070131L - LIFESTYLE

Background reading material for Year 1 Semester 2 PPSD Session on Wednesday 31^st January 2007 by Professor Omar Hasan Kasule Sr.

1.0 THE ESSENTIALS OF LIFE

The essentials of life are food, water, shelter, security, and clothing. The functions of food are providing body, body growth, and body maintenance in the best condition. Meals together strengthen social relations are a form of entertainment The Law forbids foods specific foods and drinks that are injurious to good health leaving the rest of foods as permitted. It is prudent to avoid foods whose status is doubtful. The malnutrition of the rich is over consumption that leads to disease. Malnutrition of the poor is inadequate intake.

God provides sustenance (riziki) for all living things. There is enough food in the world but its distribution is poor; some have too much while others starve. Food shortage is also caused by war, political instability, social injustice, or economic inefficiency. Humans throughout history have struggled, worked, and even went to war to ensure food security.

Water is necessary for all chemical reactions in body metabolism. It is used for cleaning and temperature regulation.

The functions of the house are protection from the weather and aggression, privacy, child-rearing, social interaction, rest and entertainment.

Humans need physical security, psychological security, and emotional security.

The functions of clothes are protection from the weather, modesty and covering nakedness, beauty, identification for social intercourse, occupational purposes, and worship. The Law enjoins covering nakedness (‘awrat) but gives a wide latitude on how that can be done. Different dress fashions enable humans derive pleasure from clothes. Dressing for arrogance of for fame is frowned upon.

2.0 DRESS AND ORNAMENTATION

Humans unlike animals must cover their nakedness for human dignity and preventing sexual stimulation. In dealing with Muslim patients in Brunei we need to understand the concept of nakedness (awrat) and its regulations. Failure to understand this could lead to many complications and mistrust in a medical encounter.

The man's nakedness (awrat) is between the navel and the knee. The woman's m nakedness (awrat) is her entire body except the face and the hands. Awrat should be covered al the time. Exposure of awrat to others is generally forbidden except for exceptions based on age, gender, social status, fear of temptation, family relations, medical or occupational needs.

Covering of awrat is relaxed for elderly women, for young children unaware of sexuality, for servants working inside the house, and for women in front of other women. The spouse can see the whole awrat. Close relatives (male and female), children, and servants in the house are allowed to see the awrat of a woman except between the navel and the knee.

Covering more than the minimum is required of temptation is feared. A handsome man should cover the legs and the upper part of the body.

Innocent non-repeated or non-purposive looks at non-awrat parts of the body are permitted. What should not be seen should also not be touched.

Covering, hijab, has great social significance. It forces society to look at a woman as an intelligent and competent member and not a beautiful body to be admired.

3.0 ENTERTAINMENT,

The Law forbids immoral and obscene poetry, singing, dancing, and art. Dramatic expositions that are moral and do not violate any provisions of the Law are permitted. Any entertainment that involves immoral mixing of men and women is forbidden. Participative sports for purposes of building body strength are encouraged. Spectator sports are discouraged. A sport is discouraged if it is associated with addiction, commercialization, gambling, and violence. All forms of gambling are forbidden.

4.0 SOCIAL FAILURE

Failure may be physical, psychological, or social but all are interrelated. Failure manifests as neglect of duties, social incompetence, lack of seriousness, misguidance, transgression, temptation, miserliness, distress and sorrow, helplessness, laziness, cowardice, indebtedness, begging from others, poverty, being overcome by others, vain talk, extravagance, and being hasty. The ultimate form of failure is loss of self-control and ending up being under the control of passions and becoming an addict to a habit or a sin. The causes of failure are: forgetting God and neglecting His commands, diseases of the heart, and peer pressure. Social failure is a result of wrong choices of what life-style to follow.

070131L - SEXUAL PERVERSIONS

Background reading material for Year 1 Semester 2 PPSD Session on Wednesday 31^st January 2007 by Professor Omar Hasan Kasule Sr.

1.0 BACKGROUND TO ZINA

The term zina is used to refer to all forms of extramarital sexual intercourse. It evokes severe moral sanctions in a Muslim society. Therefore healthcare practitioners can use it to change behavior of their patients in a very effective way.

Non-coital zina is a type of minor zina committed by the eye, the ear, the tongue, the mouth, the limbs, and the hands. These organs are involved in antecedents to the actual crime of illegal sexual intercourse. Activities that can lead to zina are condemned as much as the crime itself.

Preventive measures of zina are education, goof child upbringing, early marriage, and following the Law. Zina and its antecedents are avoided by modesty in dress; prohibition of immoral mixing of males and females (ikhtilaat) and seclusion of unrelated males with females (khalwat), and guarding the privacy of the home.

False accusation of zina is severely condemned. Pornography is forbidden because it is conducive to zina. Social disapproval of zina by the family and the community is more effective than legal deterrents.

2.0  ANTECEDENTS OF ZINA

The antecedents of zina are trans-sexual dressing and behavior, immoral mixing of the 2 genders, seclusion, lustful gazes; and indecent exposure. These either singly or in combination create an atmosphere conducive to committing zina.

3.0 ADVERSE EFFECTS OF ZINA

Adverse effects of zina are sexually transmitted diseases, out of wedlock births and illegitimate children who live in physical and emotional deprivation, family break-down, and high rates of divorce.

4.0  PROSTITUTION

Zina as a result of consensual understanding involving married or unmarried persons is severely prohibited. It may take the form of prostitution involving exchange of sexual favors in return for monetary or other benefits is prohibited. Forcing women into prostitution is forbidden. Earnings from prostitution are illegal.

5.0 ABNORMAL SEXUAL BEHAVIORS & PRACTICES

Anal intercourse (liwaat) male and male or male and female, is severely prohibited. The Law prohibits copulation with animals or use of sexual objects and fetishes. Severe punishment is prescribed for a male who commits rape. A woman forced into illegal coitus is not punished. Incest is a severe crime with severe penalties

5.0 ABNORMAL MARITAL ARRANGEMENTS

The law prohibits abnormal marital arrangements that lead to illegal sexual intercourse. These include temporary marriage; marriage with intention to divorce; nikaah al shighaar (males exchange female relatives in marriage without paying dowry), and a marriage that is concluded without following the Law.

070207L - MARRIAGE CONTRACTS: HEALTH-RELATED ASPECTS

Background reading material for Yr2 Sem2 PPSD Session on Wednedsay 7^th February 2007 by Professor Omar Hasan Kasule Sr.

1.0 PROSPECTIVE SPOUSE

Three conditions must be fulfilled in a prospective husband: adulthood, desire for marriage, and financial ability. The conditions for a prospective wife are having attained the minimum age for marriage and a desire to marry. There are no financial conditions.

Desirable characteristics in a spouse are religion, beauty, pedigree, lineage, wealth, social compatibility, and professional status. Religion is the most important.

Beyond these basic conditions prospective spouses must consider compatibility, kafaat, which includes psychological, cultural, socio-economic, and educational factors. Incompatibilities that can be identified before marriage usually break the marriage later with adverse consequences for the spouses and the children.

Looking at the prospective spouse is allowed and includes pre-marital screening for disease and genetic traits. Where closely-related persons are marrying, pre-marital genetic counseling and testing are highly recommended.

Marriage proposals can be made by men or women. It is forbidden to propose when a previous proposal is still being considered or has been accepted. It is forbidden to make any marriage proposals, direct or allusive, during the period of waiting after a reversible divorce. It is forbidden for the prospective spouses to be secluded in private without a mahram.

 

2.0 FORBIDDEN MARRIAGES

Marriage is prohibited on the basis of blood relationship (consanguinity), breastfeeding from the same woman (foster sibship), difference of religion (will lead to incompatibility), and joining closely related in marriage to the same man (will lead to break up of the women’s family relationship).

Mut'at, a marriage contracted with the knowledge that it is for a limited period, is forbidden. Such a marriage does not provide the stability needed to bring up children until adulthood. Children in broken marriages have a lot of physical and psychological disadvantages.

3.0 MARRIAGE CONTRACT AND MAHR

There are 4 pillars of marriage: pronouncement and acceptance, the guardian (waly), the bride, and the groom. No marriage is valid without witnesses or a waly (guardian). The waly must be a close male relative, and of sound judgment. In the absence of a waly the judge(kadhi) or any other male authorized by the bride can act as waly.

 

Marriage must be by free consent of both spouses irrespective of gender, age, or previous marital status. Marriage by coercion is invalid. The consent of marriage must fulfill the same conditions as informed consent in medical practice. Psychiatric examination may be necessary in conditions in which intellectual incompetence is suspected.

 

Dowry, mahr, is obligatory for validity of a marriage. Its purpose is to give the bride financial security. It is fixed by the bride before marriage and remains her. It is not returned in case of divorce of death of the husband if the marriage was consummated. Its payment can be delayed either in full or in part by mutual agreement of the spouses. The unpaid mahr is a debt that is due to be paid.

 

Marriage must be made known publicly to prevent secret illegal relations. A marriage feast, waliimat, is a highly recommended sunna.

 

Conditions in the marriage contract are respected if they are not repugnant to the Law. Examples of acceptable conditions are stipulations about monogamy and country of residence. A marriage contract is invalid if contracted during hajj.

4.0 CONJUGAL RIGHTS & OBLIGATIONS

Rights must be balanced against obligations. Both are mutual. The husband has a higher degree of responsibility because of extra legal obligations.

 

The husband and wife have mutual sexual rights. Fulfillment of these rights will prevent extra-marital sexual relations that lead to sexually transmitted diseases or unwanted pregnancies both serious medical problems. Any diseases, physical or psychological, that affect sexual relations must be treated promptly.

 

The Law stipulates financial obligations to ensure that mothers and their children have security of food, shelter, and medical care. The financial obligations of the husband are dowry(mahr) and home maintenance (nafaqat).  Failure to provide nafaqat is grounds for nullification of marriage. Unpaid nafaqat is treated as a debt. Nafaqat is obligatory in the post-divorce period of ‘iddat. It continues for a divorced pregnant woman until delivery. By mutual agreement the divorced mother is entitled to wages for looking after the infant after divorce. This is to ensure that children get maternal care but the mother need not worry about financial support since the husband is obliged by law to pay it. If these obligations were fulfilled, pediatric wards wouild see fewer physical and psychiatric problems in children.

 

Spouses are a source of comfort, sakiinat, for each other. Mutual kind and tolerant treatment between the spouses is needed in marriage. Ill-treatment of the spouse is forbidden. Mutual good treatment, husn al mu’asharat, is ordained. The wife can go out of the house for good reasons and with her husband’s permission. Since the husband is legally responsible for the physical security of his wife, he has to know where she is going. If it is safe he can let her go alone; if it not safe he has to go with her. A wife cannot go on long journeys without a husband or a male relative (mahram) for purposes of physical security. If these obligations were followed properly the millions of cases of kidnapping and trafficking in women that occur would have been prevented. Women because of less physical strength can easily fall victims to violence hence requiring this extra protection.

070328L - CHILD ABUSE and NEGLECT (REVISITED)[*]

Background reading for Year 2 Semester 2 PPSD Session on Wednesday 28^th March 2007

1.0 DEFINITION OF CHILD ABUSE AND NEGLECT

The spectrum of child abuse is wide. It includes not only children who have suffered physical abuse with fractures and bruises (“the battered child”) but also those who have experienced emotional abuse, sexual abuse, deliberate poisoning, and the infliction of fictitious illness on them by their parents (Munchausen syndrome by proxy).

Children under the age of two are most liable to suffer direct physical abuse at the hands of their parents. Such abuse is more common in families who are poor and are living under stress and in which the parents themselves suffered cruelty as children. Frequently, the child shows other evidence of poor nutrition or neglect.

Sexual abuse, in which dependent, developmentally immature children are involved in sexual activities that they do not fully comprehend and to which they cannot give informed consent, has become increasingly recognized. Girls are involved mainly, and their fathers are the usual offenders. Sexual abuse frequently does not come to light until the older girl develops a psychosomatic illness, runs away from home, or is truant from school.

2.0 PREVALENCE OF CHILD ABUSE

Surveys in North America and Europe that ask adult subjects to recall childhood mistreatment indicate that between 10 and 30 percent of young girls are subjected to exploitation or abuse as widely defined above. Estimates of abuse or neglect by parents or guardians range from about 1 out of every 100 children to more than 1 in 7, and figures are far higher if emotional abuse and neglect are included.

Although widely prevalent, child abuse often is overlooked by family, friends, and health professionals. Prejudice, anxiety, and shame—not lack of information—seem to be the major reasons for the failure to recognize these private acts of violence—a form of tacit denial that leads to their perpetuation.

Child abuse can have serious future consequences for its victims, including delays in physical growth, impaired language and cognitive abilities, and problems in personality development, learning, and behaviour.

3.0 CAUSES OF CHILD ABUSE

Cruelty to children has several major causes. Abusive patterns of behaviour by parents can be viewed as maladaptive responses to stressful situations and feelings of powerlessness. As such, they represent the warped efforts of adults to master situations that are out of their control and to regain a psychological equilibrium through the imposition of their will on defenseless children.

Psychiatric and pediatric studies have shown that a large proportion of parents who abuse their children were themselves physically or emotionally mistreated during their childhood. Typically overdisciplined and deprived of parental love in their infancy, these parents repeat the pattern with their own children, often in the belief that they are legitimately exercising their parental right to punish a child. This “cycle of abuse” is a particularly important factor in cases of sexual abuse, and it is now widely believed that many child molesters were victims of abuse as children.

LEGAL ISSUES

Legal remedies for child abuse range from the incarceration of the offender to the removal of the abused child from the custody of parents or others guilty of committing the crime. With proper social and psychotherapeutic intervention, many child abusers can be helped. In fact, many emotionally troubled abusers are relieved to be discovered, and often they respond well to the therapeutic help they receive. However, some recent theories about child molesters suggest that their conditions are less susceptible to intervention than was once believed, and many jurisdictions have resorted to strict penal solutions, such as sexual-predator laws, which provide for indefinite incarceration for habitual sexual offenders. The treatment or cure of offenders is thought to be more difficult when the victims are young children or toddlers, and compulsive pedophiles are viewed as intractable problems for both therapy and the justice system.

The legal definition of child abuse differs between societies and has changed significantly over time. For example, the age of sexual consent varies greatly between and even within countries. Some European countries prohibit the use of physical violence to enforce discipline, though others permit moderate forms of coercion. Despite these differences, the abusive treatment of children, however it is defined, is widely proscribed by criminal statutes.

Child-protection legislation proliferated during the 1960s. First developed in the United States, these laws soon became models for criminal statutes in many other countries. In 1962, American medical authorities discovered the phenomenon of “baby battering”—the infliction of physical violence on small children—and both the federal government and states adopted laws to investigate and report such acts; eventually, these laws were applied to cases of sexual abuse and molestation. In 1974 the United States created a National Center on Child Abuse and Neglect.

Since the 1970s, conservative and feminists groups, for different reasons, have sought aggressive measures to combat child abuse. Although earlier campaigns against child molestation had emphasized the threat posed by strangers, feminists stressed what they perceived as the vastly greater danger posed by male intimates, such as fathers, stepfathers, uncles, and brothers. Because abuse by male relatives is rarely reported by the family involved, child-welfare advocates called for new laws that would allow greater intervention by outside professionals. During the 1970s and '80s, most states adopted some form of mandatory-reporting procedure whereby doctors, teachers, and social workers were required to report any circumstances that might reveal suspected child abuse. The courts also revamped their procedures to grant more protection to victims. For example, to remove the need for child witnesses to confront the accused, children often were permitted to testify from behind screens or even by video link from another room, and judges and lawyers were encouraged to frame questions and language in a way that did not baffle or intimidate children.

Along with the changes in laws and attitudes came a dramatic upsurge in the number of reported abuse cases. Between 1976 and 1986, reports of child abuse and neglect across the United States rose threefold to over two million, with a further increase to nearly three million reports by the mid-1990s. However, a majority of these reports were judged to be unfounded. Reports of sexual abuse rose 18-fold between 1976 and 1985. The increases in recorded child-abuse figures, which may have been a result of greater awareness of the problem rather than a surge in abuse, contributed to a widespread impression that society was suffering an “epidemic” of child abuse, and concern reached immense proportions during the 1980s.

DANGERS OF OVERREACTION

By the mid-1980s, child abuse was considered a leading social problem in the United States and other Western countries. The extent of the problem seemed to many to be increasing, and many claims were made about the prevalence of incest, child abduction, and even child murder, as well as the operation of organized child-abuse rings. In part these charges were the result of new methods used by social workers and psychotherapists to interview children suspected of being victims of abuse. Interviews conducted with these methods often suggested that the child had been exploited, and some interviews, especially with toddlers, appeared to yield details of sexual abuse so bizarre and shocking as to suggest that it had been committed in ritualistic fashion by some kind of cult. Also contributing to the perceived increase in the incidence of child abuse was the controversial practice of some psychotherapists of attributing the problems reported by adult patients to repressed memories of sexual abuse suffered during childhood.

In fact, however, many of the children who reported sexual and other forms of abuse through the new methods were inventing the stories they told. As critics later pointed out, the methods—which involved repeatedly asking leading and suggestive questions and rewarding children for giving the “right” answers—encouraged children to tell false stories of abuse or to believe, contrary to fact, that abuse had taken place. One significant series of cases involving such reports were the trials beginning in 1984 of Virginia McMartin, founder of the McMartin Preschool in Manhattan Beach, California, and others on dozens of counts of child abuse. Most of the charges, which were based on reports of abuse collected in interviews with hundreds of students, were eventually dropped for lack of evidence. In 1990, the last case resulting from the affair ended in a mistrial; thus, no convictions were ever secured. Even so, the careers of the McMartin family, as well as their reputations, were ruined. During the decade after the revelations in the McMartin case, thousands of people worldwide were likewise accused of involvement in ritual abuse.

RECENT DEVELOPMENTS

During the early 1990s, charges of ritual abuse and recovered memory encountered serious criticism, which dealt a setback to the child-protection movement. Although concern about sexual threats to children remained undiminished, doubts about charges of abuse by parents and intimates led to renewed attention to child abuse—especially molestation—committed by strangers. These fears were often centred on the Internet, which some considered a potential means for pedophiles to stalk and seduce children and which others denounced for making child pornography widely available. Following a number of well-publicized cases of child sexual abuse and murder in the early 1990s, many U.S. states passed sexual-predator laws, which provided for the lengthy detention of sex offenders, especially those who had preyed upon children. Jurisdictions also passed other stringent laws, including variations of Megan's law, which required that local schools, day-care facilities, and residents be notified by police of the presence of convicted sex offenders in their communities. Although these measures posed a serious threat of vigilantism and arguably infringed the legal rights of the offenders, supporters justified them by citingthe extreme danger posed to children by molesters and pedophiles. The laws were widely imitated in Europe. Nevertheless, reports of child abuse in developed countries grew sharply in the 1990s. Japan, for example, recorded a ten-fold increase in the period 1990–2000.

Opinions about the scale and nature of child abuse have changed dramatically since the 1960s, and the notion that children are widely subject to abuse and exploitation has become firmly fixed in the public consciousness. Child abuse also has become a major topic of study in academia; themes of incest and abuse are now common in the social and behavioral sciences, as well as in such diverse subjects as literature, social theory, and cultural and women's studies. The surging interest in child abuse, child protection, and children's rights was one of the most significant social developments of the late 20th century.

[*] Quoted directly from Encyclopedia Britannica 2004

070401P - ISLAMIC LEGAL GUIDELINES ON POLIO VACCINATION IN INDIA

Expert opinion presented to the 16^th Session of the Fiqh Academy of India held at Jamia Islamia darul Uloom Muhazzabpur Azamghar near Varanasi India on 01^st April 2007 by Professor Dr Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine at the Institute of Medicine University of Brunei Darussalam and Visiting Professor of Epidemiology University of Malaya

SUMMARY

Polio is a serious disease. The fate of infected children is: death 10%, mild paralysis 30%, moderate-severe paralysis 30%, and severe paralysis 30%. All over the world 10-20 million live with disabilities due to polio. Polio remains endemic in only 6 countries with sizeable Muslim populations: Nigeria, India, Pakistan, Afghanistan, Niger, and Egypt. A recent polio outbreak in India raises serious concerns because it has affected Muslims disproportionately. Muslims are 20% of the Indian population but they account for 66% of polio cases. Rumors circulate in some Muslim communities that polio vaccination campaigns are an anti-Muslim plot. Community leaders have turned to religious authorities for guidance regarding response to the epidemic and the targeted vaccination campaigns.

The paper starts by reviewing the background about polio vaccination world-wide and in India and then discusses technical details about the polio vaccine: manufacture, use, indications, contraindications, and use. The polio vaccine used is manufactured by growing the polio virus in monkey kidney cells until the virus is weakened and can not cause disease if introduced into the body. The vaccine has no preservatives but has residues of antibiotics that may cause allergies. It also may have other ingredients that should be ascertained from the manufacturer.

The antigen is the main component of the vaccine. Preservatives and adjuvants may also be added. The trivalent oral polio vaccine (tOPV) protects against the three types of polio. The monovalent oral polio vaccine (mOPV) protects against one type. It is mOPV that is currently used in the Indian polio outbreak. OPV is manufactured b growing viruses in monkey kidney cells until the virus loses virulence. It has no preservatives but residues of antibiotics may be found. Contamination by other substances or other viruses is possible. The vaccine is not given to people with previous allergy to OPV, those allergic to neomycin, streptomycin, or polymyxin B; pregnant women; the immune deficient, or in the presence of certain diseases. The OPV used in India has a small risk of causing paralysis. The risk of paralysis from OPV is 1/500,000 on the first dose and 1/12,000,000 on the second dose. Paralysis tends to occur in areas where vaccination coverage is low. Because of the low risk of paralysis from OPV developed countries like the US and the UK have stopped using it and have reverted to the earlier killed virus. Polio vaccination is recommended at 6, 10, and 14 weeks from birth. In endemic areas vaccination at birth is recommended. Booster doses can also be given ages 4-6 years. Extra mass immunization can be carried out when there are outbreaks. Pulse polio is a special program started by the government of India in 1994 to vaccinate all children below the age of 5. The program has been criticized for taking away recourses from other public health activities. The program was achieving its objectives until 2005/2006 when polio outbreaks occurred in some states of India

The paper argues that vaccination of susceptible children is waajib when disease risk is high and the vaccine has been proved beyond doubt to give protection and its benefits far outweigh its risks. This ruling is based on the purpose of the shari’at to protect life, the principle of the shari’at to relieve harm, al dharar yuzaal; and the principle of the shari’at of public interest, maslahat. The individual being vaccinated may experience minor side effects but this does not prevent immunization because building up herd immunity by vaccination of as many people as possible is in the public interest and public interest takes precedence over individual interest. The paper argues an independent investigation of the situation among Muslims in Bihar and UP. The investigation should focus on Muslim acceptance of vaccination and what barriers exist to their access. It should also investigate technical aspects of the vaccination process by visiting the manufacturer’s factory to make sure that all products used are halal. Manufacturers may ingredients in the vaccine that are a trade secret and are not publicized unless requested specifically. Sanofi Pasteur India Private Limited is a polio vaccine manufacturer working at address PO Box 10815 Mehraulih New Delhi 110030 Tel 91-1121658111 and website: www.sanofipasteur.in . Checks are also needed in the endemic areas of Bihar and Uttar Pradesh on the operation of the cold chain to make sure that the vaccine remains viable until use. Specific studies should be made about vaccine uptake and viral excretion in Muslim children to discover why they are at a higher risk.

1.0 BACKGROUND

1.1 POLIO ERADICATION AT THE INTERNATIONAL LEVEL

In 1988 polio was endemic in 125 countries with a total of 350,000 children paralyzed by polio every year. In that year the World Health Assembly made a decision to eradicate polio. Since then the Global Polio Eradication Project undertaken by the World Health Organization and other organizations has reduced polio incidence by 99%^[1] at a cost of USD4 billion over 20 years^[2]. At the moment only 6 countries of the world are still endemic and these are either Muslim majority countries (Nigeria, Pakistan, Afghanistan, Niger, and Egypt) or are countries with substantial Muslim populations (India). Rumors circulate in some Muslim communities in Pakistan that polio vaccination campaigns are an anti-Muslim plot^[3]. Claims have also been made in Northern Nigeria that polio vaccines are contaminated by sterilizing agents that will prevent birth in the future^[4]. There are also unproved hypotheses linking polio vaccination to HIV/AIDS^[5]. These reports cannot be verified at the moment and we cannot take action without further proof. However the suspicions were strong enough to make the Kano State Government suspend polio vaccination in August 2003^[6]. Polio cases increased after the ban. The ban was not lifted until a new batch of the polio vaccine was received from Indonesia a fellow Muslim country^[7].

1.2 POLIO OUTBREAK IN INDIA

Childhood polio has been eradicated in virtually all countries of the world and is now found only in a few countries like India, Afghanistan, and Nigeria. The recent outbreak of polio in India has been found concentrated in 2 states, Uttar Pradesh and Bihar. The number if cases recorded so far in the year 2006 is 522 of which 438 from UP and 40 from Bihar. By comparison the number of cases recorded in India the whole of 2005 was 66[8]. As a response a mass polio vaccination campaign has been launched in the affected districts of the 2 states. Two authors from the company that manufactures mOPV1  (Panacea Biotec Ltd, New Delhi 110044) made the case for using the monovalent vaccine to deal with the outbreak[9]. The government of India has introduced use of the monovalent oral polio vaccines (mOPV1 & mOPV3) to deal with the situation[10]. It was reported that mOPV1 was given in India to 40 million children in the month of April 2005[11]. Production of mOPV is funded by the Gates Foundation^[12].

1.3 THE NATIONAL POLIO SURVEILLANCE PROJECT OF INDIA

The National Polio Surveillance Project (NPSP) was launched in India in 1997[13]. It is part of the World Health Polio Eradication Effort (PIE) under the motto ‘a world without polio’. The global project has succeeded in polio eradication in several countries and regions that have been declared by WHO to be polio free. NSPS is funded by aid organizations in the US, UK, Denmark, Japan, and other countries. The Rotary club is among the sources of financial support. The NPSP strategies are: vaccination of all children with the oral polio vaccine (OPV) that is given 3 times at ages 6, 10, and 14 weeks of infancy to provide protection against all three forms (1,2,& 3) of polio virus. In addition to this, National Immunization Days (NID) are conducted especially in the affected states of UP and Bihar. Additional doses of OPV are given to every child aged below 5 years at intervals of 4-6 weeks. This is strategy called polio pulse immunization (PPI) aims at flooding the area with OPV to interrupt any transmission. PPI is provided at both stationary centers and also by house-to-house search for children. The effort is supplemented by surveillance for Acute Flaccid Paralysis (AFP). These data are alarming because polio had been decreasing before. Before the current campaign started 35,000-100,000 cases were reported all over India annually. By 2005 there were only 66 cases country-wide. Then in 2006-2007 a surge reaching over 30,000 annually was seen.

1.4 POLIO IN UTTER PRADESH AND BIHAR

For the period January 2006 to February 2007, 32033 cases of AFP were reported all over India. The highest numbers were in the states of UP 12,487 cases and Bihar 7246 cases with 65% being in children below 2 years of age. The 2 states have high population densities. The socially disadvantaged Muslim communities have had a disproportionately higher burden of the disease. Whereas Muslims constitute 20% of the Indian population, they account for 66% of the cases. The reasons for the recent surge have been given as: decreased house to house coverage of vaccination attributed to vaccination avoidance by the Muslim community, high population density facilitating child-to-child transmission, and poor sanitation facilitating transmission. The expert opinion was that the vaccine was effective but that not everybody received it. British researchers from the Department of Infectious Disease Epidemiology, Imperial College London found that persistent polio in Bihar and UP despite multiple doses of immunization was due to high population density and poor sanitation. They suggested use of monovalent vaccines to eradicate the disease[14]. The monovalent vaccine has been found to be more effective than the trivalent vaccine in Uttar Pradesh and Bihar^[15]

1.5 MUSLIM CONCERNS

High endemicity of polio in Muslim populations both outside and inside India raises serious issues that require explanation. Without detailed data our explanations can only be tentative and speculative. It is possible that Muslims generally avoid immunization programs and with low herd immunity they are more susceptible to polio transmission and paralysis because of low herd immunity. It is also possible that Muslims live in medically under-served areas and that they have no access to vaccination services. The possibility of discrimination should also be considered that national vaccination campaigns do not make sufficient efforts to reach all Muslims.

2.0 THE ORAL POLIO VACCINE

2.1 FACTS ABOUT VACCINES IN GENERAL

2.1.1 CHARACTERISTICS OF AN IDEAL VACCINE

An ideal vaccine is safe in not causing the disease being prevented or causing side effects due to other components of the vaccine product. It must be able to provide adequate protection for the individual on being challenged by the organism in question. It must also contribute to herd immunity at the population level so that disease transmission can be interrupted. These effects must be long-lasting so that immunization does not have to be repeated frequently. The vaccine must be cheap and easy to administer.

2.1.2 CONTENTS OF A VACCINE

The antigen is the main component of the vaccine. It is the material that will stimulate the body’s natural immune mechanisms to produce either cell-mediated or humoral immunity. The antigen may be in the form of an intact organism that is either killed or is treated to be incapable of causing disease but is still able to elicit immune reaction. The antigen may also be a subunit vaccine either recombinant DNA proteins or synthetic peptides. Adjuvants are materials added to the vaccine. Preservatives may also be added. OPV has no preservatives.

2.1 POLIO VIRUS SEROTYPES

There are 3 types of polio virus that cause disease: 1,2, and 3. Type 2 is the easiest to eradicate and its transmission has been interrupted since 1999. Types 1 and 3 are responsible for the current residual endemicity. Type 3 is now localized in India, Afghanistan and Southern Niger and Northern Nigeria that are inhabited by the Muslim Hausa tribe.

2.2 TRIVALENT VACCINE

Oral polio vaccines can be trivalent or monovalent[16]. The trivalent Oral Polio Vaccine (tOPV) provides immunity against all three types. A single dose of tOPV produces 50% immunity and three doses produce 95% immunity[17].

2.3 MONOVALENT VACCINE

It was found that the tOPV was less effective because there is competition among the 3 types. To increase effectiveness of monovalent vaccines (mOPV) have been introduced. Since they consist of only 1 type they give consistently higher protection. mOPV can be used in a more targeted way because the geographical distribution of virus types is known so only the appropriate vaccine is given in a given locality. Indian authorities have decided to use mOPV especially in the endemic areas.

2.4 MANUFACTURE OF OPV

The polio viruses are grown in monkey kidney cells. This attenuates them (makes them too weak to cause disease). They however still retain the ability to stimulate the body to produce immunity against the virus. The vaccine is dispensed in a plastic container. It has no preservatives but it contains minute amounts of the antibiotics streptomycin and neomycin[18]. Manufacture of mOPV1 is undertaken using funding from the Gates Foundation. Its quality is controlled by the World Health Organization, the United Nations Children Emergency Fund, Agence Francaise Pour La Securite Sanitaire des Aliments et des Produits de Sante, National Organization for Drug Control and Research of Egypt, the Central Drugs Standard Control Organization of India.

2.5 INDICATIONS OF OPV

OPV is given in childhood as a preventive measure. It is given as part of mass vaccination during outbreaks of polio. Non-immune adults traveling to polio endemic areas are also given the vaccine.

2.6 CONTRAINDICATIONS OF OPV

People with allergies to neomycin, streptomycin, and polymyxin B should not take the virus because these antibiotics are found in small quantities in the vaccine. Children who have had a previous reaction to polio vaccine should not be vaccinated. Immune suppressed children should not be vaccinated with OPV. Pregnant women and women who are breast-feeding should preferably not be given OPV. In case of illness it is recommended to wait until recovery before giving the vaccine.

2.7 SIDE EFFECTS OF OPV

The OPV used in India has a small risk of causing paralysis. The risk of paralysis from OPV is 1/500,000 on the first dose and 1/12,000,000 on the second dose. This is because the virus is live but has been treated to weaken it and stop it from causing disease. Sometimes this does not happen but the risk as shown above is very low. Paralysis tends to occur in areas where vaccination coverage is low. Because of the low risk of paralysis from OPV developed countries like the US and the UK have stopped using it and have reverted to the earlier killed virus. The reasoning being that the risk is high given that polio transmission has been interrupted in those countries.

Polio vaccines are prepared in monkey cells and may be contaminated by the SV40 virus that has been suspected but not proved to cause certain forms of cancer. Large scale studies have not shown an increased risk of cancer in those vaccinated so we can discount this risk altogether[19].

2.8 THE IMMUNIZATION SCHEDULE

Polio vaccination is recommended at 6, 10, and 14 weeks from birth. In endemic areas vaccination at birth is recommended. Booster doses can also be given ages 4-6 years. Extra mass immunization can be carried out when there are outbreaks. Pulse polio is a special program started by the government of India in 1994 to vaccinate all children below the age of 5. The program has been criticized for taking away recourses from other public health activities. The program was achieving its objectives until 2005/2006 when polio outbreaks occurred in some states of India[20].

3.0 ISLAMIC BASIS OF IMMINIZATION AS THE CONCEPT OF PREVENTION OF DISEASE, a; ta asil al islami li al tat’im huwa al wiqaaya min al amraadh

3.1 DISEASE TREATMENT IS PART OF QADAR AND IS NOT CONTRARY TO QADAR

Disease treatment is part of qadar[21]. Seeking treatment does not contradict qadar or tawakkul. Disease treatment is part of qadr. The principle that applies here is reversal of qadar by another qadar , rad al qadr bi al qadr.

3.2 THE CONCEPT OF PREVENTION IN THE QUR’AN

The Qur’an has used the concept of wiqaya in many situations to refer to taking preventive action against entering hell-fire, wiqaya min al naar, against punishment, wiqaya min al adhaab[22], against evil, wiqaya min al sharr[23], against greed, wiqaya min al shuhhu[24], against bad acts, wiqayat min al sayi’at[25], against injury/harm, wiqayat min al adha[26], against jealousy, wiqayat min al hasad, against oppressive rulers, wiqaya min al taghoot[27], against annoyance, wiqayat min al adha[28],  and against heat, wiqayat min al harr[29]. Prevention is therefore one of the fixed laws of Allah in the universe, sunan llah fi alkawn. Its application to medicine therefore becomes most obvious.

3.3 DISEASE PREVENTION AND QADAR

Disease could be prevented before occurrence or could be treated after occurrence. The concept of prevention, wiqayat, does not involve claiming to know the future or the unseen, ghaib, or even trying to reverse qadar. The human using limited human knowledge attempts to extrapolate from the present situation and anticipates certain disease conditions for which preventive measures can be taken. Only Allah knows for sure whether the diseases will occur or not. The human uses knowledge of risk factors for particular diseases established empirically to predict disease risk. Preventive action usually involves alleviation or reversal of those risk factors. For example stopping cigarette smoking can prevent lung cancer and ischemic heart disease. Obeying fire regulations can prevent fire accidents. Careful driving prevents road traffic accidents and trauma. Immunization prevents viral and bacterial infections.

3.4 IMMUNIZATION IS A FORM OF DISEASE PREVENTION

Physicians conceive of three forms of prevention. Primary prevention is taking measures to stop disease from being initiated. Immunization is a form of primary prevention. Secondary prevention is detection and treatment of disease which prevents further progress of the disease. Tertiary prevention is rehabilitation which prevents further complications of the disease.

4.0 IMMUNIZATION AND PURPOSES OF THE LAW, al tat’iim min mandhuur maqasid al shari’at

4.1 THE PURPOSE OF LIFE

Immunization has been proved effective in preventing childhood infectious diseases. It therefore fulfills the purpose of preserving life. Its benefits are both individual and community. The individual gets individual immunity against the disease. The community develops what is called herd or population immunity in that the disease cannot be transmitted. Even if an immunized person gets the disease, he cannot transmit it any further because many who come into contact with him are immune and the organism will die if it gains entrance to their bodies.

4.2 THE PURPOSE OF RESOURCES

Immunization is a very cost-effective way of dealing with infectious disease. The cost of immunization is only a small fraction of the cost of treating the disease and its complications. Also to be counted are costs of pain, suffering, anxiety, and loss of earnings during recovery from disease. In some cases residual disability occurs even after recovery.

5.0 ISSUES IN IMMUNIZATION AND THE PRINCIPLES OF THE LAW, qadhaayat al tat’iim min mandhuur qawa’id al shari”at

5.1 THE PRINCIPLE OF HARM, QAIDAT AL DHARAR

Medical treatment is justified on the basic principle is that injury, if it occurs, should be relieved, al dharar yuzaal. Immunization is justified under the principle that injury should be prevented or mitigated as much as is possible, al dharar yudfau bi qadr al imkaan. However injury should be minimized according to the principle of la dharara wa la dhirar. When an injury is found in a patient it is presumed to be of recent origin unless there is evidence to the contrary, al dharar la yakuun qadiiman. It therefore must be alleviated. Thus focal polio outbreaks should be treated and it should not be assumed that they are endemic and should be left alone. Immunization to prevent disease should not leads to side effects of the same magnitude as the disease, al dharar la yuzaal bi mithlihi.

In a situation in which immunization has side effects, we follow the principle that 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. In the case of polio the benefits far outweigh the risks that are in any case very rare. In the case of polio vaccination there is no haram material but if there were, we would be in a situation in which halaal (immunization) and haram (prohibited materials) co-exist. The guidance of the Law is that the prohibited has priority of recognition over the permitted if the two occur together and a choice has to be made, idha ijtama'a al halaal wa al haram ghalaba al haraam al halaaal.  There are 2 evils in the immunization program. The bigger injury is the disease and the lesser injury are the side effects of immunization. In such a case and without an alternative, the lesser harm is committed, 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. Polio immunization as described before builds up population immunity to interrupt disease transmission. Vaccinated children release the virus in their stools and unvaccinated children who get into contact also acquire immunity. Therefore vaccination is in the public interest. Medical interventions that in the public interest have priority over consideration of the individual interest, al maslahat al aamat muqaddamat ala al maslahat al khaassat. The individual may have to sustain some risk in order to protect public interest, yatahammalu al dharar al khaas li dafiu al dharar al aam. In the course of preventing polio and fighting its outbreaks, the state cannot infringe the rights of the public unless there is a public benefit to be achieved, al tasarruf ala al ra'iyat manuutu bi al maslahat.

 

5.2 THE PRINCIPLE OF DIFFICULTY

The principle of hardship is applied to immunization only in the situation of interrupting the lives of the families who have to go to vaccination centers or allow vaccinators into the home. It would have found wider application if there was prohibited materials in the vaccine. Necessity legalizes the prohibited, al dharuraat tubiihu al mahdhuuraat.dharuurat. In the medical setting a hardship is defined as any condition that will seriously impair physical and mental health if not relieved promptly. Hardship mitigates easing of the sharia rules and obligations, al mashaqqa tajlibu al tayseer. This is predicated on the general principle of Islam as an easy religion that cannot be made difficult and a burden for its followers, al ddiin yusr wa lan yashaada hadha al ddiin illa ghalabahu. The law is relaxed in restrictive situations, al amr idha dhaaqa ittasa. The law is restrictive in lax situations, al amr idha ittas’a dhaqa. Committing the otherwise prohibited action should not extend beyond the limits needed to preserve the Purpose of the Law that is the basis for the legalization, al dharuraat tuqaddar bi qadriha. Necessity however does not permanently abrogate the patient’s rights that must be restored or recompensed in due course; necessity only legalizes temporary violation of rights, al idhtiraar la yubtilu haqq al ghair. The temporary legalization of prohibited medical action ends with the end of the necessity that justified it in the first place, ma jaaza bi ‘udhri batala bi zawaalihi. This can be stated in al alternative way if the obstacle ends, enforcement of the prohibited resumes, idha zaala al maniu, aada al mamnuu’u.

5.3 THE PRINCIPLE OF CERTAINTY

Certainty, yaqeen, as a situation when there is no shakk or taraddud, does not exist in medicine. Everything is probabilistic and relative. Vaccinated children may get polio and the unvaccinated may not get the disease even if exposed to it. Using the best available medical evidence we adopt practical procedures. This provides for stability and a situation of quasi-certainty without which practical procedures will be taken reluctantly and inefficiently. In this case we apply the principle of the Law that a certainty cannot be voided, changed or modified by an uncertainty, al yaqeen la yazuulu bi al shakk. When an assertion is an established truth, it should not be changed by a mere doubt being raised about all or some of its components. Existing assertions should continue in force until there is compelling evidence to change them, al asl baqau ma kaana ala ma kaana. All medical procedures are considered permissible unless there is evidence to prove their prohibition, al asl fi al ashiya al ibaaha. Exceptions to this rule are conditions related to the sexual and reproductive functions. All matters related to the sexual function are presumed forbidden unless there is evidence to prove permissibility, al asl fi al abdhai al tahriim.

6.0 SPECIAL SITUATION OF MUSLIMS IN INDIA

The situation of polio in India is unique being found in a higher proportion among Muslims and in specific areas of the country. The paper argues an independent investigation of the situation among Muslims in Bihar and UP. The investigation should focus on Muslim acceptance of vaccination and what barriers exist to their access. It should also investigate technical aspects of the vaccination process by visiting the manufacturer’s factory to make sure that all products used are halal and checking the cold chain to make sure that the vaccine remains viable until use. Specific studies should be made about vaccine uptake and viral excretion among Muslim children.

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[12] Indian J Med Sci. 2005 Jan;59(1):46-7.

[13] http://www.npspindia.org accessed 24^th February 2007. This is the official website of the National Polio Surveillance Project a collaborative effort with the World Health Organization.

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[15] www.nature.com News@Nature Number 13, pages 8-9 28^th December 2006 – accessed 4^th March 2006

[16]http://www.polioeradication.org/content/meetings/MediaMaterials_12OctMediaEvent/mOPVFactSheetfinal.2005.pdf. Website of the Global Polio Eradciation Initiative accessed on 24^th February 2007

[17] http://sprojects.mmi.mcgill.ca/tropmed/disease/polio/vaccine.htm fact CDC factsheet on poliomyelitis accessed on 24^th February 2007

[18] http://sprojects.mmi.mcgill.ca/tropmed/disease/polio/vaccine.htm fact CDC factsheet on poliomyelitis accessed on 24^th February 2007

[19] http://en.wikipedia.org/wiki/Polio_Vaccine accessed March 4, 2007

[20] http://en.wikipedia.org/wiki/Pulse_Polio accessed March 4, 2007

[21] Tirmidhi K26 B21, K30 B12

[22] Qur’an 2:201, 3:16, 3:191, 3:34, 13:37, 40:7, 40:9, 40:21, 44:56, 52:18, 52:27, 70:11)

[23] Qur’an 86:11

[24] Qur’an 59:9, 64:16

[25] Qur’an 40:9, 40:45

[26] Qur’an 16:81

[27] Qur’an 3:28

[28] Qur’an 16:81

[29] Qur’an 16:81