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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0206-HEALTH AND SICKNESS: THE PATIENTS PERSPECTIVE

Lecture to Year 3 students at IIUM Kuantan on 10th June 2002 by Prof Omar Hasan Kasule Sr.

A. DEFINITION OF HEALTH

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. 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. The holistic outlook also means that physical, emotional, psychological, and spiritual health are considered together. 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 by gender, females generally being more worried about disease than males. Those with strong iman and trust in Allah, tawakkul, may feel subjectively healthier than those who do not have these attributes.

B. DEFINITION OF DISEASE

Health is a condition in which all of the body functions are integrated and are being maintained within the limits of optimal design (Bowman p. 4.2). 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. In most cases, a deviation must also be related to other adverse changes to be able to constitute disease. The demarcation between pathology and normal physiological variation can be fine. Hunger and thirst for example are psychological warning signs and are not pathological conditions. A hungry person is not in immediate physiological danger. When the situation of food deprivation persists over a long time then physiological disturbances within the compensatory range occur. Pathological changes appear if food deprivation extends beyond that. 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 for example homosexuality was considered a mental disorder half a century ago but is now accepted as normal sexual expression in Europe and America. 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. A distinction must be made between disease as a pathological manifestation and illness that is a subjective feeling.

 

C. NATURE OF DISEASE

Disease is reaction and readjustment, it has benefits for the patient, and is both a trial and a punishment. A pathophysiological 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. Most disease processes operate at the cellular level. The causes of cell injury are: hypoxia, physical agents, chemical agents, infectious agents, immunological anomalies, genetic, and nutritional disorders. Cells respond to injury in two ways: adaptation or death. Adaptation manifests as hypertrophy and hyperplasia. Acute injury could terminate in cell death if not reversed.  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. 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. The trials that one goes through and the eventual patience can be rewarded by Allah’s forgiveness. Patience with chronic disease/disability is associated with high reward for example epilepsy  and loss of sight. Patience in the face of severe illness is a reason for entering paradise, jannat. 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.

 

D. THE BIOMEDICAL MODEL, DISEASE AND ILLNESS

The biomedical model is invasive, costly, materialist, narrowly focussed, inflexible, and seeks to control and regiment. Its materialistic background treats health as a commodity; dehumanizes and demystifies the body by treating it as a ‘machine’, a ‘thing’ or a ‘physico-chemical phenomenon’; depersonalizes the patient as a case of pathology and not as a human because; is more interested in the disease and not the person; and allows a technical relation to replace the human physician-patient bond. Biomedicine is not holistic. It concentrates only on somatic aspects of disease and equates disease to illness whereas the latter is wider in scope that the former. It limits disease causation to pathological anatomy or patho-physiology and rejects or marginalizes spiritual, cultural, social, and psychological factors. The limitations of the biomedical model cannot be overcome until a serious re-examination of its philosophical background whose major tenets are materialism, secularism, modernism, and post modernism. An alternative holistic model of health care delivery can be reconstructed 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). This alternative will be cheaper and more effective than the biomedical model.

 

E. ETIQUETTE and ATTITUDES OF THE PATIENT

The patient should always express gratitude to those taking care of him or her even if there is no marked physical improvement. The patient should complain only to draw attention to problems that need attention. Complaints for other purposes should be minimal. The patient should be patient in the knowledge that illness is kaffaarat. There is a lot of reward for the patient who surrenders to Allah. The patient should make dua for himself and others. The dua of the patient has a special position with Allah. The patient should never hesitate to make dua for a visitor who asks for it. The believing patient should never lose hope from Allah. He should never wish for death. The patient should try his best to avoid anger directed at himself or others. Getting angry is a sign of losing patience. The patient must have a positive attitude to death. Death and its occurrence are in the hands of Allah. The attitude to death varies according to the spiritual well being of those involved. The good people welcome death as a rite de passage to a better existence in the hereafter. They look forward to death as a happy event. The approach of death is an opportunity for repentance. Death is an occasion for reminding and remembering the hereafter. It makes the good prepare better by doing more good deeds. Humans are apprehensive about death and often fear it. This is basically the human fear of the unknown. It is useless to fear an event that is inevitable and over which a human has no control. Fear of inevitable death itself in illogical but anxiety about the manner and circumstances of death is reasonable and is expected from a normal human. Death may be feared because of leaving behind beloved ones. Wishing for death in desperation with severe painful illness is discouraged. The wish for death can be negative for the escapist who looks to death as a relief from present psychological or physical distress Committing suicide is definitely forbidden and puts someone outside the fold of Islam. Death is a trial and is a calamity. This trial involves both the person dying and the relatives and friends left behind. Death is a calamity for the relatives, friends, and the society but not the deceased. If he is good he is going earlier to his Lord. If he is bad he has no more time to do bad; however he might have made tawbat and improved his situation had he lived longer. Death is a test for humans. The test for the deceased is to be aware of death and prepare for it by doing good work, amal hasan. For the relatives and loved ones death is a calamity calling for patience and forbearance.

 

F. DEALING WITH PATIENTS

Caregivers have to allay fear and anxiety. Death of the believer is an easy process that should not be faced with fear or apprehension. The process of death should be easier for the believer than the non-believer. The soul of the believer is removed gently. Believers will look at death pleasantly as an opportunity to go to Allah. Allah loves to receive those who love going to Him. The patient should be encouraged to look forward to death because death from some forms of disease confers martyrdom. Patients should be told that Allah looks forward to meeting those who want to meet Him. Dying with Allah's pleasure is the best of death and is a culmination of a life-time of good work. Thinking well of Allah is part of faith and is very necessary in the last moments when the pain and anxiety of the terminal illness may distract the patient's thoughts away from Allah. Having hope in Allah at the moment of death makes the process of dying more acceptable. The dying patient should be encouraged to repent because Allah accepts repentance until the last moment.

Omar Hasan Kasule Sr. June 2002