By Dr Omar Hasan Kasule Sr MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics Faculty of Medicine King Fahad Medical City and Visiting Professor University of Malaya and University of Brunei. WEB: http://omarkasule-tib.blogspot.com
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- Imbued with Islamic values in all its operations
- Provides holistic care
- Shari’at compliant
- Strives for excellence, ihsan
- Uses modern scientific medicine and spiritual approaches to cure
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1.0 EVOLUTION OF THE HOSPITAL IN GENERAL
1.1 A hospital is an institution for diagnosing and treating disease. The concept of a hospital as a place of treating and curing disease is fairly new in human history. For millennia the sick were treated and died in homes.
1.2 The first hospitals were related to religious institutions. Places of worship were also used as places of treating patients. Since treatment in the ancient times involved a lot of spiritual modalities, priests acted as healers of the body and the soul. Hospitals were known in Sri Lanka by 431 BC, in India around 230BC, and in Rome around 100BC.
1.3 Church-founded hospitals: When the Roman Emperor Constantine converted to Christianity in the beginning of the 4th century of the Christian era, he abolished all existing non-Christian hospitals and the Christian Church took on the role of caring for the sick. The Church provided services for the poor and disadvantaged members of society: the elderly, the lepers, and the wayfarers. The well-to-do continued to receive treatment at home.
1.4 Monastery based hospitals were founded in Lyon in 542 and Paris in 660. The monasteries had infirmaries to care for the sick in addition to pharmacies and gardens of medicinal plants. During the crusades military hospitals were established along the routes of crusader armies as they moved from Europe to fight Muslims in Palestine. The St John Ambulance movement started as a religious order during the crusades.
1.5 Secular hospitals were established in Europe in the Middle Ages. Among the first secular hospitals were: the Westminster hospital in 1719, Guy’s hospital in 1724, and the London hospital in 1740. A hospital was opened in Edinburgh in 1729.
1.6 Hospitals in European colonies: Europeans built hospitals in new territories occupied in the Americas, Asia, and Africa. Cortes built the first hospital in America in Mexico City in 1524. Hospitals were established in Quebec in 1639 and Montreal in 1644. Hospitals were established in Manhattan in 1663 and Philadelphia in 1751.
1.7 Change in the outcomes of hospitals: Hospitals were known as places where patients go die because before the 20th century there were few effective therapies. Advances in medicine in the 20th century led to effective surgical and medical interventions that greatly changed the outcome of disease. The earliest hospitals were also dangerous places to visit or stay in. By having many sick people with infectious diseases hospitals contagion spread easily and there were no effective antibiotics. Hospitals became safer after discovery of bacteria and antibiotics(i) .
1.8 The modern hospital has become a very sophisticated institution. It provides preventive and curative medical services. It is a bureaucratic pyramidal organization. It is hierarchic with a narrow span of control for managers because of the need to provide safe care and avoid mistakes. Work is highly differentiated and specialized. Hospitals can be classified by their location as rural or urban, by the number of beds, by ownership (community and non-community, government vs. non government) and by financial objective (for profit vs. not for profit).
1.9 Characterization of hospitals is based on the number of beds, the average patient stay, the bed occupancy%, and the average cost per day. Provision of out-patient services decreases the need for in-patient beds and is more cost effective. Out-patient services include: specialty clinics, day surgical centers, ambulatory surgery, ancillary outpatient services: lab, imaging, physical therapy, group practice within the hospital
1.10 Emergency services: Quick transport systems and advanced medical technology have led to expansion of emergency services. Critically ill patients who before could not be expected to reach hospital in time to save their lives can now be transported quickly and can be treated successfully. The emergency room is misused for primary health care when patients do not get primary care and have to be brought to the hospital with acute conditions. Emergency services are very expensive because they have to be staffed 24 hours.
1.11 The impact of technology is manifest in a modern hospital has more people working in ancillary, support, facility, and administrative services than those working in direct patient care. This is because sophisticated patient care requires so many other functions. Ancillary services include laboratories, imaging, anesthesiology, rehabilitation, pharmacy. Support services include dietary services, social services, pastoral care, patient transport, and patient ombudsman. Support services include environmental services, maintenance, plant engineering, parking, security, biomedical engineering, contract management. Administrative services include: purchasing, human resources, volunteer organizations and telecom management.
2.0 EVOLUTION OF THE HOSPITAL IN THE MUSLIM EXPERIENCE
2.1 Bimaristan (house of the sick) was a Persian word used in the Muslim world to refer to hospital. The same concept is employed in Bahasa Melayu by referring to a hospital as rumah sakit.
2.2 The Madina Hospital: The first hospital in Islam was the hospital tent that the prophet ordered erected in the mosque of Madina during the battle of the confederates and Rufaidat used it to treat the wounded. The complete hospital was established in 88H for the lepers and the blind by the Omayyad Khalifat al Waliid bin ‘Abd al Malik.
2.3 Hospitals in the Abassid era: The establishment of hospitals picked up pace in the early Abassid era and this coincided with the growth of medical knowledge in the Muslim world. Various types of hospitals were set up. There were general hospitals as well as specialized ones for prisons and schools. There were hospitals for isolating patients who mad or those with chronic diseases like leprosy. A psychiatric hospital was built in Baghdad in 705CE. The army had mobile hospitals.
2.4 Golden era of Muslim hospitals: In the 8-10th centuries CE Hospitals were built in Baghdad, Cairo, Qairawan, Andalusia, and Damascus. Muslim hospitals had separate sections for each type of disease. They had gardens. Fans were used to cool the hospital. Cleanliness was observed by workers in all areas of the hospital especially the kitchen and the pharmacy. Daily clinical rounds were carried out. Patients were given some money on discharge. These hospitals reached high level of professional care for patients in a comfortable environment. The hospitals treated patients regardless of religion, race, or socio-economic status. The Muslim hospitals transformed the paradigm of a hospital from providing comfort and care for dying patients to attempting to cure the disease . The hospital thus acquired its modern perspective as a place of cure and not a place of dying. Europeans coming out of the Middle Ages learned a lot from Muslim hospitals.
2.5 Decline of Muslim hospitals: There was a decline of Muslim civilization after the 4th century of hijra. This decline affected all aspects of the communities including medicine and hospitals. All through the period of decline spanning nearly 10 centuries there were revival movements that aimed at rebuilding Muslim civilization. The most sustained of these started after the fall of the Uthmani Khilafat and continues its growth until today. It has manifest in many aspects: politics (Islamic parties), economics (Islamic banks, Islamic finance, Islamic insurance), and medicine (Islamic hospitals and Islamic medical colleges).
2.6 Muslim renaissance in Medicine started in earnest with the commencement of the new hijra century 1400 H/1980M. It started with expressions of pride in the past achievements of Muslim medicine and a determination to excel in the present. This renaissance is manifesting as seminars, conferences, memorial buildings, books, and publications dealing with Islamic medicine. Islamic Medical Associations have been set up and are operating in the US, S Africa, Pakistan, Egypt, Sudan, and Jordan. Among their activities are: journals, bulletins, conventions, research, direct care services, medico-legal fatwas, advocacy, Islamic clinics and hospitals. There is research on remedies of tibb nabawi. There is experimental study of medical aspects of the revelation in the Qur’an and sunnat. In the practical arena Islamic relief agencies: medical services in war and devastated areas, medical services for the poor, medical services and dawa. In the field of fiqh, medico-legal fatwas are being published by fiqh academies. As part of the renaissance, modern Muslim hospitals have been set up in Indonesia, Malaysia, Thailand, Jordan, Egypt, Sudan, etc.
3.0 THE CONCEPT OF ISLAMIZATION
3.1 Islam is dynamic: It has been said by many activists that Islam is not a state of being but is dynamic action. Islam is a verb and not a noun or an adjective. The best term to use to express the dynamicity of Islam is ‘Islamization’. Islamization is putting concepts and actions within the Islamic framework. It is not rejecting or abandoning what exists; it is rather improving and promoting. This means that as Muslims we are engaged in a continuous process of Islamizing concepts, ideas, and practices to conform to the highest and universal moral values.
3.2 Building and not destroying: Islam does not seek to destroy and rebuild from zero. It always builds on what exists. It preserves whatever is good from the Islamic perspective and Islamizes what is not. Existing customs after Islamization become part of the shari’at and are referred to as ‘aadat which is one of the five pillars of the Law, al kulliyaat al khamsat.
3.3 Islamic concepts, paradigms, and moral framework: Islamization in most cases is providing a new moral framework or changing the concepts underlying a practice. For example the circumbulation around the kaaba in Islam is physically the same as that during the jahiliyyah pre-Islamic era but is now done for Allah whereas before it was done for idols. A very telling event occurred at the time of the prophet when he said a Muslim should help his brother Muslim whether the brother is right or wrong. One of the companions noting that that was the practice in the pre-Islamic period expressed dismay at what the prophet said. The prophet reaffirmed the statement and explained that you help your brother when he is wronged by relieving the harm and injury done to him. You help him when he is in the wrong by stopping him from doing the wrong. Thus the same phrase in jahiliyyat has a different meaning in Islam because of a different moral and conceptual framework. This is what we call Islamization.
3.4 A Muslim hospital as values and shari’at compliance: Thus when we talk about Islamizing the hospital we are not talking about changing its physical appearance or using new treatment modalities. We are talking about infusing universal moral values and making the hospital shari’at compliant.
4.0 DISTINGUISHING CHARACTERISTICS OF THE MUSLIM HOSPITAL
4.1 A Muslim hospital is not parochial
An Islamic hospital is not parochial serving only Muslims. It is serving all humans regardless of their race or religion. It is also not a missionary hospital set up to help patients as a means to converting them to another faith or belief system.
4.2 A Muslim hospital is not traditional
A Muslim hospital is a modern hospital practicing scientific medicine within the Islamic value system and being shari’at compliant. It is not set up exclusively to offer traditional Muslim treatment modalities such as unani or other herbal medicine. It can incorporate traditional medicine treatment modalities that have been proved to be effective and safe by scientific experiments. It can also offer spiritual treatment modalities in addition to and not excluding modern scientific medicine.
4.3 A Muslim hospital is not charity
A modern Muslim hospital should be based on firm financial basis and should be run to generate enough revenue to cover its costs. It should not set itself the task of providing free treatment to those who cannot afford because it will fail financially and be forced to close. The approach to the Islamic requirement to help the needy is for the foundation that sets up the hospital to set up a parallel charity body. The charity body collects funds from various sources including the ‘profit’ made by the hospital. These funds are used to settle the bills of those who cannot pay. Indigent patients should approach the charity body for help before presenting at the hospital. However emergency treatment required to stabilize a patient should be provided to all regardless of their financial circumstances.
4.4 A Muslim hospital is modern and is advanced
A Muslim hospital should reflect the new spirit of self-confidence and looking to the future that characterizes modern Islamic renaissance. It should within the local constraints strive to be advanced and respected. We do not want a situation in which the term ‘Muslim Hospital’ is equivalent to ‘Low Quality Hospital’. In practical terms it may not be feasible t set up a state of the art hospital from the beginning because the Muslim community may not be able to mobilize the necessary resources. We can start low but aim in the long run to reach the state of the art.
4.5 A Muslim hospital is quality
Ihsan, or quality performance, is the third and highest fundamental of Islamic ‘aqidat superseding Islam and iman. Quality should permeate all activities of a Muslim. A Muslim hospital must therefore maintain the highest standards of quality in all its operations.
4.6 A Muslim hospital is holistic
The Islamic civilization is built on the doctrine of tauhid which implies integration of all phenomena in the cosmos because the Creator is one and everything must relate to everything else. The integrating paradigm of tauhid rejects dealing with any phenomenon or action in isolation. A Muslim hospital should therefore offer total care that integrates the spiritual, physical, and psycho-social aspects of preventing and treating disease.
4.7 A Muslim hospital is shari’at compliant
The architecture, management, and therapeutic procedures in the hospital should not violate the general purposes of the shari’at and should conform to rulings on halal and haram. Islamic law being very flexible does allow violations of legal rulings under the doctrine of necessity, dharurat, when the requirement of protecting the life of the patient supersedes a haram ruling.
5.0 ISLAMIZING HOSPITAL MANAGEMENT
5.1 Organizational management
The Organizational chart is very important but does not show the informal structures that are equally important. The informal structures are very important in a Muslim hospital because management in Islam is more human-oriented than task-oriented. Relationships of brotherhood, ukhuwat, should exist among all members of the hospital staff. All are equal in their personal worth whatever job titles they may carry. The different job titles are degrees of responsibility that various staff carry and do not confer any superiority. These titles also do not indicate the importance of the job because what may be considered lowly jobs like cleaning may be the most important in terms of overall patient safety.
The hospital has a 3–tiered power structure with relations defined by laws: the board of trustees, the CEO and managers (COO, CFO), and the professional staff. CEO is accountable to the board for inside and outside the hospital. A hospital may be part of a system or alliance of hospitals. The selection of the board of trustees and the senior managers is more elaborate for a Muslim hospital than other hospitals because of the need to vet candidates’ Islamic commitment and akhlaq.
5.2 Admission department
The admission department is the first point of contact between the patient and the hospital. It reflects the image of the hospital. Negative impressions on admission cannot be wiped out by later good performance. A Muslim hospital can distinguish itself by training its entire admissions staff to follow the Islamic guidelines on receiving and handling a visitor. The patient should not be looked at as a case of pathology but as an honored guest who has the full rights of a visitor. The Islamic etiquette of greeting and conversation should be followed. The patient’s rights should be respected and it includes: t respectful and courteous treatment, respect for autonomy, and respect for privacy.
5.3 Physician services: The Islamic etiquette of the physician should be incorporated in the training process to make sure it is internalized and becomes part of life-long learning. This etiquette will be discussed in a follow up presentation.
5.4 Nursing services should follow standard operating procedures that have been Islamized to incorporate Islamic values and fiqh guidelines. These are discussed in a subsequent presentation.
5.5 Hospital Revenue: A hospital is a complex organization that requires a lot of financial resources to operate efficiently. These resources are increasing exponentially because of the increasing cost of technology. The sources of revenue are (a) health insurance (b) charity (c) and patient payments. A Muslim hospital whether for profit or not for profit should be run with good financial planning to make sure that the revenue covers the costs. Failures in financial management will end with the hospital failing financially and closing which will deny services to many. As explained before the charity and the medical care operations should be separated. The hospital should not offer charity directly. It should charge for its services. Another body should be charged with mobilizing charity funds to meet the medical bills of patients who cannot afford to pay for themselves.
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(i) Don Griffin. Hospitals what they are and how they work. 3rd edition. Jones and Bartlett Publisher Boston 2006
Romana Romani F [The origins of the Islamic model of hospital]. Med Secoli. 2002;14(1):69-99
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