards can not be ascertained. It is recommended to use the left hand[18] so that the right hand is used only for feeding thus preventing spread of infective and toxic material to human food. It is forbidden to defecate or urinate in water. Defecation must be in special places to avoid environmental contamination. Excretion is forbidden on the road, shades where people sit, and on the banks of rivers[19]. The toilet is an undesirable place[20]. Toilet stay must be as short as possible and the stay should never be prolonged beyond need. Shoes or sandals must be worn to prevent the feet from being soiled by filth.
Hands play a big role in the spread of feco-oral infection. Islam therefore emphasizes their regular cleansing. After istinjah and before start of wudu the hands must be washed. Hands are also washed on waking up from sleep because they might have touched the anal or urethral openings[21]. On waking up from sleep, the hands cannot put into any utensil until they are washed three times.
URINARY HYGIENE
It is a great sin not to protect the body and clothes from urine, istibrau min al bawl[22]. Care must be taken not to be contaminated by urine, al tawaqqi min al bawl[23]. Care must be taken to avoid splashing urine. In cases of urinary incompetence, the person is exempted and can pray even if the clothes are contaminated. Touching the penis requires repeat of wudhu[24].
The regulations about urine are logical measures to prevent urinary contamination and infection. Attempts must be made to empty the bladder fully to prevent spotting after urination[25]. Urethral massage for both the male and the female is recommended for this purpose. Urethral massage should be repeated three times to ensure complete emptying of the penis[26]. The following are prohibited: urination on hard ground, urination in a vessel, urinating in a bath, urinating in a hole, urinating in stagnant water[27], and urination on any edible material. It is prohibited to urinate while standing[28] if it is feared that it will cause splashing of urine. In some cases it is better to stand when urine splashing is less likely that away. Urination is a vessel is forbidden[29].
Urine of adults, male and female, is washed away[30]. Floors contaminated by urine are washed with water[31]. The urine of babies still breast-feeding is treated differently because it has less content of impurities; for boys splashing of water is enough but for girls washing is necessary[32]. There is a difference in the composition of the urine of male and female infants[33].
Human urine is more infectious to humans than is animal urine. Animal urine may contain organisms generally not pathogenic to humans. The Prophet ordered people to drink camel urine for medicinal reasons[34]. Dog's urine in the mosque was not washed away[35] whereas human urine was. Human urine cannot be used as medicine[36].
PHYSIOLOGICAL SECRETIONS
Skin secretions: Washing of the whole body, ghusl, is obligatory in connection with many acts to make sure that the body is regularly cleared of accumulated secretions. In wudhu, it is recommended to pass fingers between the bases of toes and fingers to clear away collected secretions that can be a substrate for infection. Rings and other coverings on the body must be removed before wudhu and ghusl to make sure that all parts of the body are washed.
Tears: Tears are not najs but should be wiped or washed away. Normal eye discharge seen in the morning is also not najs but must be washed away quickly because it could be a focus of infection.
Ear secretions: The secretions of the external ear can accumulate and become earwax or could facilitate bacterial infection leading to otitis media. It is recommended in wudhu to clean the external meatus and the ear canal as deep as is safe. This regular cleaning prevents ear infection.
Nasal Secretions: Nasal secretions are not najs[37]. The Prophet recommended blowing the nose three times on waking up, istinshaar[38] to clear away secretions and accumulated infectious and toxic material. During wudhu washing the inside of the nostrils, istinshaaq, removes secretions and infections[39]. Care should be taken not to blow the nose in the open air because that spreads air-borne infections.
GIT secretions: Contents of the upper GIT are mostly recently ingested food. Upper GIT vomitus is not najs and does not nullify wudhu. The lower GIT vomitus especially the lower intestine has fecal excretory material that is najs. Vomitus that is severe may contain intestinal contents and should always be considered najs. The vomitus of a baby is treated like its urine.
Throat secretions: Throat clearings are not najs but should be disposed of carefully because they transmit air-borne bacterial and viral infections.
Oral secretions: Saliva, su'ur, is the main oral secretion. It is not najs[40]. It is useful for lubricating food, initiating the digestive process, keeping the oral mucosa well moistened, and being an anti-microbial. Spitting saliva should however be discouraged because it leads to spread of air-borne infection. Spitting in the mosque or the public highway is esthetically not acceptable.
Oral hygiene: The prophet taught two methods of maintaining oral hygiene, rinsing the mouth during wudhu, madhmadhat[41], and using the tooth-pick, siwaak. Use of the toothpick is emphasized[42]. The prophet would have ordained it for every salaat were it not for fear of burdening people[43]. The prophet emphasized regular use of the toothpick to maintain oral hygiene and prevent infection. It is recommended to use the toothpick in the following cases: entering the mosque, reading Qur'an, after eating, before salaat, and on waking up at night. The toothpick must be washed between uses.
Vaginal discharges: The vaginal canal has no glands, its moisture is a transudate. The cervix secretes some fluids. Bartholin's glands near the introitus are also secretory. The moisture inside the vaginal canal is not najs as long as it is inside the vaginal canal. Inter-menstrual vaginal discharges are not najs[44]. Ritual washing, ghusl, is needed when there is a vaginal discharge following a wet sexual dream[45] although the fluid itself is not najs. All vaginal discharges and any other fluids in the perineal area should be washed away very quickly because of the high potential of infection. Chronic vaginal discharges or bleeding do not prevent a woman from praying. She should wash her vagina, pad it, make wudhu, and pray immediately. Any delay nullifies the wudhu. Menstrual blood is washed off the cloth. If dry it is scraped off the cloth. The cloth can then be used for prayer even if traces of the blood can be seen[46]. Touching the perineal area of one self or someone else nullifies wudhu. This also applies if the perineum is of a child or an animal.
Penile discharges: There are three types of penile discharges: seminal fluid, mani, prostatic discharge, madhi, and urethral discharge, wadi. Semen is not najs because it contains sperms that are living human hereditary material. Dry semen on a cloth is scraped away while the wet one is washed with water[47] and the cloth can be used for prayer. Wudhu has to be repeated when prostatic fluid, madhi, is passed[48]. Touching the penis or self or another person nullifies wudhu[49].
INTRAVASCULAR FLUIDS and SEROUS CAVITY SECRETIONS
Intravascular fluids: There are 2 types of intra-vascular fluids: blood (hemorrhage, epistaxis, and menstruation) and lymph. Blood is the most often encountered intravascular fluid. Blood is cleaned away with water[50]. The liver and spleen are not considered blood and can be eaten[51]. Blood of epistaxis is not najs[52] but must be washed away immediately. Normal blood is washed away[53]
Membranous cavity secretions: Pleural, peritoneal, pericardial, and synovial fluids are not najs and must be washed away if they are outside their cavities.
HAIR
Scalp hair: Scalp hair can trap and accumulate infectious and toxic material because of its continuous exposure to the atmosphere. Rubbing the hair with wet hands in wudhu, mash al ra'as, helps remove accumulation of possible air-borne pathogens. Scalp hair must be washed and combed regularly to prevent any accumulation of filth. Dyeing, plaiting, hair locking of hair are permissible provided they do not prevent proper cleaning. Proper cleaning of hair requires that water reach the root of the hair. Shaving scalp hair is needed when lice and other ecto-parasites are feared to grow in it. It is however offensive, makruh, to shave only part of the head unless there is a medical indication. Shaving of scalp hair for women is discouraged without the consent of the husband. She however is allowed to shave it off for a medical indication. In hajj the woman trims but does not shave her hair.
The moustache: It is recommended to trim the moustache and grow the beard. The sunnat is to decrease the moustache, qass al shaarib, and not to shave it off, halq al shaarib. The prophet said ‘jazzuu al shawaarib wa arakhuu al lihaa khaalifuu al majuus[54]. He also said ‘man lam ya akhudhu min shaaribihi fa laisa minnaa’[55]. He also said ‘man tasahabbaha bi qawmi fa huwa minhum’[56]. ‘Laisa minna man tashabbaha bi ghayrina la tashabbahuu bi al yahuud wa la bi al nasaara[57].
Beard: The male beard must be kept to maintain gender identity. The prophet said ‘jazzuu al shawaarib wa arakhuu al lihaa khaalifuu al majuus[58]. He also said that 10 practices were part of fitra and mentioned qass al shaarib and i’ifaau al llahiya[59]. Cheek hair is considered part of the beard. Some jurists see that the beard should be left alone to grow without any interference. Other jurists see that any beard growth beyond the hand width, al qabdhat, should be trimmed. The beard should be trimmed and not left to grow wild. The beard should not be allowed to grow beyond the size that can be maintained hygienically. Grey hair can be dyed with any color but black. The beard should be washed during wudhu. Regular combing of the beard is necessary to prevent accumulation of dirt.
Armpit hair: Cutting axillary hair, natf al ibt, is sunnat and is necessary for hygiene
Pubic hair: Cutting and regular cleaning of pubic hair is a sunnat that ensures cleanliness. It is recommended to cut pubic hair every 40 days[60].
Trunk hair: Skin hair can be shaved as needed for cleanliness. Regular washing and shaving of abdominal, chest hair, pubic hair, and axillary hair is recommended for hair hygiene. Women are allowed to shave off excess body hair. The woman is allowed to shave face hair.
SKIN
Nails, adhfar, It is sunnat to trim fingernails and toenails. Letting nails grow is against the sunnat. If left to grow, nails accumulate dirt and pathogens. Some of the excreta may lodge under the nails during istinjah and be a nidus for infection. It is recommended to cut nails every 40 days[61]. Nails should be thrown away after cutting.
Ablution, wudhu: Regular ablution involves washing the parts of the body that are most likely exposed to environmental pollution. The exposed organs that are washed are the face, the forearm, hands, the feet, and the head. It is recommended to wash or pass the wet hand over parts of the body that are normally exposed to the atmosphere such as the nostrils, the ear, and the back of the neck.
Bathing, ghusl: Washing of the whole body is obligatory after menstruation, haidh; post-natal bleeding, nifaas; and coitus, janaba. Bathing is also undertaken before for hajj, umrah, and on Fridays. The prophet recommended at least one bath a week preferably on Friday.
Tattoing is haram
Circumcision, khitaan: circumcision is sunnat for males and is recommended for females. In men only the prepuce is removed. Male circumcision is a hygienic measure to prevent accumulation of urethral discharges and urine under the prepuce that can lead to infection. In females circumcision should not involve clitoridectomy and should not cause any disfigurement of the perineal area.
PATIENT HYGIENE, nadhafat al mariidh
Intra-Vascular Fluids: Modern medical procedures, diagnostic and therapeutic, involve dealing with blood. Phlebotomy is one of the commonest procedures in medicine. Venepuncture for diagnostic or therapeutic purposes is more common than operations on arteries. Lymphatic channels are rarely operated on. Surgery and catheterization also involve dealing with blood. Fresh blood is not najs when in the body. At the time of the prophet the therapeutic procedure of cupping, hijaamah, was common and the blood was not treated as najs[62].
Interstitial space fluids: Diagnostic and therapeutic procedures are carried out involving pleural, peritoneal, pericardial, cerebro-spinal, synovial, and amniotic cavities or spaces. The fluids and effusions are generally not considered najs.
Intubation: Esophageal, gastric, and naso-gastric tubes are inserted for diagnostic or therapeutic purposes. The fluids involved are not najs but must be washed away to prevent their becoming nidi of infection. A tracheostomy tube may be inserted in cases of respiratory distress and respiratory secretions may accumulate in it. These secretions are not najs.
Catheterisation
Catheters can be introduced into the heart and the bladder for diagnostic or therapeutic purposes.
Stoma:
A Stoma is an opening of the GIT onto the surface of the abdomen. It may be temporary as in esophagostomy, gastrostomy, jejunosotomy, and cecostomy. It may be permanent as in ileostomy and colostomy. Ileostomies are usually constructed following proctocolectomy. They discharge small amounts of liquids continuously. They do not need irrigation but an appliance must be worn all the time. Colostomies may be sigmoid or transverse. The sigmoid colostomy discharges solid stool on an average once a day and a pattern similar to normal defecation may develop. An appliance is not needed but a pouch must be worn for reassurance. Irrigation is achieved by use of a catheter. A transverse colostomy discharges liquid foul-smelling stool and is best avoided. The fluids from an ileostomy are not najs but those from the colostomy are definitely najs and must be dealt with accordingly. Enterostomy therapy is a specialised area of nursing that involves, inter alia, post-operative education and counseling of patients and their families (b) care of the stoma (c) dealing with long-term emotional and physical problems.
Fistulae:
Bladder fistulae may join the vagina (vesico-vaginal fistula) or the colon (vesico-intestinal fistula). They usually follow trauma, infection, or irradiation. Rarely intestinal fistulae may discharge to the outside. Urethral fistulae may open into the vagina (urethro-vaginal), the rectum (urethro-rectal) or the skin (urethro-cutaneous). The contents of the fistula must be washed away. Those that contain stool or urine are treated as najs and they can nullify wudhu.
[1] (Fatawa Ibn Taymiyyat 1:44)
[2] (Ahmad 2:97)
[3] (Bukhari K4 B34)
[4] (Bukhari 1:281)
[5] (BG121 Bukhari and Abudaud)
[6] (Bukhari 1:173)
[7] (BG9 Abudaud, Nisai, Tirmidhi, Ibnb Majah)
[8] (BG24 Ahmad and Tirmidhi)
[9] (Bukhari 1:176)
[10] (Bukhari 1:157)
[11] (Bukhari 1:158)
[12] (BG93 Bazzaar)
[13] (Bukhari 1:145)
[14] (BG1 Abudaud, Nisai, Tirmidhi, Ibn Majah)
[15] (BG3 Ibn Majah)
[16] (BG4 Abudaud, Nisai, Tirmidhi, Ibn Majah)
[17] (BG82 Ahmad)
[18] (Bukhari 1:155)
[19] (BG81 Abudaud)
[20] (Bukhari 1:144)
[21] (Bukhari 1:163)
[22] (Bukhari 1:215)
[23] (Ahmad 4:396)
[24] (BG68 Ahmad, Abudaud, Nisai, Tirmidhi, Ibn Majah)
[25] (BG92 Ibn Majah)
[26] (BG92 Ibn Majah)
[27] (Bukhari 1:239)
[28] (Ahmad 6:136)
[29] (Abudaud K1 B13)
[30] (Bukhari 1:216)
[31] (Bukhari 1:219)
[32] (Ahmad 1:86)
[33] (Ibn Majah K1 B77)
[34] (Bukhari 1:234)
[35] (Bukhari 1:174)
[36] (Bukhari K74 B15)
[37] (Bukhari 1:242)
[38] (BG34 Bukhari and Muslim)
[39] (BG36 Abudaud, Nisai, Tirmidhi, Ibn Majah)
[40] (Bukhari 1:242)
[41] (BG48 Abudaud and Nisai)
[42] (Bukhari 1:245)
[43] (BG29 Malik, Ahmad, and Nisai)
[44] (Bukhari 1:323)
[45] (BG96 Bukhari and Muslim)
[46] (BG27 Bukhari and Muslim)
[47] (Bukhari 1:229)
[48] (BG69 Ibn Majah and Ahmad)
[49] (BG68 Ahmad, Abudaud, Nisai, Tirmidhi, Ibn Majah)
[50] (Bukhari 1:228)
[51] (BG11 Ahmad and Ibn Majah)
[52] (BG69 Ibn Majah and Ahmad)
[53] (Bukhari 1:227)
[54] (Muslim 1:153)
[55] (Ahmad 4:366)
[56] (Ahmad 1:50)
[57] (Tirmidhi 2695)
[58] (Ahmad 3:365)
[59] (Muslim)
[60] (Muslim 1:153)
[61] (Muslim 1:153)
[62] (BG74 Darqutni)