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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0206-ECONOMICS OF PREVENTIVE MEDICINE (A Critique of the Biomedical Model) (PART I)

Paper presented at the 4th International Scientific Meeting of the Islamic Medical Association of Malaysia in Conjunction with the 19th Council Meeting of the Federation of Islamic Medical Associations in Shah Alam, Selangor, 4-7th July 2002 by Professor Omar Hasan Kasule, Sr. MB ChB (MUK), MPH, DrPH (Harvard), Deputy Dean for Research, Kulliyah of Medicine, International Islamic University, PO Box 231 Kuantan, MALAYSIA. Fax 609 513 3615. EM: omarkasule@yahoo.com

ABSTRACT

This paper argues that health care based on a holistic medical model is superior to one based solely on the biomedical model. Evaluation of the biomedical model using classical economic analysis (cost-benefit, cost-effectiveness, and cost-utility) based on valuing human life and health is not appropriate. Health is not an economic ‘commodity’ that can be bought or sold but is a product of human life-style and behavior. Cost comparison of curative and preventive medicine is not appropriate because curative medicine is a form of prevention. The appropriate comparison is that of holistic model with the biomedical model.

 

The biomedical model is invasive, costly, materialistic, narrowly focussed, inflexible, and seeks to control and regiment. Its materialism makes it treat health as a commodity; dehumanize and demystify the body by treating it as a ‘machine’, a ‘thing’ or a ‘physico-chemical phenomenon’; depersonalize the patient as a case of pathology and not as a human because it is more interested in the disease and not the person; and allow a technical relation to replace the human physician-patient bond. Biomedicine is not holistic because it concentrates only on somatic aspects of disease and equates disease to illness whereas the latter is wider in scope. It limits disease causation to pathological anatomy or patho-physiology and rejects or marginalizes spiritual, cultural, social, and psychological factors.

 

The paper uses historical evidence from 18th and 19th century England (era of placebo medicine before biomedicine became dominant) to show that trends of falling morbidity and mortality paralleled general socio-economic improvement (better housing and nutrition, environmental sanitation, sewage disposal, and clean water supply) and not specific biomedical interventions. The benefits of biomedicine have been confined to decrease in infant mortality and control of infectious diseases by immunization. In the late 20th and early 21st centuries, the biomedical model has failed to make a major impact on chronic degenerative diseases because it does not have the tools to change life-style and human behavior. Life-style related emerging and re-emerging non-communicable diseases like HIV and STD are increasing despite sophisticated biomedicine. TBThis poses a challenge to medical policy makers to explain why most resources for health are allocated to curative services based on the biomedical model when its overall effectiveness is questioned.

 

The limitations of the biomedical model cannot be overcome until a serious re-examination of its European philosophical background whose major tenets are materialism, secularism, modernism, and post modernism. The paper describes an alternative holistic model of health care delivery based on the tenets of tauhid, universal moral values, purposes of the Law, maqasid al shari’at, and principles of the Law, qawa’id al shari’at. The paper describes the Islamic concepts of life, health, disease and illness, disease treatment and prevention. This model will involve a holistic approach that emphasizes spiritual and social excellence, behavioral and lifestyle change, environmental amelioration, and primary health care (health promotion, and disease prevention). 

 

1.0 INTRODUCTION

The objective of this paper is to show the superiority of a holistic medical model to one based solely on the biomedical model. It presents a critique of the biomedical model and proposes a holistic Islamic alternative to it. The biomedical model is critiqued based on its basic philosophical assumptions and on data that shows its marginal contribution to improvement of health overall. Data from 18th and 19th century England is used to show that falling morbidity and mortality trends paralleled general socio-economic improvement and application of specific preventive measures. There was no remarkable change in the trends with major biomedical breakthroughs.

 

The paper has avoided use of health economic analytic tools[i] to compare holistic and biomedical models because of the inherent limitations of the underlying assumptions of health economics. There are doubts whether economic analysis is relevant to the present discussion for several reasons. First. Evaluation of biomedicine using classical economic analysis (cost-benefit, cost-effectiveness, and cost-utility) based on valuing human life and health is not reliable or relevant because health is not an economic ‘commodity’ that can be bought or sold but is a product of human life-style and behavior. Second: Health is a necessity, dharuurat, and humans do not make choices about buying health care as they do when buying cars. The demand for health is such a strong human drive related to survival that it cannot be modulated fully by price as are commodities in open competitive markets. Third: Secondly the usual rules of demand and supply do not apply to the health care market because the physician who supplies health are is the same person who determines demand.  Fourth: Economic analysis used to compare alternative interventions of the biomedical model suffers from a methodological deficiency that  documentation and measurement of all costs, benefits, and outcomes is not possible rendering any analysis based on them incomplete and inconclusive.

 

Fifth: Economic analyses are based on healthcare as the product but inferences are made wrongly on health. Conventional economic analysis, driven by a materialistic world view, considers health as a commodity. This is oversimplification since health is a complicated entity, little understood, and impossible to measure accurately. Healthcare on the other hand can be considered a commodity under the ordinary economic principles of demand and supply. The ultimate objective is health but it cannot be measured easily. What can be measured is health care. The relation between health and healthcare is complicated and is non-linear. Health status and health outcome are not determined by health care alone. The historical record shows that decline in mortality starting in the 18th and 19th century Europe was not due to medical interventions but due to public health measures, improved environmental conditions, and improved sanitation. Change in life style is a major determinant of health status and health outcome. Socio-economic status is a determinant of health status independent of health care. Health is a capital good and an investment. It is not bought but is produced by the individual. This explains the big role of SES and education on health. The number of years of schooling is a determinant of health status through an unknown mechanism. Most probably schooling develops discipline in the child and youth to wake up every morning, go to school, sit in the class room and obey all the rules. Such a person has more self-discipline and is likely to take correct measures to protect and promote health. It seems that medical care has had its impact on special segments of the population. Improved access has improved the health status of minority groups that were previously excluded. Infants and children mortality and morbidity have greatly reduced because of specific medical interventions.

 

The paper presents the main concepts of an Islamic holistic model of health care. This model has been piloted as the Islamic Input Curriculum (IIC) at the Kulliyah of Medicine, International Islamic University, Malaysia. The objectives[ii] of IIC and its course content[iii] are described.

 

2.0 CRITIQUE OF THE BIOMEDICAL MODEL

2.1 PHILOSOPHICAL BACKGROUND

Understanding of the underlying biomedical model is necessary for assessing health policy alternatives. Current medical practice is based on the biomedical model. Biomedicine has achieved a lot in prevention and treatment of many diseases but is being challenged by chronic non-communicable diseases and the rising costs of curative medicine not accompanied by corresponding improvements in health.

 

The biomedical model is the culmination of philosophical developments in Europe over the past 500 years that have transformed metaphysical medicine into scientific medicine. The philosophical changes were a materialization of life (empiricism), marginalization of spiritual and other considerations in health (secularism), and physical reductionism (ie understanding by breaking up into components). The biomedical model that has several distinguishing characteristics: (a) It is empirical, materialist, and scientific. (b) It is narrowly focussed. (c) it is not flexible. (d) It seeks to control and regiment.

 

2.2 BASIC CHARACTERISTICS

Biomedicine is empirical. Empiricism is the basis for cause-effect relations. It uses the empirical methodology to minimize subjectivity. It considers facts and not dogmas. It relies on reason and not faith or myth. The empirical basis is accepted by Islam. Islam encourages empirical observation as the basis for evidence-based knowledge. It shuns all forms of superstition in medical practice.

 

The materialist background of biomedicine contradicts Islamic concepts. Materialism leads to consideration of health as a commodity that can be bought with money. The materialist background dehumanizes and demystifies the body and treating it like a ‘machine’, a ‘thing’ or a ‘physico-chemical phenomenon’. Besides dehumanization, it depersonalizes the patient who is looked at as a case of pathology and not as a human. It is more interested in the disease and not the person. A technical relation replaces the human physician-patient bond. Patients do not get emotional and psychological satisfaction from encounters with physicians even if their pathological disorders are resolved satisfactorily. Biomedicine relies exclusively on the scientific disease theory which asserts that symptoms reflect specific disease entities and that each disease entity has a unique cause and a unique therapy[iv]. It asserts that disease is due to either pathological anatomy[v] or patho-physiology[vi]. It assumes that causes of disease disturb the equilibrium and the purpose of medicine is to restore equilibrium. Biomedicine does not readily accept other causes of disease outside anatomical and physiological derangements. It therefore bases its diagnosis exclusively on physical assessments[vii]. It does not consider any other ways of defining and diagnosing disease. Definition of abnormality in biomedicine is inadequate since it focuses on biology and ignores culture and psyche. Biomedicine has no fixed criteria for distinguishing the normal from the abnormal in body structure and function. It relies on statistical measures to define the norms. It also considers points of equilibrium as the norm. Despite the claims of scientific objectivity, the biomedical model has not always been able to operate away from subjectivity in practice. Subjectivity can not be avoided in diagnostic and treatment decisions. Reality depends on the starting point.

 

Biomedicine is not holistic. It ignores cultural, social, spiritual, and psychological aspects of illness and concentrates only on somatic aspects. It de-emphasizes overall wellness and welfare and narrowly focusses on pathological anatomy and patho-physiology. Biomedicine has failed to handle psychosomatic disorders that have no obvious anatomical or physiological origin. In its approach to factors of disease it marginalizes environmental medicine[viii] and behavioral medicine[ix].  Biomedicine equates illness with disease. Illness is wider and more holistic than disease. Illness is affected by both somatic and non-somatic factors whereas disease is affected by somatic factors alone. The elderly may for example be ill but with no specific disease. In the same way people with serious pathological conditions may not be aware of them or may not be concerned and they feel that they are in good health. Biomedicine fails to distinguish illness from disease because it concerns itself with the body and not the mind. It rejects the body-mind dualism that human traditions have accepted throughout history. It also rejects the dualism of soul and matter that is the unique characteristic of humans.

 

Biomedicine is not flexible. Biomedicine has not been able to respond effectively to the epidemiological shift from acute to chronic disease and the demographic shift from younger to older population distributions. Biomedicine is more applicable to acute than to chronic diseases. It has been very successful in curing acute infectious diseases by use of specific anti-microbials. It has not been flexible enough to performed equally well in cure of chronic and degenerative diseases

 

Biomedicine seeks to predict, control, and regiment. Biomedicine is not democratic. It gives all decision-making power to the physician and leaves the patient powerless. It has medicalized human life. It has distorted relations between humans and medicine. Pre-biomedicine humans controlled medicine and used it as they like. Post-biomedicine medicine controls human life and behavior.

 

2.3 HEALTH IMPROVEMENT WITHOUT BIOMEDICINE

Epidemiological evidence in England and Wales shows that mortality and morbidity have been falling since the 18th and 9th centuries and that these trends were not affected in any remarkable way by the biomedical interventions of the late 20th century. These trends paralleled general socio-economic improvement and adoption of general preventive measures such as improved nutrition, improved sanitation, better sewage, and cleaner water. The data discussed below was abstracted from a book titled ‘Disease Mortality and Population in Transition’ by Alex Mercer[x] as well as other sources of British data as indicated.

 

Economic improvement: Figure 1 shows that population and economic prosperity have been rising in England since mid-16th century. The rising population is explained by increasing survival since the gross reproductive rate (GRR) did not change that remarkably.

 

Mortality from communicable diseases has been falling progressively. Figure #2 shows falling annual death rates for main causes recorded in the Bills of Mortality for the period 1700-1839. Figure #3 shows falling death rates from tuberculosis in the period 1851-1921. Figure #4 shows that this fall affected all birth cohorts. Figure #5 shows a precipitous fall in smallpox towards the end of the 18th century due to discovery of vaccination.

 

Mortality from non-communicable diseases has not followed the patterns of communicable diseases. Figure #6 shows a pattern of falling death rates from circulatory disease in the period 1861-1921, a rise in the period 1921-1951 followed by a steady fall.

Figure #7 shows a general rise in cancer deaths in the 20th century.

 

Infant and child mortality: Figures #8. #9, #10, #11, and #12 show falling death rates from infectious diseases among children. Figure #13 shows fall of infant mortality rates in the period 1843-1983.

 

Demographic transition: Figure #14 shows falling patterns of communicable diseases accompanied by rising patterns of non communicable disease. This has been accompanied by increasing life expectancy as shown in figure #15.

 

Contemporary evidence of the effect of socio-economic conditions is the relation between mortality on one hand and income as well as social class on the other hand. Figure #16 shows variation of mortality by GNP with richer countries enjoying longer life expectancies. Figure #17 shows variation of mortality by social class with the better-off groups experiencing lower mortality. 

 

Conclusions: Available evidence points to general social and economic improvement as the major determinant of health status and not biomedical interventions. Biomedical interventions have made changes to children and for infectious diseases. Mortality improvements in the era of biomedicine benefited the children and the youths more tan the elderly. 

 

2.4 PARADIGMATIC CHANGE FROM BIOMEDICAL TO HOLITISTIC MODELS Need for reform: Many thinkers and physicians are aware of the limitations of the biomedical model. Efforts have been made to correct its deficiencies by adding missing dimensions. A bio-psycho-social model has been proposed to take care of psychological and social aspects. Spiritual aspects have so far not been recognized widely. Radical changes to the biomedical model will only occur if the philosophical background is re-examined. European materialism, secularism, modernism, and post modernism are the dominant philosophical tenets in medicine. No major changes can occur until these are examined critically. Unfortunately Muslim physicians have been very complacent in accepting without challenge most of the European philosophical under-pinnings of biomedicine. This is the lizard hole phenomenon that the prophet (PBUH) warned his community. The European concepts have to be replaced by Islamic ones.

 

Three Islamic concepts: tauhid, wasatiyyat, & shumuliyyat. The concept of tauhid motivates looking at the patient, the disease, and the environment as one system that is in equilibrium; thus all factors that are involved with the three elements are considered while making decisions. The concept of wasatiyyat motivates the need for moderation and not doing anything in excess. The concept of shumiliyyat extends the tauhidi principle by requiring an overall comprehensive bird’s view of the disease and treatment situation. The argument is not that biomedicine is good or bad. The science and technology are good and needed. The problems are the philosophical pre-assumptions that limit medicine to biomedicine and reject other necessary components of medical care. The Islamic concept of tauhid will give medical science and medical technology the appropriate conceptual context.

 

3.0 ISLAMIC CONCEPTS OF HOLISTIC MEDICINE

3.1 CONCEPT OF LIFE

Life is a complex phenomenon with biological, chemical, and spiritual components. Life on earth has a definite time span, ajal[xi]. No human endeavor including the most advanced medical procedures can shorten or extend this time span. The whole purpose of medicine is to exert maximum efforts to improve the quality of remaining life since Allah alone knows the timing of the ajal. Humans do not know ajal, jahl al insaan bi zaman al mawt[xii]. They have no means of foretelling in a certain way the moment of death[xiii]. They can predict or extrapolate from their empirical observations and experience but this remains at best an approximation. Death occurs immediately when the appointed hour strikes, majiu al ajal & buluugh al ajal[xiv]. The hour of death is fixed ajal musamma, ajal ma’aluum[xv]. It can not be advanced or forwarded[xvi]. Humans naturally want to live for long[xvii]. This may be because they want to enjoy the earth as long as possible or for fear of the unknown after death. Some humans desire a long life to be able to make a maximum contribution to improving themselves and the earth on which they live.  Human life must have some quality. It is not enough to eat and breathe or maintain the vegetative functions only. A human can not live like a plant or an animal. The quality of life can be defined in physical, mental, or spiritual dimensions. The physical criteria are: absence of disease, comfortable environment, and basic necessities. The mental criteria are: calmness, absence of neurosis and anxiety, and purposive life. The spiritual criterion is correct relation with the creator.

 

Each human has an inalienable right to life from Allah, haqq al hayat. This life cannot be taken away or impaired by any human being except in cases of judicial execution after due process of the law. Life is sacred and its sanctity, hurmat al nafs is guaranteed by the Qur’an[xviii]. The life of each single individual whatever be his or her age, social status or state of health is important and is as equally important as the life of any other human[xix]. Protection of life, ‘ismat al hayat/hifdh al nafs, is the second most important purpose of the shariat coming second only to the protection of the diin. Legal compensation for bodily damage or homicide is replacement of lost earnings and not paying for the value of life. The compensation is a legal provision to provide sustenance to surviving relatives in case of death. It also provides sustenance to the person whose organ was severed and therefore cannot work to support himself. Every life is as important as any other life. Destroying the life of one person is equivalent to destroying the life of all humans[xx].

 

3.2 CONCEPT OF HEALTH

The prophet said that good health, sihhat, and afiyat are two bounties that many people do not enjoy[xxi]. Few people are healthy in all their organs and at all times. Health is a positive state of being and not just absence of disease. The traditional view of health looked at it as the absence of disease. Before the development of scientific medicine, few diseases were curable. With increasing ability to cure disease we find that people may not be in optimal health and well being even if all physical ailments were eradicated. This has led to the realization that good health is an independent entity that can be defined and handled independent of disease. Stated in other words, individuals who are disease-free may not be healthy. The components of good health are spiritual health, sihat ruhiyyat; physical health, sihat al jasad/rahat jasadiyyat; psychological and mental, sihat nafsiyyat/rahat nafsiyat), and social health. Spiritual health is maintaining correct relations with the creator that in turn orders relations with other humans and with the environment. Health in the biological sense is maintaining physiological function in the optimal situation. Psychological health is being aware of and at peace with the self as well as the social environment around. Health in the social sense means harmonious functioning in the social milieu involving give and take relations. The various components of health are inter-related and closely inter-dependent such that a problem in one can easily lead to disequilibria in others. Islam looks at health in a holistic sense. If any part of the body is sick the whole body is sick, mathal al jasad al waahid idha ishtaka minhu ‘udhuwun tadaa’a lahu saairu al jasad bi al sahar wa al humma. If a member of a family is sick the rest of the family are affected emotionally and psychologically. Any sickness in the community will sooner or later have some negative impact on all the members. The holistic outlook also means that physical, emotional, psychological, and spiritual health are considered together. A person who is spiritually sick will sooner or later also become physically sick. The reverse is also true unless the iman is very strong.

 

Health is relative and subjective. It varies by age, place, norms, gender, and state of iman or tawakkul. A physical state that is healthy in an elderly person may not be so in a younger one. The conventions and norms, aadat, of what is good health vary from place to place and even in the same place may vary from era to era. The subjective feeling of good health varies among individuals and groups of people. Those with strong iman and trust in Allah, tawakkul, may feel subjectively healthier than those who do not have these attributes. Health is often assessed subjectively using terms such as ‘good health’, ‘healthy’, ‘poor health’ and ‘unhealthy’. There are measurable statistical indicators of good health that are useful for a group of persons since they describe the average or the range of the normal. Health status of  a community is usually measured by morbidity, mortality, and disability. For the individual, the assessment of health is very individualized and cannot be summarized as indices or statistical measures. The indices of health are limited in that they indicate only the final state of health and do not take into account the intermediate stages. They also cannot measure the intangible spiritual and mental components of good health. The best index would be one that includes both spiritual and physical parameters. Such an Islamic index has not yet been constructed to our knowledge. This index would also include criteria that reflect relations with Allah, with the self, with other humans, and with the environment.

 

Keeping the body in good health is a responsibility, amanat. The Muslim must keep his body physically fit to be able to undertake the functions of istikhlaf and isti’mar.  Poor health not only deprives society of the contributions of an individual but also creates a burden for others. Neglect of one's health is a sin. It is a religious obligation, fardh, for the sick to seek treatment. It is also obligatory to undertake disease-preventing measures such as dietary regulation, general and oral hygiene, avoiding violence, avoiding diseases of the qalb that precede mental illness, or in general avoiding anything that impairs good health. Good health is a gift from Allah, ni’mat al sihat wa al faragh[xxii].

 

The concept of community health was not recognized widely until the last quarter century. It is however a very old concept found in the Qur'an. The Qur'an has told us about many communities in the past as lessons for us[xxiii]. Good, al balad al taib[xxiv] and safe, al balad al amiin[xxv] are adjectives that the Qur'an has used about some communities. Some of them were blessed and lived in peace and plenty[xxvi]. Makka was described as a city of peace and general welfare[xxvii]. The Qur'an also told of communities that were victims of collapse, khiraab[xxviii], those that were punished by famine[xxix], or were destroyed by Allah, ihlaak[xxx]. The physical destruction was due to moral deviations like batar[xxxi], transgression, dhulm[xxxii], and corruption, fasaad[xxxiii]. No community is destroyed or is punished until it receives a warning from Allah[xxxiv].

 

3.3 CONCEPTS OF ILLNESS and DISEASE

Health is a condition in which all of the body functions are integrated and are being maintained within the limits of optimal design[xxxv]. A distinction must be made between disease as a pathological manifestation and illness that is a subjective feeling. Disease is divergence from the normal, gaussian mean, but not all deviation is disease because of the reserve capacity and ability of the body to adjust to variations. The demarcation between pathology and normal physiological variation can be fine. The definition of disease is very relative. A high blood pressure in an elderly person does not have the same implication as the same level in a younger person. Temperature levels have different interpretations in neonatal and adult infections. Adolescent behavior that may be normal would be considered illness in adults. There are changes in the body that should be accepted as normal processes of ageing and not as diseases. There is a space-time variation in definition and perception of disease depending on the culture, beliefs, attitudes, and prevalence of diseases. In localities where the burden of major diseases is high, some minor ailments may be ignored whereas in other places they are taken as serious diseases. There are diseases that may be associated with social status. One socio-economic group may perceive them as serious whereas another one does not. Some diseases become reclassified with changing public opinion and perceptions. New diseases continue to be defined due to changes in the causative agents, host factors, or new scientific knowledge. Today's disease entities may be redefined and re-classified in the future. Definition of disease considers several dimensions that may operate singly or in combination: moral or spiritual, biological or pathological, psychosocial, or normative statistical.

 

Overall disease is a state of dis-equilibrium, khuruuj al badan ‘an al i’itidaal. Loss of spiritual equilibrium is a disease in itself and soon leads to physical disease. Appreciation of this fundamental principle distinguishes a believing from a non-believing physician. Most diseases involve disturbances in the equilibrium of the normal body physiology. These biological disturbances may be within the range of normal physiological variation or may be clearly pathological. The psychosocial dimension of disease is associated with loss of equilibrium and may precede or follow physical disturbances. The normative or statistical dimension of disease is the most confusing. Sometimes people are branded ill because they fall at the extreme end of the health-illness spectrum as measured biochemically or physically. In the final analysis it is the perception of disease by the victim, the family or the health care givers that defines disease. The underlying pathology need not correspond with the victim’s disease complaint; perception operates in between.

 

Diseases may also be classified by cause as diseases of the heart, amradh al qalb[xxxvi], and diseases of the body, amradh al badan. Diseases of the heart include: lahw[xxxvii], ghaflat[xxxviii], ghill[xxxix], ghaidh[xl], kibr[xli], and nifaq[xlii]. These diseases of the heart lead directly or indirectly to somatic diseases. There is a relation between diseases of the heart, amradh al qalb, and diseases of the body, amradh al badan. The mental and spiritual disease of kufr leads to a lot of human cruelty like genocide because of lack of moral restraint. Diseases of the heart such as jealousy lead to violence and even death. Failure of appetite control leads to obesity and other attendant diseases. Addiction to alcohol leads to many physical and mental derangements. Loss of sexual self-control leads to promiscuity and sexually transmitted diseases. Protein energy malnutrition of the poor manifests social injustice in the community. Lack of spiritual equilibrium leads to inability of handling the normal stresses of life. This is often followed by addiction to alcohol and psychoactive substances. Physical diseases may cause so much depression and loss of hope that they develop diseases of the heart.

 

3.4 NATURE OF DISEASE

Disease is both reaction and adjustment. A patho-physiological disturbance is normally a response to a biological, physical, or chemical insult or injury to the body. Thus most disease manifestations including their symptoms and signs are a reaction to the injury and an attempt to re-adjust.

 

Disease as a bounty: In an Islamic context, disease does not always connote a negative or bad event. There are indeed many situations when what is a disease situation is actually beneficial. Falling ill may be Allah’s way of forcing the person to take a desired rest or care for the body before it can deteriorate further. Death from some diseases was said by the Prophet to be martyrdom, shahadat. The pain due to disease is a reminder of the punishment and suffering that the evildoers will suffer from in hell. Disease can be an opportunity for personal redemption by expiation/atonement for previous sins, al maradh kaffaarat ‘an ba’adhi al dhunuubi[xliii]. Disease may enable a person return to the due equilibrium in life. Falling sick may at times be Allah’s blessing in disguise that a person is incapacitated and thus is prevented from pursuits that could prove more dangerous for him. While a person is sick and is not busy with the routines of life he may have time to reflect and remember Allah. Disease is a trial: The trials that one goes through and the eventual patience can be rewarded by Allah’s forgiveness[xliv]. Patience with chronic disease/disability is associated with high reward. The prophet (PBUH) talked about rewards for epileptics[xlv] and the blind[xlvi]. Patience in the face of severe illness is a reason for entering paradise, jannat.

 

Disease as punishment: Some diseases are due to disobedience. Acts of disobedience may be followed by epidemic disease or by disease in an individual. The disease may be directly related to the sin such as liver cirrhosis due to chronic alcohol consumption or there may be no direct relationship. The prophet taught that when communities commit inequities, Allah sends them diseases unknown in their ancestors. Many of the diseases of industrialized societies are related to lifestyle and may be Allah’s punishment for various transgressions.

 

Causality in disease: According to the Islamic perspective every phenomenon in life has an immediate cause, sabab, that humans can search for and find. However behind all these causes is the power and majesty of Allah who alone is the source of all causes, musabbib al asbaab. When all the factors that produce a certain pathological condition exist, we say that there is a sufficient cause of disease. However humans can never know for sure that there is a sufficient cause because Allah’s divine will, qadar, is involved. There are many cases when all the humanly known factors of a disease exist but the disease does not occur. This is because of the unknown factor attributable to Allah alone. There are empirical factors that must operate for a certain pathological condition to occur. These are referred to as necessary causes. For example the tubercle bacillus is a necessary cause for the disease of tuberculosis. Humans must know the necessary causes of diseases. Denying their existence is denying the cardinal principle of sunan Allah fi al kawn and is akin to superstitious belief.

 

Multi-factorial causality of disease: Human diseases, like the human organism, are complicated and usually several factors are involved in their causation. Humans may know some of the factors and ignore others. It is not necessary to know all the factors in order to treat a disease. Since the factors usually act in sequence, knowledge of only one may be sufficient to interrupt the causal pathway.

 

Pre-determination, qadar, in disease: The causation, progression, and resolution of disease are in the hands of Allah and are part of qadar. It is Allah’s pre-determination that a person falls sick. Humans try to understand disease processes in order to reverse them. This is not contradicting or opposing Allah’s will. All what a physician does is with Allah’s permission and is therefore part of pre-determination. Treatment and prevention of disease are not against qadar but are subsumed under the principle that qadar can reverse another qadar, radd al qadar bi al qadar. In the end all cure is from Allah and not the human[xlvii].

 

3.5 DETERMINANTS OF DISEASE

Environmental causes of disease: heat, cold, radiation, water, smoke, and high altitude can lead to patho-physiological disturbances and disease. Extreme heat can cause heat stroke and dehydration. Water kills drowning people, gharaq[xlviii].

 

Contagion, adwah, from the microbiological environment is part of Allah’s plan especially in fulfilling the food chain. It is part of the balance of the eco-system. This does not however mean that such diseases should be left alone. There has been some confusion about hadiths of the prophet dealing with infection and contagiousness of disease. The Prophet was speaking about different diseases on different occasions. Some were contagious while others were not. Even with one disease like leprosy there are contagious and non-contagious forms[xlix].  

 

Other determinants of disease are malnutrition, genetic anomalies, immunological anomalies, neoplastic and degenerative change. Islamically speaking we cannot say that there was a genetic or chromosomal mistake. It is all part of Allah’s grand design.

The Qur’an teaches that degeneration occurs with aging[l].

 

3.6 CONCEPTS OF TREATMENT and CURE OF DISEASE

Every disease has a treatment. The prophet Muhammad (PBUH) said in an authentic hadith that Allah did not reveal any disease, bau, without also revealing its cure, dawau[li]. Humans are encouraged to seek treatment, al hatthu ‘ala al dawaa[lii]. The Qur’an described cure, shifa[liii]. The Qur’an is itself a cure[liv]. Honey is described in the Qur’an as a cure[lv]. Some people may know the cure and others may ignore it but it nevertheless exists. The Qur’an described disease in prophet Ayyub (PBUH) and its eventual cure[lvi]. The Qur’an described how Isa cured chronic diseases[lvii]. Humans try, but it is Allah who cures, Allah huwa al shafi[lviii]. Humans should not be arrogant by attributing cure to themselves and not Allah. In the same way humans cannot refuse to take measures to cure disease claiming that Allah will take care of it. It is true that Allah cures but in some cases that cure operates through the agency of humans. Sometimes the measures that humans take to cure a disease may not be sufficient on their own to alleviate the condition; it is Allah’s divine intervention and mercy that brings about the complete cure. Disease treatment is part of qadar[lix]. 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.

 

3.7 CURATIVE MEDICINE, TIBB ‘ILAJI

Curative medicine may be invasive or non-invasive. Where possible non-invasive approaches are preferred because invasive disease treatment whatever its nature involves some element of risk to the patient. A non-invasive approach that aims at helping or assisting the body to fight the disease is the best. Many physicians forget the tremendous potential that the body has to take care of itself and cure disease with the help of Allah. Medical treatment in most cases should be supportive to the body’s natural healing processes.

 

Among spiritual approaches to disease management is use of dua from the Qur’an[lx]  and hadith as ruqiy. Dua was reported to have been used for madness, dua min al junoon [lxi] and for fever[lxii]. The formulas for ruqy reported from the prophet, al ruqiy al mathuur, consist of the following chapters of the Qur’an: al fatihat, al falaq, al naas, ayat al kursi, and the various supplications reported from the prophet, dua ma’athurat. The Qur’an is the best medicine[lxiii]. Dua is medicine[lxiv]. Asking for protection from Allah, isti’adhat, is medicine. A strong iman and trust in Allah, tawakkul, play a role in the cure of diseases. Salat is a cure[lxv]. The spiritual approach to cure is mediated through the physical processes. Psychosomatic processes affect the immune functions and other metabolic functions of the body. A believer who is spiritually calm will have positive psychosomatic experiences because he or she will be psychologically healthy and at ease. Faith can change the very perception of disease symptoms. Pain is for example subjective. A believing person who trusts in Allah may feel less pain from an injury than a non-believer with the same injury.

 

Among physical approaches to disease management are: diet, natural agents (chemical, animal and plant products), manufactured chemical agents, surgery, jiraha, and physical treatment e.g. heat. All therapeutic agents and procedures are allowed unless they contravene a specific provision of the law. This provides a wide scope for the practice of medicine. Bad medicine is forbidden[lxvi]. Bad medicine causes more harm than benefit. While seeking treatment, the moral teachings of Islam must be respected. The end never justifies the means. Haram material is not allowed as medicine except in special circumstances where the legal principle of necessity, dharurat, applies. Alcohol is for example not an accepted cure for any disease; it is actually itself a disease. The side effects of medication must be considered alongside the benefits. Harmful treatments are not allowed in situations in which the cure is worse than the disease. Choice of what treatment modality to use should involve a careful weighing of benefits and possible harm or injury. It is a principal of Islamic Law to give priority to preventing harm over accruing a benefit.

 

3.8 CONCEPT OF PREVENTION:

Preventive medicine is a pro-active measure: 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[lxvii], against punishment, wiqaya min al adhaab[lxviii], against evil, wiqaya min al sharr[lxix], against greed, wiqaya min al shuhhu[lxx], against bad acts, wiqayat min al sayi’at[lxxi], against injury/harm, wiqayat min al adha[lxxii], against jealousy, wiqayat min al hasad, against oppressive rulers, wiqaya min al taghoot[lxxiii], against annoyance, wiqayat min al adha[lxxiv], and against heat, wiqayat min al harr[lxxv]. Prevention is therefore one of the fixed laws of Allah in the universe, sunan llah fi a lkawn. Its application to medicine therefore becomes most obvious. 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.

 

Three levels of prevention: The concept of prevention can be understood at three levels. Primary prevention aims at making sure the disease does not occur at all. Secondary prevention aims at limiting the impact of the disease once it has occurred; this is usually by attempting to detect the disease early and instituting necessary treatment. Tertiary prevention aims at mitigating the long-term sequelae and complications of a disease. Prevention also involves avoiding any act that can hurt good health or destroy life, halaak[lxxvi]. There are activities that promote good health and 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. Examples of such activities are: physical exercise, rest and recreation, diet, dhikr llah, happy marriage and good family life.

 

LEGEND OF FIGURES

Figure 1: Quinquennial indices of economic and demographic change in England, 1541-1951 

 

Figure 2:  J. Marshall (1838) Mortality in the Metropolis (London). Population base discussed in Chapter 3, note 45.  Gastro-intestinal

 

APPENDIX #1: TECHNIQUES OF ECONOMIC ANALYSIS

ECONOMICS AS A DISCIPLINE

Economics is a discipline that deals with scarcity of resources. It can be descriptive, explanatory or evaluative. Descriptive economics is used to describe medical care (such as number of physician visits or number of bed-days of hospitalization) or health status (such as morbidity, mortality, and functional capacity). Explanatory economics deals with demand and supply issues in health care, average and marginal costs of health interventions, and markets (competition and monopoly). Evaluative economics analyzes the allocation of healthcare resources in terms of efficiency, accessibility, equity, and fairness). Health economics is application of micro-economic tools to health. It studies supply and demand of health care services and their effects on the population. Economic appraisal is employment of economic tools to make allocation decisions. Health care ethics are principles used to solve the conflict between healthcare and economics. Healthcare wants to maximize health benefit. Economics wants to minimize utilization of scarce resources of to use them in the most efficient way which translates in practice into restricted health care delivery. Health economics represents an integration of medicine and economics in its concern for quality which is a medical objective and efficient allocation of health care resources which is an economic objective.

 

MOTIVATION FOR ECONOMIC ANALYSIS IN HEALTH

Rising expenditures in health care have forced economic analyses to understand the behavior of the medical care market and to find ways of controlling costs. Expenditure on health is rising in all countries. Health expenditure constitutes a  high proportion of GDP. Per capita health expenditure is also very high. There are in addition unrecorded health expenditures such as out-of-pocket payments and payments in-kind. The traditional cost containment strategies such as insurance deductibles, co-payments, and exclusion of certain services from coverage have not been effective. The rising costs of health have forced a review of the issue of access using managed care, health care rationing, and coverage prioritizing. The reasons for rising health care costs are higher demand for care, higher wages of health care workers, and more sophisticated and expensive medical technology. New modes of health care delivery have been started to control costs: HMOs, PPOs and IPAs. Other methods of cost control used are: reimbursements based on DRGs, utilization review, and pre-admission certification. In practice the zeal to control costs has serious side effects such as inadequate care, inappropriate care, exclusion of high risk patients like the elderly, and lack of equity in health care delivery. The issue of high costs becomes more urgent when problems of quality and access persist despite increasing expenditure. Hospital expenditure is the biggest component of health care expenditure yet epidemiological data over the past century shows that preventive, socio-economic, environmental, and lifestyle factors have had a bigger impact on health than curative medicine. The interest of health economists is usually in comparing various types of curative intervention and rarely do they compare the impact of general socio-economic improvement to medical intervention.

 
Go to Part II

[i] See appendix #1 for description and appraisal of these tools

[ii] See appendix #2 for description of the vision, mission, and objectives of the Islamic Input Curriculum

[iii] See appendix #3 for the course content of the Islamic Input over the 5 years of the medical course

[iv]  This assertion is seriously challenged by chronic diseases

[v]  Disease is due to anatomical anomaly

[vi]  Disease is due to deranged physiological or biochemical function

[vii]  Clinical examination for signs, medical imaging, and medical chemistry

[viii]  Environmental medicine asserts that disease is related to the physical and social environments

[ix] behavioral medicine is based on the doctrine of mind-body dualism asserts that immune, endocrine, and nervous systems are inter-related)

[x] Alex Mercer: Disease, Mortality, and Population in Transition: Epidemiological-Demographic Change in England Since the Eighteenth Century as part of a Global Phenomenon. Leicester University Press. Leicester 1990.

[xi] 6:2, 6:128, 11:3, 13:38

[xii] 31:34

[xiii]  31:34

[xiv]  63:11

[xv]  35:45

[xvi]  15:4, 16:61, 71:4, 63:10-11

[xvii]  2:96

[xviii]  2:84-85, 4:29, 5:32, 6:151, 17:33, 18:74, 25:68

[xix]  5:32

[xx]  2 5:32

[xxi]  Bukhari K81 B1, Tirmidhi K24 B1, Ibn Majah K37 B15, Darimi K20 B2

[xxii] Bukhari K81 B1, Tirmidhi K34 B1, Ibn Majah K37 B15, Darimi K20 B2

[xxiii]  11:100

[xxiv]  7:58, 34:15

[xxv]  95:3

[xxvi]  2:58, 7:96, 7:161, 16:112

[xxvii]  2:126, 14:35

[xxviii] 2:259, 27:34

[xxix]  7:94-95, 16:112, 65:8-9

[xxx] 6:131, 7:4, 7:96-98, 11:102, 11:117, 1:4, 17:16, 17:58, 18:59, 21:95, 22:45, 22:48, 25:40, 26:208, 27:56-58, 28:58-59, 29:31, 29;34, 46:27, 47:13

[xxxi] 16:112, 17:16, 28:58, 34:34, 43:23

[xxxii] 4:57, 11:102, 18:59, 21:11, 22:45, 22:48, 28:59

[xxxiii] 6:123, 7:82, 7:88, 7:96, 17:16, 18:77, 21:74, 27:56, 28:58, 34:34, 43:23

[xxxiv]  6:92, 6:131, 12:109, 25:51, 26:208, 28:59, 34:34, 36:13, 42:7, 34:23

[xxxv] Bowman p. 4.2: Textbook of Pharmacology

[xxxvi] 2:10, 5:52, 8:49, 22:53, 24:50, 33:12, 33:60, 47:20, 74:31

[xxxvii]  p958 21:3

[xxxviii] 58 18:28

[xxxix] 58 7:43, 15:47, 59:10

[xl]  3:118-119

[xli] 40:35, 40:56

[xlii]  2:8-10, 2:2-4, 3:167, 5:41, 9:8, 9:64, 9:75-77, 48:11

[xliii] Bukhari K75 B1, Bukhari K75 B2, Bukhari K75 B3, Bukhari K75 B13, Bukhari K75 B14, Bukhari K75 B16, Muslim K45 H45, Muslim K45 H46, Muslim K45 H47, Muslim K45 H48, Muslim K45 H49, Muslim K45 H50, Muslim K45 H51, Muslim K45 H52, Muslim K45 H53, Abudaud K20 B1, Tirmidhi K8 B1, Ibn Majah K31 B18, Darimi K20 B56, Darimi K20 B57, Muwatta K50 H6, Muwatta K50 H8, Ibn Sa’ad J2 Q2 p11-13, Zaid H346, Ahmad 1:11, Ahmad 1:172, Ahmad 1:173, Ahmad 1:180, Ahmad 1:185, Ahmad 1:195, Ahmad 1:196, Ahmad 1:201, Ahmad 1:381, Ahmad 1:441, Ahmad 1:455, Ahmad 2: 194, Ahmad 2:198, Ahmad 2:203, Ahmad 2:205, Ahmad 2:248, Ahmad 2:287, Ahmad 2:303, Ahmad 2:335, Ahmad 2:388, Ahmad 2:402, Ahmad 2:450, Ahmad 2:500, Ahmad 3: 4, Ahmad 3:18, Ahmad 3:23, Ahmad 3:24, Ahmad 3:38, Ahmad 3:48, Ahmad 3:61, Ahmad 3:81, Ahmad 3:238, Ahmad 3:258, Ahmad 3:316, Ahmad 3:346, Ahmad 3:386, Ahmad 3:400, Ahmad 4:56, Ahmad 4:70, Ahmad 4:123, Ahmad 5:198, Ahmad 5:199, Ahmad 5:316, Ahmad 5:329, Ahmad 5:330, Ahmad 5:412, Ahmad 6:39, Ahmad 6:42, Ahmad 6:53, Ahmad 6:88, Ahmad 6:113, Ahmad 6:120, Ahmad 6:157, Ahmad 6:159, Ahmad 6:167, Ahmad 6:173, Ahmad 6:175, Ahmad 6:203, Ahmad 6:215, Ahmad 6:218, Ahmad 6:247, Ahmad 6:254, Ahmad 6:257, Ahmad 6:261, Ahmad 6:278, Ahmad 6:279, Ahmad 6:309, Ahmad 6:448, Tayalisi H227, Tayalisi H370, Tayalisi H1380, Tayalisi H1447, Tayalisi H1584, Tayalisi H1773, MB1949

[xliv] MB1948, MB1951

[xlv] MB1954

[xlvi]  MB1955

[xlvii] 26:80

[xlviii]  2:50, 7:64, 7:136, 8:54, 10:73, 10:90, 11:35, 11:43, 17:6, 17:103, 21:77, 23:27, 25:37, 26:66, 26:120, 29:40, 37:82, 43:55, 44:24, 71:25

[xlix]  Ibn al Qayim: At Tibb al Nabawi. p. 154

[l] 36:68

[li] MB1962, KS338 Bukhari K76 B1, Muslim K39 H69, Abudaud K27 B1, Abudaud K27 B10, Tirmidhi K26 B2, Ibn Majah K31 B1, Zaid H987

[lii] MB1962, KS338 Tirmidhi K26 B2, Ibn Majah K31 B1, Ibn Majah K31 B23, Muwatta K50 H12, Ahmad 4:278

[liii] 3:49, 5:110, 9:14, 10:57, 10:69, 17:82, 26:80, 41:44

[liv] 17:82

[lv] 16:69

[lvi]  21:83-84, 38:41-44

[lvii] 3:49, 5:11

[lviii] 21:83-84, 26:80, 38:41-42

[lix] Tirmidhi K26 B21, K30 B12, Ibn Majah K31 B23, Ahmad 3:421, Ahmad 5:371

[lx] 17:82

[lxi] Ahmad 1:302

[lxii] Tirmidhi K45 B36, 111, 118, Zaid H349, 350

[lxiii] Ibn Majah K31 B28, Ibn Majah K31 B41

[lxiv] Ahmad 2:446

[lxv] Ibn Majah K31 B10, Ahmad 2:390, Ahmad 2:403

[lxvi] Tirmidhi K26 B7, Ibn Majah K31 B11, Ahmad 2:305, Ahmad 2:446, Ahmad 2:478

[lxvii] 66:6

[lxviii] 2:201, 3:16, 3:191, 3:34, 13:37, 40:7, 40:9, 40:21, 44:56, 52:18, 52:27, 70:11

[lxix] 86:11

[lxx]  59:9, 64:16

[lxxi]  40:9, 40:45

[lxxii] 16:81

[lxxiii] 3:28

[lxxiv] 16:81

[lxxv] 16:81

[lxxvi] 4:176, 67:28

Omar Hasan Kasule Sr July 2002