120312L - DISEASE PREVENTION and HEALTH PROMOTION: AN ISLAMIC PERSPECTIVE

Lecture for 4^th Year Family Medicine Rotation at the Faculty of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia on 12^th March 2012 by Professor Omar Hasan Kasule Sr.

1.0 INTRODUCTION

Disease prevention and health promotion have a very strong and clear basis in Islamic teachings. If Muslims followed the teachings of their religion fully they would be a very healthy nation. Efforts at health education lead to acquisition of new knowledge but little change in behavior modification to a healthier life style. These efforts would have been more effective if they were based on Islamic teachings because Muslims are more likely to practice rulings from the Qur'an and sunnat. For purposes of this presentation, health promotion is treated as part of disease prevention because a healthy body will resist any future disease.

2.0 PREVENTIVE MEDICINE: LEGAL BASIS

2.1 Concept of prevention (wiqayat)

Preventive medicine, tibb wiqa’i, is a series of pro-active measures that subsumed under the Islamic concept of prevention, wiqayat. The Qur’an has used the concept of wiqaya as taking preventive and anticipatory action against punishment (2:201, 3:16), greed (59:9, 64:16), bad acts (40:9, 40:45), injury/harm, (16:81), jealousy, oppressive rulers (3:28), annoyance (16:81), and heat (16:81). Prevention is therefore one of the fixed laws in the universe, sunan al Allah fi al kawn. Its application to medicine is therefore a special case of a general phenomenon.

The concept of prevention does not involve claiming to know the future or the unseen, 'ilm al ghaib, or even trying to reverse pre-determination, qadar. The human using limited empirical knowledge attempts to extrapolate, anticipate, and predict disease risk from the known distribution of risk factors. Preventive action is modification, alleviation, or reversal of the effects of risk factors. Prevention, besides avoiding any act that can hurt good health or destroy life, halaak (4:176, 67:28), also embraces activities that promote good health like physical exercise; rest; recreation; good diet; meditation, dhikr llah; and positive social relations. These activities and states of being are part of preventive medicine because they put the body in the best possible status to be able to fight and overcome any disease that occurs. All preventive measures that are taken against disease can be subsumed and explained by 2 major concepts in Islamic Law: the Purposes of the Law and Principles of the Law. There are 5 purposes of the Law, maqasid al shariat, and 5 Principles of the Law, qawaid al shariat.

2.2 Purposes of the law (maqasid al shariat) in preventive medicine

The law was revealed to fulfill specific underlying purposes that will ensure success in this world and fulfill the interests and benefits, masaalih, of the people. The 5 Purposes of the Law, maqasid al sharia, arranged here in order of importance are: preservation of morals and religion, hifdh al diin; protection and maintenance of human life, hifdh al nafs; protection of the human intellect, hifdh al aql; protection of the progeny, hifdh al nasl; and protection of property rights, hifdh al maal. Protection of morality includes taking measures to ensure freedom, basic human rights, rule of the law, equity, and justice. Violation of these moral principles is the social root cause of much human disease. Protection of life includes health promotion, disease prevention, and treatment. Protection of the mind is avoiding what impairs human intellect like alcohol. Protection of progeny covers reproductive, fetal and child rights. Protection of property rights assures resources for health promotion and disease prevention. The 5 Purposes of the Law are permanent and are unchangeable, kulliyat abadiyat.

Most of preventive medicine falls under the second Purpose of the Law. Application of this purpose to public health is neither simple nor straight-forward. What we generally consider as risk factors of disease have beneficial effects as well. For example cholesterol is required in metabolism but it involved in coronary atheroma formation. Preventive measures could carry a quantum of risk such that preventing one disease creates another one. Imaam al Shatibi, the leading Muslim thinker on the Purposes of the Law, provided guidance on the resolution of such issues. He argued that there is no absolute benefit, maslaha mutlaqatt, or absolute harm, mafsadat mutlaqat. The purpose of the law is therefore to choose the best equilibrium between the harm and the benefit. It is not always true that benefits are permitted, halal, and harms are prohibited, haram; each case is considered according to its circumstances. We can safely conclude that in the field of preventive medicine, the best that humans can do is carry out empirical studies and arrive at objective conclusions but must always have the humility to admit that they could be wrong

2.3 Principles of the law (qawaid al shariat)

Five principles are recognized by most scholars: intention, qasd, certainty, yaqueen, injury, dharar, difficulty, mashaqqat and custom or precedent, aadat .Each of the 5 Principles is a group of legal rulings or axioms that share a common derivation.

The Principle of Motive, qa'idat al qasd, states that each action is judged by the intention behind it, al umuur bi maqasidiha. Means are judged with the same criteria as the intentions, al wasail laha hukm al maqasid, If the intention, qasd is wrong the means, wasiilah, is wrong. What matters are intentions, maqasid, and underlying meanings, ma’aani, and not literal terms, alfaadh, or structures, mabaani. The principle of motive applies to disease prevention messages. The recipients of the message must understand the purposes behind the behavioral change that is requested. We can speculate that failures of health education program are due to health educators providing information and instructions on behavioral change without taking time to make sure that the recipients understand the underlying motives.

The Principle of Certainty, qa'idat al yaqeen, states that a certainty can not be voided, changed or modified by an uncertainty, al yaqeen la yazuulu bi al shakk. The principle of certainty finds application in preventive prescriptions that seek to change people's behavior based on new evidence that is not at the level of certainty. Existing assertions should continue in force until there is compelling evidence to change them, al asl baqau ma kaana ala ma kaana. Frequent changes in preventive prescriptions could lead disinterest among the general public about disease prevention. This could have been avoided if changes were based only on evidence of highest certainty.

The Principle of Injury, qa'idat al dharar, states that an individual should not harm others or be harmed by others, la dharara wa la dhirar. This principle is the basis for pro-active action to prevent or treat disease rather than being fatalistic. Injury should be mitigated as much as is possible, al dharar yudfau bi qadr al imkaan and should be relieved, al dharar yuzaal, if possible. An injury should not be relieved by a similar injury, al dharar la yuzaal bi mithlihi.

The Principle of Hardship, qa'idat al mashaqqat,  states that necessity legalizes the prohibited, al  dharuraat tubiihu al mahdhuuraat. Necessity is defined as what is required to preserve the 5 Purposes of the Law. If any of these 5 is at risk, permission is given to commit an otherwise legally prohibited or commonly unacceptable things like violation of individual rights. Coercive public health measures are permitted under this rubric. Prevention of a harm has priority over pursuit of a benefit of equal worth, dariu an mafasid awla min jalbi al masaalih.  If the benefit has far more importance and worth than the harm, then the pursuit of the benefit has priority. The lesser of two harms is selected, ikhtiyaar ahwan al sharrain. A lesser harm is committed in order to prevent a bigger harm, al dharar al ashadd yuzaalu bi al dharar al akhaff. Public interest has priority over individual interest, al maslahat al aamat muqaddamat ala al maslahat al khaassat.

The Principle of custom, qa'idat al aadat, should be studied and used more by practitioners of preventive medicine. What is considered customary is what is uniform, wide-spread, and predominant, innama tutabaru al aaadat idha atradat aw ghalabat, and not rare, al ibrat li al ghaalib al shaiu la al naadir... Customs are not static; they eventually change with time and place, la yunkiru taghayyur al ahkaam bi taghayyuri al azmaan wa al ahwaal wa al aadaat wa a’raaf. Most customs are not harmful if they were they would not have survived. The aim should be the identification of those aspects that are injurious to good health rather than condemning all the customs of the people. We should be very circumspect before declaring common customs as dangerous to health. In the same way if we want our preventive messages to have an impact, we should try to include them in what is considered customary.

3.0 PREVENTIVE MEDICINE: MODERATION, BALANCE, and EQUILIBRIUM

3.1 Conceptual basis

The concept of wasatiyyat, is very important in all biological, physical, social, and even spiritual phenomena in the universe The Qur'an describes wasatiyyat as a defining characteristic of the ummat (2:143) and righteous individuals (68:28). It is the average or center that is a good representative of the whole (5:89). The Qur'anic concept of mizaan refers to establishing balance between two opposing or contradictory tendencies. Mizaan is mentioned as a general concept of balance ( 42:17, 55:7, 57:25) and with specific application to measurements in trade (6:152, 7:85, 11:84-85, 17:35, 26:182, 55:8-9, 83:1-3). The concept of 'adl is described in biology (82:7), speech (6:152), and the judicial process (5:106, 65:2, 5:8). The concept of 'adl or i'itidal is the practical active establishment of a just equilibrium. The equilibrium may be in the center or at some other optimal point. It is not easy for humans to locate the just equilibrium without the guidance of revelation, wahy.

The practical life and teachings of the prophet emphasize the concept of central tendency and avoiding either extreme. Extremes of any action even if permitted, halal, are usually destructive and are not desired; the best is the equilibrium of the middle path, khair al umuur awsatuha (Mukhtasar Bukhari # 2014). There must be a balance between rest and activity, release (istifragh) and retention (ihtibaas), sadness (huzn) and happiness (inshiraah). Applications of the concept of moderation, balance, and equilibrium is found in almost all aspects of life: human behavior, medical treatment, and use of environmental resources. The human habitat or the larger ecosystem that humans share with other living things must be maintained at a certain optimum equilibrium otherwise there will be adverse effects on life.

Scientific knowledge on which preventive prescriptions are based is not perfect. This could raise serious practical problems in situations of uncertainty. We will divide these problems in two distinct groups: problems dealing with finding the moderate position and problems involving choice between two contradictory positions each with its own risks and benefits. The right solution is not always easy to find and no general rules can be given. Each situation should be considered on its own merits.

3.2 Establishing and maintaining the optimum

We can be guided in the choice of the correct preventive approach by using the theory of Purposes of the Law. The law was revealed to fulfill specific underlying purposes that will ensure success in this world and fulfill the interests and benefits, masaalih, of the people. The 5 Purposes of the Law, maqasid al sharia, arranged here in order of importance are: preservation of morals and religion, hifdh al diin, protection and maintenance of human life, hifdh al nafs, protection of the human intellect, hifdh al aql, and protection of the progeny, hifdh al nasl, and protection of property rights, hifdh al maal. The order of priority in selecting preventive interventions should follow the order above.

3.3 Resolving contradictions

In real life we meet situations that require choice between two positions that appear contradictory. Finding the right decision must be based on the guiding principles of the law and empirical evidence. Five principles are recognized by most scholars: intention, qasd, certainty, yaqeen, injury, dharar, difficulty, mashaqqat and custom or precedent, aadat .Each of the 5 Principles is a group of legal rulings or axioms that share a common derivation. We will refer to only two of the five principles in this paper: dharar and masghaqqat. The Principle of Injury, dharar, states that an individual should not harm others or be harmed by others, la dharara wa la dhirar. This leads to prohibition of both active smoking, harm to self, and passive smoking, harm to others. Injury should be mitigated as much as is possible, al dharar yudfau bi qadr al imkaan or should be relieved, al dharar yuzaal, if possible. This sub-principle is the basis for pro-active action to maintain homeostasis, prevent, or treat disease rather than being fatalistic. An injury should not be relieved by a similar injury, al dharar la yuzaal bi mithlihi, as happens in situations of vicious circles. The Principle of hardship, mashaqqa states that necessity legalizes the prohibited, al  dharuraat tubiihu al mahdhuuraat. Necessity is defined as what is required to preserve the 5 Purposes of the Law. If any of these 5 is at risk, permission is given to commit an otherwise legally prohibited or commonly unacceptable things like violation of individual rights. Coercive public health measures are permitted under this rubric. Prevention of a harm has priority over pursuit of a benefit of equal worth, dariu an mafasid awla min jalbi al masaalih.  A harmful new treatment modality is prohibited even if it has some efficacy against disease. If the benefit has far more importance and worth than the harm, then the pursuit of the benefit has priority for example when the benefits of the new treatment outweigh its harmful effects by a very large margin. When confronted with a choice between 2 harmful choices, the lesser of two harms is selected, ikhtiyaar ahwan al sharrain and a lesser harm is committed in order to prevent a bigger harm, al dharar al ashadd yuzaalu bi al dharar al akhaff. Amputation of a cancerous limb is a lesser evil that the spread of fatal malignancy. Public interest has priority over individual interest, al maslahat al aamat muqaddamat ala al maslahat al khaassat. The individual's freedom of choice is abridged by laws against smoking in public places because public interest is paramount.

4.0 PRACTICAL APPLICATION: DIET AND DISEASE

Generally malnutrition is an underlying factor in all diseases due to its effect on the immune system. Specific diseases are known to be related to malnutrition: hypertension, coronary heart disease (CHD), diabetes mellitus, and various types of cancer. Hypertension is associated with high sodium intake. CHD is associated with intake of saturated fat. Stomach cancer is associated with dietary intake of nitrosamines. Colon cancer is associated with diets that have high protein and high fat content.  Gallstones are associated with high cholesterol and high sugar diets. Dental caries are associated with prolonged contact of sugar with the teeth. Urinary calculi are associated with high phosphate diets.

Epidemiological evidence indicates that for most nutritional diseases, it is excessive intake that constitutes a risk. Moderate intake of nutrients is not harmful and is even needed for homeostasis. Preventive medicine could lead to elimination of much human disease by encouraging change of dietary habits. The teachings of the prophet on nutritional intake reflect the concepts of moderation, balance, and equilibrium that were defined above. The prophet taught the rule of the thirds as a guide for food intake: one third for solid food, one third for water, and one third for air (Musnad al Imaam Ahmad). He also taught that Muslims are a community who do not eat until they are hungry and when they eat they do not fill their belly. Ibn al Qayim defined three levels of food as necessary, hajat, sufficient, kifayat, and excess, fadhlat. The necessary amount of food is that necessary for maintenance of life and health. The sufficient is more than the necessary and satisfies the psychological desire for food. The excess is what is beyond the body's needs and is definitely harmful to health. Excessive intake will lead to disease by overwhelming and impairing homeostatic mechanisms.

Humans appetite for food, a survival instinct, is so strong that the important obligation of salat is delayed when food is presented (Muslim # 1134, 1137, 17. Mukhtasar Bukhari# 403). Besides the instinctive urge to eat, underlying visions of life and its purpose, culturally-dependent food preferences, patterns of social eating, food availability, and food advertising. There is a difference in attitude to feeding between the believer and non-believer (Shahih al Bukhari Kitaab 70 Baab 12; Sahih Muslim Kitaab 36; 20. Sunan al Tirmidhi Kitaab 23 Baab 20, 21. Sunan Ibn Majah Kitaab 29 Baab 3; 22. Sunan al Darimi Kitaab 8 Baab 13; 23. Muwatta Malik Kitaab 49 Baab 9 and 10). The believer eats to get energy for ibadat. The non-believer may eat for enjoyment or to get energy for evil. There is blessing in the food of the believer; he gets satisfied easily. The non-believer has to eat more food to get the same satisfaction. The Prophet Muhammad (PBUH) in a very revealing hadith mentioned that a believer eats in one bowel whereas a non-believer eats in 7 bowels.

Fasting of Ramadhan is one the major acts of obligatory physical ibadat. Muslims are encouraged to undertake supererogatory fasting. Fasting cleanses the body, al siyam zakat al jism (Sunan Ibn Majah Kitaab 7 Baab 44). It is a lesson in self-control. Its biological implication is teaching self-control and self-discipline in a practical way. Fasting besides its function as a type of ibadat, is training in the control of human appetite.

5.0 PRACTICAL APPLICATION: PHYSICAL ACTIVITY

Overview: Physical activity is any physical movement involving the musculo-skeletal system. Physical activity is a type of physical activity that is undertaken for the specific purpose of improving fitness, promotion of health, or prevention of disease. Over the past 3 decades public health officials have been warning people about the risks of a sedentary life and in many countries people have taken up physical exercise with beneficial effects. This is a sort of a practical compromise since the basic problem of reducing calories intake in view of decreased demand could not be resolved satisfactorily because it involves change of ingrained cultural habits of food intake.

Physiological benefits: Physical activity is necessary for maintenance of muscle and bone growth. Children play a lot and are more physically active than adults because of their growing muscles and bones. In the absence of physical activity, disused atrophy of muscles and bones occurs. Physical activity makes muscles and joints stronger and more flexible because of constant use. The physically active are able to do more physically demanding work. Physical activity leads to decrease of body lipid levels with consequent health benefits. Exercise increases the efficiency and endurance of the cardio respiratory system. Physical exercise has positive impact on cardiac performance. The mass and filling of the left ventricle increase with increased cardiac output and more efficient pumping of the blood. Exercise increases muscle blood flow and with time will increase the efficiency of oxygen transport. The respiratory muscles of the physically active are more efficient in inspiration and expiration.

Health benefits: Epidemiological evidence has related morbidity and mortality to a sedentary life style with little physical activity. Exercise has been shown to decrease death from coronary heart disease. Regular physical activity decreases risk factors of coronary heart disease such as lip-proteins, hypertension, and obesity. Physical activity has been shown to decrease the risk of diabetes mellitus and some forms of cancer such as colon cancer. Physical exercise has some risks but these are outweighed by the benefits. These are mostly in the form of physical injuries especially sports injuries.

Other benefits: Bidet, social and psychological benefits: Being physically active has many religious and social benefits. The physically active have the strength to undertake physical acts of bidet like salad or hajj. They have the energy to undertake work to be economically productive and thus support themselves and their community. The physically active are able to travel and engage in social activities such as visiting relatives, visiting the sick, and participating in social activities. All these have social and psychological benefits that would not be achieved in the absence of physical fitness.

Work as exercise: In the modern technological society, physical exercise is undertaken as an end in itself with the result that most activities benefit the individual physiologically and in health promotion but have no contribution to society. We need to change the concept of exercise to be able to accrue maximum advantage. This can be achieved if people exercise while doing some socially beneficial work. This will be an appropriate return to the start of human history when people were active physically in hunting, gathering, and agriculture that were direct social benefits.

Rulings on physical exercise: Physical activity is mustahabb or manduub for its physiological and health benefits. It is waajib when it is required as part of disease treatment or part of military preparation for defense of Muslim lands. It is also mustahabb as a recreation. Participative sports are preferred over spectator sports. Males and females should be separated in sports activities. Sports involving show of cruelty, high risk for participants or spectators, or gambling is either haram or makruuh.

Examples from the Prophetic practice of walking: Walking may take the form of jogging, hiking, mountaineering, competitive speed running. Walking must have a purpose. Humans unlike animals should not walk and wander aimlessly. Walking can be for any of the following worthy purposes: work and employment, ‘ibadat, seeking knowledge, physical exercise for fitness, recreation or race walking, and social visits. Walking for purposes of ibadat is the most worthy purpose. The reward is increased according to the number of steps taken to the masjid. The Prophet taught the importance of walking as a physical exercise by walking around Madina on foot even when he could have ridden a horse or a donkey. The prophet taught by example that the best manner of walking is taking quick and big steps, harwalat. The Prophet’s walk is described as form of jogging ,harwala, as he was always in a hurry. He never walked lazily. He used to walk around Madina with his wives or his companions. He also used to walk in the open desert. He climbed mountains. One day in Madina he climbed Mount Uhud accompanied by Abubakar, Omar, and Othman. The mountain quaked and he calmed it saying ‘ithbut ya uhud. ‘alayka rasul al llaah wa siddiq wa shahiidan. The prophet is reported to have engaged in foot-racing with his wife Aisha. Early in their marriage Aisha was small and light and she used to win the race. Later in her life she put on weight and the prophet used to win the races.