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FEATURE: Aziz Sheikh Should Muslims have faith based health services? BMJ 2007; 334: 74 [Full text]

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Working Side by Side-Where is the Head to Head Here?

Kawaldip Sehmi   (12 January 2007)

Individual healthcare

Adrian Davis   (13 January 2007)

Spiritually sensitive healthcare services

Trevor Stammers   (13 January 2007)

A plea for non-discrimination

Gerald Freshwater   (13 January 2007)

Muslims and Health Needs in Vanishing Health Service

Nigel S de Kare-Silver   (13 January 2007)

An Eye on the Models Eye?

Andy Wood   (14 January 2007)

Should muslims have faith based health services?

Ben Hart   (14 January 2007)

Religious intolerance in the West

Munjed Farid Al Qutob   (14 January 2007)

Individual Services

Mishell Sajid   (14 January 2007)

The wrong question

Joseph P Sweetman   (14 January 2007)

Doctors of the future need education and religious awareness to provide good care to all patients.

Atika Sabharwal   (14 January 2007)

Shiekh's political agenda disguised as health

Ahmad A Bajalan   (14 January 2007)

misleading question

Usama Alkhaddour   (15 January 2007)

Medicine must be secular, not religious

Edward Haworth   (15 January 2007)

Male infant circumcision for non-medical reasons should not be available on the NHS

Paul A Burgess   (15 January 2007)

Towards a more respectful NHS...

Abdulkareem Carlyle   (15 January 2007)

"Faith" -based hospitals in the United Kingdom

Dr JK Anand   (15 January 2007)

Mecca on the Exchequer

Paul W Keeley   (16 January 2007)

Consider Other Faiths

Anoushka C Chelvendra, Shyamali Griffiths and Nij Bhala   (16 January 2007)

Faith Based Heath Services-The Title & the Front Page Picture!

Syed Kazmi   (16 January 2007)

Viewing from America

A.A.W. Amarasinghe,MD,   (16 January 2007)

'Good Medical Practice' and good common sense

Faizal Moosa   (16 January 2007)

Education is the key

Ghaleb W El-Farouki   (16 January 2007)

Re: "Faith" -based hospitals in the United Kingdom

Sankar K. Das, Dr. M.S. Kataria   (16 January 2007)

Faith based services may be helpful

Ahmed Mohammed Iqbal   (17 January 2007)

Individualized Medicine

Adrian Mondry   (17 January 2007)

Poor health not related to religious faith

Michael Crawford   (18 January 2007)

"Et tu BMJ"

Adedeji T Odelola   (18 January 2007)

Use faith, but not necessarily faith-based

M Justin S Zaman   (18 January 2007)

What role has faith in Medicine?

Somasundari Gopalakrishnan   (24 January 2007)

Should Muslims have faith based health services

andrew peacock   (24 January 2007)

Re: Religious intolerance in the West

Carol Teasdale   (27 January 2007)

Re: Individual healthcare

Hazem A Sayala   (27 January 2007)

Faith-based medical journals

Philip J Cowen, Nicholas M Cowen, Civitas, London SW1P 2EZ   (27 January 2007)

Medical training of Multicultural Students in a Multicultural Society. Time for multicultural training?

Rishi R Duggal   (31 January 2007)

Re: 'Good Medical Practice' and good common sense

Paul A Burgess   (7 February 2007)

Working Side by Side-Where is the Head to Head Here? 12 January 2007
Kawaldip Sehmi, Director Health Inequality Health Inequality EC1V 9NR Send response to journal: Re: Working Side by Side-Where is the Head to Head Here?	At the outset, some headline writer at the BMJ inserted the text "Head to Head" before this pair of very useful articles that give a good insight into Muslim health in the UK. These kind of headlines introduce an artificial and confrontational persona to any meaningful debate. There is nothing “head to head” in this issue, we are all working side by side and the patient’s informed choice must come first in any discussion. (1) (2) Having worked on the smoke-free Ramadans and other the initiatives led by the Muslim Health Network (www.muslimhealthnetwork.org), my experience is that when it comes to ill-health and medical treatment, Islam is very flexible and understanding in giving many dispensations to the patient and their treatment choice. For example, during Ramadan patients suffering ill health (especially diabetic patients), breast-feeding mothers and those old/infirm who cannot fast are exempt from any obligations to fast. They can substitute it with community development and charity. “Allah (swt) wishes for you convenience, not hardship……”: Al Koran Verse 2:185 " Ramadan is the month during which the Quran was revealed, providing guidance for the people, clear teachings, and the statute book. Those of you who witness this month shall fast therein. Those who are ill or travelling may substitute the same number of other days. Allah (swt) wishes for you convenience, not hardship, that you may fulfil your obligations, and to glorify GOD for guiding you, and to express your appreciation." Evidence, in numerous papers in the BMJ, shows that ANY patient is best served if he or she is given timely, pertinent and accurate information before they exercise an informed choice. Also, from a PCT and financial point of view, a service will only be used if it meets the needs of the patient groups. One PCT put it very succinctly recently: “Around 18% of people who try and stop smoking nationally use a stop smoking service – this suggests either the services are not marketing themselves effectively at smoking populations, or the populations do not find the services fit their needs.” Do we need to say more! 1) Should Muslims have faith based health services? Aziz Sheikh BMJ 2007;334:74 (13 January) 2) Should Muslims have faith based health services? Aneez Esmail BMJ 2007;334:75 (13 January) Competing interests: None declared
Individual healthcare 13 January 2007
Adrian Davis, GP Lightwater Surgery GU18 5SQ Send response to journal: Re: Individual healthcare	GPs should and generally do provide good quality health care tailored to any individuals needs. Discussing options and involving patients in their own care is well promoted by the royal college. Surely better to focus on the individual rather than wider categorisation? Form filling, ticking boxes and endless recording of data will offer little benefit to patients in primary care. The key must be to engage with the patient. Breaking down health inequalities is a goal for all of us. However I don't see how offering genital mutilation on the NHS will help this. Competing interests: None declared
Spiritually sensitive healthcare services 13 January 2007
Trevor Stammers, Lecturer in Healthcare Ethics. St Mary's University College, Twickenham TW1 Send response to journal: Re: Spiritually sensitive healthcare services	Whether or not Muslims, or those of any other faith, should have specific faith-based services is indeed open to debate in an NHS with increasingly limited resources. However, this debate highlights the importance of spiritual history- taking in medicine, as there is no doubt that religious belief has a profound influence on patient compliance and other health-related matters(1). There is no medical school in the UK as far as I am aware that teaches spiritual history-taking(2). Perhaps this would be as good a place as any to start educating health care professionals to provide spiritually -sensitive services even if they are not specifically faith-based? 1. Koenig HG Taking a spiritual history JAMA. 2004 291:2881 2. King DE. Blue A. Mallin R. Thiedke C. Implementation and assessment of a spiritual history taking curriculum in the first year of medical school. Teaching & Learning in Medicine 2004 16:64-8 Competing interests: Vice-Chair of Christian Medical Fellowship
A plea for non-discrimination 13 January 2007
Gerald Freshwater, Occupational Physician Lerwick, Shetland Isles ZE1 0EL Send response to journal: Re: A plea for non-discrimination	Editor, Professor Sheikh’s proposition (BMJ 2007;334:74 (13 January)), even if it had merit on grounds of religion, is so impractical as to be ridiculous. Accepting that a majority of Muslims in the UK live in cities, many, however, do not, and there are small numbers who live in relative isolation. In the Scottish islands there are Muslims well established within the community, but the total of their number does not reach three figures, and it is already difficult to provide a full range of services to the entire population, without a duplicate service for one religious group. If he seeks greater equality, presumably Sheikh also wants separate services offered to the few Buddhists, Taoists, Jews et cetera living in remote areas? Allowances can be made by all practitioners for those of other faiths, but Sheikh perhaps deems this inadequate. The only practicable alternative is to require the population to live in religious ghettos; history suggests this does nothing for equality in any society. Besides, the Muslims living in rural areas of Scotland, like the English and other minorities, do so out of choice, knowing there are only a few of their peers providing local health care, education and other nationally funded services. Let us just ensure that health services are provided equally to all those of common physiology, with each individual’s religious belief (or even the lack thereof) accorded respect, and privacy. Competing interests: None declared
Muslims and Health Needs in Vanishing Health Service 13 January 2007
Nigel S de Kare-Silver, GP Principal, GP Program Director Gladstone Medcial Centre, London NW2 6JH Send response to journal: Re: Muslims and Health Needs in Vanishing Health Service	Professor Sheikh's comments are extremely valid to current health needs. The pluralist society we enjoy cannot be naiively treated with the same broad brush. As a practice in Brent we surveyed our population a couple of years ago. Brent has the highest ethnic mix in the country and one welcomes this article albeit from Edinburgh. We carried out a small survey on our own practice population about 18 months ago. Over 36% of those who responded to questionaires distributed in our reception ie to members of our practice population who attended this health centre, responded they were concerned about the possibility of animal food products being used in the manufacturing of their medication and 23% admitted they would not take many medications prescribed. At the very least there is a need for a medication labelling system stating clearly whether medication contents are approved by a series of religious authorities and guidelines, a readily available list of approved alternatives in electronic and printed BNF and software support to electronic prescribers. Furthermore clear statements should be issued and available to prescribers and dispensers, approved again by religious authorities for the circumstances and conditions where the 'forbidden' medications may be used. The problem I have with Professor Sheik's article is its timing. We hear of continued investment and development of the Scottish Health Service. Paradoxically, despite a strong general economy, the English version of the NHS is being savagely cut away. Over the 18 years I have been in practice I have worked hard to contribute to near patient services, interpreting services and the support which people need in order to effect the health care instructions given out by clinicians. On the same day as this article we received notice in Brent of the withdrawl of funding for a long established interpreting service. Over recent weeks District Nursing, GP based clinic services such as dietetics and other facilities which have taken years to construct have been torn down. The general media appears to pay little attention to these changes so far and currently adopts an attitude either of ambivalence or of doctor bashing in its coverage. It is impossible to deliver primary care as a vetinarary service to those who do not speak English. As much as there is a large focus on the high tech and emergency drama end of health provision, there is a crucial need to investigate and probe for infant sexual and physical abuse, educate young adolescents from all backgrounds about sexual health and family development, explore physical symptoms as being the result of deeply masked psychological and psychiatric illness and provide our near universally obese population with nutritional advice. None of this can be provided where the staffing levels have been reduced to primitive levels and the nearest service is three bus rides away. Primary care, as is the whole health service, in England at least, is in a highly vulnerable state at present and Professor Sheikh's calls must not be ignored. Competing interests: None declared
An Eye on the Models Eye? 14 January 2007
Andy Wood, SHO Ophthalmology Glasgow Send response to journal: Re: An Eye on the Models Eye?	Whilst I understand the BMJ's wish to be provocative at times, I do have some difficulty in understanding the purpose of this article. Is the BMJ being very clever? I cannot help but notice at least in my printed edition that the front page models iris on the left appears slightly lighter in colour that the right or the right darker than the left whichever you prefer. Is this a subtle case of Iris Heterochromia and is the point being made that despite cultural sensitivities one should "lift the veil" and concern ourselves with a proper history and ocular and systemic examinations rather than worry about secondary cultural concerns of minor importance? Competing interests: None declared
Should muslims have faith based health services? 14 January 2007
Ben Hart, GP principal Chrisp Street Health Centre E14 6PG Send response to journal: Re: Should muslims have faith based health services?	I work as a gp in a group practice in East London serving a mixed population with a 30% Bangladeshi, mainly Muslim, minority. We have been asked to collect details on people’s religious beliefs before and took the collective decision to not to participate as a practice; I have not changed my mind and would oppose any other attempt to collect information on personal belief systems. Aneez Esmail’s argument that a reductivist notion of identity will not help patients receive appropriate care is right. Setting aside the specious conflation of religion, social class and immigrant status underpinning Prof Sheikh’s piece there is an assumption that there is a consensus amongst British Muslims on behavioural norms. The notion that behavioural norms are homogenous for the nominally Christian majority in the UK is palpably absurd so why must it be true for most Muslims? Doctors need to focus on the care and help the patient wants, eliciting their ideas and concerns directly rather than making assumptions about what care and help we think they might want because of their faith, family background, sexuality or whatever. A good example is the issue of Muslim women seeking abortions, a common occurrence in my practice and no doubt elsewhere, and a situation that needs to be handled delicately due to the highly charged normative views in many communities, not least the muslim. I routinely ask a patient when a pregnancy is announced if it is good news or not, having previously contributed to many women’s awkwardness and embarrassment by assuming the best. If bad I will raise the issue of a termination. Should I alter this routine for my female patients by first enquiring as to their nominal religious belief and possibly contributing to any discomfort and shame? Special affordances for women (Muslim and non) like offering chaperones and a female professional for consultations or intimate examinations are a humane response not a faith based one; they are usually not offered due to a lack of resources and not religious prejudice. Surely we can support and advocate extension of these services without resorting to stereotyping ideas of religion and identity. Yours Competing interests: None declared
Religious intolerance in the West 14 January 2007
Munjed Farid Al Qutob, Dental Surgeon Amman, Jordan, Tela Al Ali, P.O.Box 933, Zip Code (119-53), Amman, Jordan Send response to journal: Re: Religious intolerance in the West	As a Muslim fundamentalist, I found your Journal cover quite offensive. This stands as a brilliant testimony to the persecution and religious intolerance encountered by Muslim communities living in Western Europe. Sadly, since the abhorrent terrorist attacks in the US and Britain, Muslims have been the quintessential victims of discrimination; tarred with the same brush as unrepentant fanatics wedded to violence and criminality. Islam has been painted as vociferously incompatible with Western values. The satirical cartoons lampooning Prophet Muhammad (peace be upon him), and Pope Benedict's comments linking Islam with extremism and terrorism stand as witnesses to the irrational Islamphobia so prevalent in the West. In the light of the unspeakable hardships, threats, hate mail, ethnic slurs, vandalism, and shootings (as in Forest Gate)faced by British Muslims, I cannot see how Aziz Sheikh's argument pertaining to religious affiliation, would help alleviate the above mentioned, and moreover integrate 1.6 million Muslims into society? Competing interests: None declared
Individual Services 14 January 2007
Mishell Sajid, AS Level Student Redland High School BS6 7EF Send response to journal: Re: Individual Services	As far the NHS goes, as i am aware it is a service available for every person and their needs. As i am writing this, it states on the NHS website that one of its core principles is shaping 'its services around the needs and preferances of individual patients, their families and their carers.' From this and what i have experienced and seen, i get the impression that the NHS already aims to try to provide the services that all communities need, the success rate is as ever arguable. I agree that this should be done on a personal basis, by each individual patient having their needs met. As said in the article, it is easy to assume that a muslim would automatically have certain preferances, and although in some cases it would be a good idea to automatically provide these services, in others it would be beneficial for patients to be informed of the services they have on offer withought the assuming that they will definately want to use each one, as everybody has their own preferance. In my opinion (as a student who has an ambition to study Medicine and contribute positively to the health of all people) those who work in Medicine and health care do so because they do really care about each individual patient. The National Health Service was created for everybody, and therefore everybody should be able to recieve the health services they require. If they choose to go private, that should be their decision, they should not have to go private because they have no other alternative. When looking at the UK as a whole there are people of diverse ethnicity and religion each combining ethnic related medical needs with religiously orientated needs, therefore it does seem unnatural to pinpoint one religion as having extra or special needs, instead of creating an almost discriminative situation, it should be looked at positively as the future of medicine in the United Kingdom. Competing interests: None declared
The wrong question 14 January 2007
Joseph P Sweetman, Doctoral Candidate School of Psychology, Cardiff University, Tower Building, Park Place, Cardiff, CF10 3AT Send response to journal: Re: The wrong question	It will be suggested here that Sheikh (2007) is asking the wrong questions and sparking a somewhat irrelevant and circular debate. Furthermore, those that join the debate are attempting to come up with a ‘one-size-fits-all’ answer for a level of problem which can have no absolute answers. Leaving aside these concerns for the moment, at its most basic level the debate is between multiculturalist theory (MT) and liberal egalitarianism. MT can be characterised, broadly speaking, by: (1) its recognition of the equal value of different cultures and (2) the accommodation of minority culture interests, as opposed to the implementation of uniformity. Liberal egalitarianism has its roots in classical liberalism and the enlightenment – the work of von Humbolt, Rousseau and others (see Chomsky, 2005). Essentially, it emphasises the individual's right to freedom from oppression and equality of opportunities. Here state intervention is minimal, not infringing upon human freedom and the limited actions of the state provide resources and opportunities (i.e. education and healthcare) ‘equally’ among all. In a general critique of multiculturalism, Barry (2001) proposes that the idea of ensuring a particular culture’s survival and allocating cultural group- specific rights is fundamentally incompatible with commitments to liberal egalitarianism (for an elaboration of this debate see Kelly, 2002). Both multicultural theory and liberal egalitarianism have some merit and associated dangers; unfortunately, there is not space to cover them here. Those interested in getting a better understanding should see Kelly's 'Multiculturalism reconsidered' – many of the leading theorists contribute to the volume. Pragmatically, suffice it here to say that the balance between group/cultural specific rights and individual equal treatment/opportunities is a matter that needs careful consideration on an individual case by case basis – there are plenty of cases where application of MT seems reasonable and others when it does not. The major concern highlighted here is the situation when multicultural policy is simply taken as an axiom! This is something that seems implicit in Sheikh’s article. To those engaged in the study of power and group-based hierarchy (e.g. Sidanius and Pratto, 1999; Chomsky, 2003), there is always a certain hesitancy to accept, at face value at least, any ideas (e.g. Runnymede Trust, 2004) that are supposedly quickly accepted by powerful institutions and elites. A good case can be made that MT and health policy based on multiculturalism may be taking away from the real issue of group-based (health) inequality, discrimination and oppression. For example, if we give Muslims some non-alcohol gel, but we do nothing about the conditions rightly cited by the author of the article: "Muslims are predominantly congregated in the innercity slums, have the lowest household income, poorest educational attainment, and highest unemployment and experience more poverty than any other faith community." We are faced with a strange – so ‘here's your non-alcohol gel’ situation. There are two problems here 1) is that racist or simply relatively deprived and threatened ‘whites’, who have some justification for their feelings of deprivation (see Hewitt, 2005), focus on Muslims as the target of their deprivation (egged on, in part, by media/government scaremongering). This stops them from realising more causal reasons for their feelings of deprivation (see Philo & Miller, 2001), which in turn means that they are less likely to organise to bring about improvements in their own lives 2) on the behalf of the institutions, this benevolent action of gel provision enables ‘the great and the good’ to think how nice they are to ‘different’ people, and the only debate is as to whether they have gone too far with their gel supplying actions. To people with a rudimentary consideration for logic, power, human rights, egalitarianism or even democracy this is not the debate to be having or the questions to be answering – it is completely removed and oblivious to the fundamental facts underlying poor health in ‘black and minority ethnic’ groups: power and group-based hierarchy (see Sidanius and Pratto, 1999; Ahmad, 1993). Unfortunately, we find ourselves here, sadly, arguing about handwash. It is suggested here that the debate should be about more fundamental issues that are actually at the causal level of the phenomenon we are supposedly addressing: health. But surely this isn’t the responsibility of a health professional? Unfortunately, there is no department of power sharing or ministry for group-based hierarchy. There are, however, plenty of social movements, organisers and collective action to be involved with. The choice is the same for health professional as for others. Ahmad, W. I. U. (1993). Race and Health in Contemporary Britian. Milton Keynes, Open University Press. Barry, B. (2001). Culture and Equality Cambridge, UK: Polity Press. Chomsky, N. (2003). Understanding Power. London: Vintage. Chomsky, N. (2005). Government in the future. New York: Seven Stories Press. Hewitt, R. (2005). White Backlash and the politics of Multiculturalism Cambridge: Cambridge University Press. Kelly, P. (2002). Multiculturalism Reconsidered. Cambridge, UK: Polity Press. Philo, G., & Miller, D. (Eds.). (2001). Market Killing: What the free market does and what social scientists can do about it. London: Longman. Sidanius, J., & Pratto, F. (1999). Social dominance theory: an intergroup theory of social hierarchy and oppression. Cambridge: Cambridge University Press. Runnymede Trust (2004). Realising the vision: Progress and further challenges. The report of the commission on the Future of Multi-ethnic Britain (2000) revisited in 2004, Briefing paper. Competing interests: None declared
Doctors of the future need education and religious awareness to provide good care to all patients. 14 January 2007
Atika Sabharwal, SHO Anaesthetics Hammersmith Hospital W12 0HS Send response to journal: Re: Doctors of the future need education and religious awareness to provide good care to all patients.	Having read both articles I have to say that the topic is very controversial. The NHS whatever deficits it may have has an aim to provide a high standard of healthcare to patients regardless of their status or religious background. If anything your article only highlights the need for doctors to be educated on the needs of different faiths, not just Islam. This should be instituted at medical school and reinforced within each sub speciality especially primary care. Of Hindu descent and practicing medicine for 4 years I have never thought of the spiritual impact of giving Hindu patients gelofusin. Some patients don’t eat eggs, should we be anaesthetising them with propofol (contains egg). Should we be asking each patient about their dietary preferences prior to treating them? Should pharmaceutical companies be responsible for labelling medication, for example does not contain animal products? These are the important questions as doctors we should be asking ourselves. As Britain becomes more cosmopolitan, as professionals it is our responsibility to prevent ‘categorising’ our patients and treat them as individuals. We should be educating ourselves and our patients on how they need to be aware that certain medications may contain products that clash with their spiritual practices as well as tailoring their medication to suit their lifestyle. Medicine is a universal practice and we live and work amongst people of different ethnic backgrounds and I hate to think as some of us strive for integration and tolerance others feel that certain cultures deserve preferential treatment. Competing interests: None declared
Shiekh's political agenda disguised as health 14 January 2007
Ahmad A Bajalan, Consultnat Neurophysiologists Hull Royal Infirmary Send response to journal: Re: Shiekh's political agenda disguised as health	Professor Shiekh claims that there are 1.6 million Moslems in Britain? Where does he get this statestics? Is it built on the assumption that anybody with Quranic name is a Moslem? He asserts that " the 2001 Home Office Citizenship Survey—for example, found that for Muslims religion was a more important marker of identity than ethnicity "? I and I am sure many others who belong to at least by virtue of our "names" and our parents to the Moslem society challenge such a survey and Shiekh's assertion. In my own Kurdish communitty and the middle Eastern communities I am in touch with except for those who support Militant Selafi pan-Islamic mainly terrorist organisations, even those practicing Islam identify themselves by their ethnicity. I suggest despite his protestations that to the native British Islam means Arabs and Asians, it is clear from the health issues he highlights that these are issues of poor Pakistani and Bengali communities, not greatly different from needs of other poor communities. Professor Shiekh needs to be reminded that 9/11 was not "the bombing of New York's twin towers" but a terrorist attack where no bombs where used but Airoplanes full of innocent people. A Freudian slip, Professor Shiekh, surely? Competing interests: None declared
misleading question 15 January 2007
Usama Alkhaddour, ENT Staff Grade Derbyshire Royal Infirmary, Derby, DE1 2QY Send response to journal: Re: misleading question	I come from a muslim background. I have been working in uk for several years, and I follow the medical and non medical media. I must say that I have not learnt, so far, that muslims in this counry demanded a faith based health sevices, as the qustion implies. Any way,I disagree with having a health service for muslims based on their faith unless all other minorities have similar services. Then It is fair enough. I do not think muslims in the UK need special health sevices for them. The health service as it stands is good enough for muslims as for non muslims. However,I can see no harm or extra cost in introducing minor alterations to the current services to accommodate certain beliefs by muslims or others. A good example would be performing the male circumcision in the NHS as a paid for sevice by parents . Competing interests: None declared
Medicine must be secular, not religious 15 January 2007
Edward Haworth, FY2, Paediatrics Lister Hospital, Stevenage SG1 4AB Send response to journal: Re: Medicine must be secular, not religious	The socioeconomic deprivation and health inequalities facing many UK Muslims are not inherently religious in origin. It is hard therefore to see how the concept of 'faith based health services' can help alleviate this burden. Such services indeed may only further isolate people along religious lines. Whilst we all should be aware of a patient’s religious sensitivities and wishes, it is not always possible or even desirable to uphold them. Requests to see a doctor of the same sex are normally followed but may be unworkable at night or during busy periods. Circumcising children for religious reasons is unethical and should be outlawed rather than funded on the NHS, there is no such thing as a Christian or Muslim child, only a child of Christian or Muslim parents. It would be criminal for over- stretched trusts to spend money on religious chaplains or prayer facilities over front line services. One may agree or disagree with Professor Sheikh’s goal of “understanding the importance of religious identity” but it is hard to see why this battle should be fought in the NHS. Competing interests: None declared
Male infant circumcision for non-medical reasons should not be available on the NHS 15 January 2007
Paul A Burgess, General Practitioner Gosport Health Centre PO12 3PN Send response to journal: Re: Male infant circumcision for non-medical reasons should not be available on the NHS	Male infant circumcision is irreversible and contravenes the cornerstone of ethics, namely consent. Infants and boys are unable to give informed consent for this operation. If it is to be done for non-medical reasons it should be done when the young man is old enough to make an informed decision. At that time it is also arguable that like most plastic surgery it should have to be paid for privately. Religions can and must alter their teaching on the age for circumcision to bring it in line with accepted medical ethics and human rights. The latest research that male circumcision reduces the transmision of HIV should not alter this view as the age when young men might start sexual intercourse would likely correlate with the age when informed consent for circumcision could be given. Competing interests: None declared
Towards a more respectful NHS... 15 January 2007
Abdulkareem Carlyle, SPR in Child Psychiatry Huddersfield CAMHS, HD3 3BB Send response to journal: Re: Towards a more respectful NHS...	Prof Sheikh makes a number of very valid points in his article, as indeed does Aneez Esmail. Essentially, however, I cannot help feeling that the very existence of these articles at present are driven more by a wider political agenda than anything else. Muslims, difference, integration, the veil, the politics of fear...all buzzwords in recent years. One needs only to read the responses to see how quickly divisive this issue currently is in our society. Each person has a particular set of views that they quickly 'shape' a position around, and shift the debate from its origins towards a more value-laden, politicized version. Male circumcision is quickly labeled as 'unethical', the basis of multiculturalism is questioned, and a defensive climate is engendered around probing into people's beliefs. These responses are however out of touch with Government policy which remains firmly footed towards meeting the needs of people from 'minority ethnic' groups. As health professionals we are being expected to promote engagement with individuals and families from these varied communities, and to be confident and knowledgable in respecting their beliefs and health needs. It strikes me that there are multiple issues here with no easy answers - I certainly would not promote any 'separate' service for Muslims or any other groups (I'm not sure this is what Prof Sheikh suggests anyway), but there needs to be progress in creating a more 'respectful' NHS. To this end, there must be certain areas of focus. I would suggest these include: 1. Education about identity, culture and faith: this remains very poor in my experience, and is an essential component to improve the situation for all groups, not just muslims. This involve an awareness of the diversity that exists within groups as much as between them. Part of this must seek to engender a reflective and respectful stance towards all patients and colleagues. Racism is not the only problem: as a White Scottish Muslim I have myself experienced prejudice in the NHS several times. 2. Resourcing: as pointed out, with diminishing resources, then it is difficult to always provide an appropriate service to anyone. My view would be that it is choice that is the most important issue of all -and this applies equally to all patients, irrespective of belief or cultural background. Choice, of course, depends in turn on understanding, information and resources. 3. Audit and research: this has increased over recent years, but the data is still lacking to reach firm conclusions. Qualitative studies are an important part of this. Recent literature has also pointed out the shortcoming in using terms such as 'Asian' in conducting research. For example, it may mask underlying differences between Indian Hindus and Muslim Pakistanis. Many studies have illustrated this, and suggested that the world-view is the main issue: not the skin colour, nationality, language or dress. Hence there is a place for acknowledging world-view, whether religious or not. In summary, this debate raises important questions, but in my view questions that are already largely answered by existing policy from government and Royal Colleges. The main issue is whether these are carried out (in a locally appropriate way), and whether professionals, given the responses to this article, have the will to implement them in a respectful fashion. This of course is the real issue in wider society, and, I rather cynically assume, the very reason for the article. The cover picture speaks volumes in this regard. Competing interests: None declared
"Faith" -based hospitals in the United Kingdom 15 January 2007
Dr JK Anand, Retired N/A Send response to journal: Re: "Faith" -based hospitals in the United Kingdom	In the current issue of the BMJ a plea is made by Sheikh for faith- based hospitals for one particular religious sect. There is nothing wrong with the idea. Some readers will recall that in London there used to be the Mildmay Mission Hospital, the London Jewish Hospital, the Hospital of St John and St Elizabeth. These were voluntary hospitals which were then "adopted" by the National Health Service. There was also the Royal Masonic Hospital which remained outside the NHS. In Karachi there is a noted hospital-complex funded by the Aga Khan. In Lahore there is likewise the United Christian Hospital. There were - and probably still are - Christian mission hospitals in Gurdaspur, Ludhiana and Vellore. Karachi and Lahore are in the Islamic Republic of Pakistan. The other three hospitals mentioned above are in the Republic of India. So, let us have the type of hospital sought by Sheikh. But let the funding come exclusively from non-UK Exchequer funds. True, such a hospital will take some load off the already inadequately funded NHS. But, if Sheikh wants Exchequer funds - then there ought to be a referendum on the matter. [I take the same view in respect of funding for schools - regardless of which faith the schools belong to.] Are NHS staff unsympathetic to the needs of a particular religion? Very likeley. They may sometimes be simply ignorant. I tried (14 March 1969, pp 142-3, THE MEDICAL OFFICER) to shed a thin beam of light in the dense dark ignorance, "..... the ignorance of British doctors.....of even the rudiments of the religions practised by vast numbers of immigrants and their progeny." I was wasting my breath, perhaps. JK Anand (A man without a religion) Competing interests: Please see the text below
Mecca on the Exchequer 16 January 2007
Paul W Keeley, Consultant Palliative Physician Glasgow Royal Infirmary, G4 0SF Send response to journal: Re: Mecca on the Exchequer	It is difficult to know where to begin in answering Professor Sheikh’s jaw-dropping proposal and some of the responses to it.[1] In essence Professor Sheikh is seeking religious apartheid in the NHS and I’m not sure what appals me most – the fact that this is being proposed by an academic at a British University or that a previously respectable journal like the BMJ would print it. First a factual point: Islam is NOT the largest single minority religious group – Roman Catholicism is. It is distinct from other Christian denominations in that it is the only religious group with discriminatory legislation on the statutes - the Act of Settlement, 1701. There are suggestions that Professor Sheikh makes which go beyond Islam alone and which are not unreasonable. Jews and Hindus would similarly be less than keen to have products derived from pork – devout Hindus might furthermore be less than keen to have any animal-derived product for consumption or injection. Likewise Roman Catholics and other Christians might have objections to technologies or medicines derived from research on embryos. The BMJ seems to have fallen prey to the metropolitan fallacy of equating the demands of political Islam as exemplified by the Muslim Council of Britain (for which Prof Sheikh has undertaken work) and the proper respect that should be accorded to Muslims and people of any or no religion. Most obvious have been the previous puff-pieces on Islam: one extolling the virtues of Islamic medicine, another on the Hajj. [2],[3]As for the contribution of medieval Islam to modern medicine I leave the medical historians to fight that battle out. My one observation would be that in modern times the stampede to gain medical education seems to be one-way traffic. As to the piece on the Hajj – I’ve searched the BMJ for pieces on pilgrimages to Lourdes and the Kumbh Mela and they are strangely absent. More Britons, I would venture are likely to travel to Lourdes each year than to Mecca (roughly four million Catholics make their way there each Summer – roughly equal to the figure for Mecca). Certainly the four- yearly Kumbh Mela, with an estimated 60 million pilgrims dwarfs both.[4] If I were a Hindu I might be aggrieved. Munjed Farid Al Qutob’s response warrants particular attention. At least he labels himself a fundamentalist so we know where we stand. His comments beggar belief: the practice of Islam is open to anyone in the UK – would that such religious freedom were available in some Islamic countries.[5] Anyone may convert to Islam in this country – sometimes with disastrous consequences.[6].On the subject of the Hajj, it might be interesting to observe such a phenomenon first hand. But, wait a minute, no I can’t - as a non-Muslim, I may not even enter its environs: that's apartheid. Mr Qutob raises the slur of racism. Racism is levelled against Asians in this country – it is to be deplored and opposed. But Islam is not a race – it is a creed and it is as ethnically diverse as Christianity: it has Nordic Swedes and black Africans, ethnic Chinese and Arabs among its adherents. In Sikhism and Judaism one may talk of race, but not with Islam. To conflate Islam and race is obfuscation - and one would expect better of an educated man in Mr Qutob’s case and certainly a university teacher in Prof Sheikh’s case. Mr Qutob also includes an unwarranted attack on Pope Benedict XVI (pbuh). The Pontiff quoted a c15 Byzantine emperor to the effect that Islam in its political expression had violent tendencies [7]: riots broke out in predominantly Islamic countries. A nun was shot dead in Somalia.[8] QED. I really feel for my Muslim colleagues who are, to a man and a woman, personable, devoted, dutiful, hard-working professionals, who go about their jobs and lives peacefully. They suffer abuse because of the political aspirations and actions of political Islamists. They suffer discrimation because their name looks Islamic when they travel through passport control because of those who carry out acts of terror in the name of a caliphate. But I for one oppose Prof Sheikh’s proposed apartheid. “Rome on the Rates” used to be the complaint of Scots Protestants to popery. This looks like “Mecca on the Exchequer”. So just for the record, as a non-Muslim, lan astaslem - I will not submit . At least in the UK I free to say this. For how much longer, I do not know. As for the BMJ it is fast becoming a joke. I can just imagine the editorial meeting that led to this piece: “Let’s do something edgy about Islam – and put a provocative image of a woman in a niqab on the cover”. Pathetic - truly sixth-form thinking. Were it not for the fact that my copy comes with membership of my trade union, I would cancel my subscription. You are losing all claim to being a serious medical journal. [1]Sheikh A Should Muslims have faith based health services? BMJ 2007;334:74 (13 January), doi:10.1136/bmj.39072.347720.68 [2]Majeed A How Islam changed medicine BMJ, Dec 2005; 331: 1486 - 1487 ; doi:10.1136/bmj.331.7531.1486 [3] Gatrad AR Sheikh A Hajj: journey of a lifetime. BMJ, Jan 2005; 330: 133 - 137 ; doi:10.1136/bmj.330.7483.133 [4]http://news.bbc.co.uk/1/hi/world/south_asia/1106514.stm [5] Afghan convert 'was ready to die' http://news.bbc.co.uk/1/hi/world/south_asia/4852426.stm [6]Terror plotter sentenced to life. Daily Telegraph 8th November 2006. http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/11/07/ubarot107.xml [7]Lecture of the Holy Father Aula Magna of the University of Regensburg Tuesday, 12 September 2006 http://www.vatican.va/holy_father/benedict_xvi/speeches/2006/september/documents/hf_ben -xvi_spe_20060912_university-regensburg_en.html [8]Nun shot dead as Pope fails to calm militant Muslims. The Times 18th September 2006. http://www.timesonline.co.uk/article/0,,13509- 2362945,00.html Competing interests: None declared
Consider Other Faiths 16 January 2007
Anoushka C Chelvendra, Senior House Officer in Medicine University Hospital of Coventry & Warwickshire CV2 2DX, Shyamali Griffiths and Nij Bhala Send response to journal: Re: Consider Other Faiths	We have read with interest the debate regarding healthcare provision for the faith-based services in the United Kingdom. Although Muslims constitute a significant proportion of the British population, we would like to highlight the healthcare requirements of other faith communities. In the 2001 Census, 1% of citizens registered themselves as Hindu, 0.6% as Sikh, 0.5% as Jewish and 0.3% as Buddhist (1). We accept that there may be a need for specific initiatives for ethnic minorities, as they have distinct healthcare problems. This is eloquently demonstrated by a three to five-fold increased cardiovascular risk in South Asians (2). As well as possible pathophysiological mechanisms, there are undoubtedly differences in healthseeking behaviours and access. However, it would not be appropriate to consider these individuals as one homogenous group. For example, risk of coronary heart disease is not uniform among South Asians, differing according to nationality (3). Many of these underlying differences can be related to cultural differences, such as alcohol intake in non-Muslim faiths (4). As Aziz Sheikh rightly points out, faith-based differences are not known, and we undoubtedly need further research in this area. We feel both education and resource allocation in this field are of paramount importance. The focus should be on educating healthcare professionals about religious diversity, health-seeking behaviours and the possible requirements of different faiths. References 1.National Statistics-www.statistics.gov.uk/cci/nugget.asp?id=954 2.Gupta M, Singh N, Verma S. South Asians and cardiovascular risk: what clinicians should know. Circulation. 2006 Jun 27;113(25):e924-9. 3.Bhopal R, Unwin N, White M, et al. Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study. BMJ. 1999 Jul 24;319(7204):215- 20. 4.Douds AC, Cox MA, Iqbal TH, Cooper BT. Ethnic differences in cirrhosis of the liver in a British city: alcoholic cirrhosis in South Asian men. Alcohol Alcohol. 2003 Mar-Apr;38(2):148-50. Competing interests: NB is a Trustee of the South Asian Health Foundation, a non-profit medical research charity looking at ethnic minority differences.
Faith Based Heath Services-The Title & the Front Page Picture! 16 January 2007
Syed Kazmi, Surgeon Ninewells Hospital Dundee, DD2 4TN Send response to journal: Re: Faith Based Heath Services-The Title & the Front Page Picture!	I and many of my doctor friends, I spoke to, found the title picture of veiled woman on the BMJ of 13 January 2007 very offensive. Does this mean that BMJ has also joined the band wagon of 'sensationalism' and Muslim bashing (order of the day)? It was really not necessary to use such a picture and instead some other type of non-provocative picture could be used. Or was it also aimed to add and promote the stereotype against Muslims in this day and age? After all how many Muslims use veil in the world and for that matter in the UK. A large percentage of Muslim women does not wear and doesn't even approve it. How many female Muslim doctors and other worker in the health and other services and even patients here use a veil that it was necessary to show a veiled woman to represent Muslims. It seems that BMJ has also joined the same group as ‘The tabloids and other propaganda machinery who single out Muslims by placing stereotypical, stigmatic and offensive pictures on the front pages and news headlines to show or at least try to prove that Muslims are backward. Do not forget that many leaders in the Muslim world are and have been women and they do not wear veils. I think there was no need to title this article specifying Muslims in the UK. It could discuss all the ethnic minorities and religions in general. I feel that we do respect all faiths and beliefs while treating our patients. We do care for Catholics when discussing their view on family planning, we do care for Jehovah’s Witnesses when considering blood and its products and also we do respect the rights of Hindus that they will prefer non-animal origin food and medicines. We also respect the views and beliefs of Jews when it comes to providing kosher food. Then why was there a specific need for this article singling out Muslims? There was no need to stir up another debate about Muslims. It could simply be a debate considering all religions and faiths as I mentioned above. Whatever the two authors have mentioned does not all specifically apply to Muslims, it also applies to all the ethnic and religious minorities in the UK and elsewhere. I am sure that they would not even be aware that such a picture would be used to highlight their articles in this issue. We expect BMJ to be very much above all the bias as it represents medical professionals with so many different faiths and beliefs. Hope the BMJ will rise above all this and show itself to be neutral and non-biased professional medical journal with no political aims. Leave anti-Muslim propaganda to the media and tabloids please. Competing interests: None declared
Viewing from America 16 January 2007
A.A.W. Amarasinghe,MD,, Consultant Psychiatrist 102 Bayberry Hills, McDonough, Georgia 30253 USA Send response to journal: Re: Viewing from America	In the dual presentations on the same subject (" ... faith based health services " ) and the ensuing responses, I witnessed meetings of many minds - those of physicians, non-physician professionals, erudites and self labelled not-so-erudites. Each of them expressed own thoughts and feelings with utmost gravitas. They held me spellbound as did in the bygone days by Dr.Ridgeon, Mr. Micawber, the Jiggses and Mrs. Hyacinth Buckett ( pronounced Bookay ). Certainly, this issue of hallowed British Journal of Medicine was fun to read. ' got two for the price of one ! Competing interests: None declared
'Good Medical Practice' and good common sense 16 January 2007
Faizal Moosa, Staff Grade Child and Adolescent Psychiatrist Birmingham CAMHS, Hunters Road, Birmingham, B19 1DR Send response to journal: Re: 'Good Medical Practice' and good common sense	Congratulations to one and all, for bringing to light, once again, the health inequalities that exist, both for patients and healthcare professionals, within the United Kingdom. In so doing, highlighting the factors that may be contributing towards this and the need for this aspect to be addressed at various levels in the healthcare hierarchy. The BMJ and its contributors have raised important issues pertaining to the current world climate and political agenda - the need for respect, tolerance, preservation and sanctity of human life, as well as, the awareness, understanding, recognition and addressing of the needs of all individuals we serve as healthcare professionals. However, in so doing and in the sensationalist manner in which it has been done, they have opened the doors to literary prowess and skilful debate, nil else. The question to ask is: What will be achieved at the end of the day? Will it be that the needs of all communities we serve will be addressed in a collective, co-ordinated, concerted and meaningful way, OR, that some of us will speak out, on behalf of others in a representative capacity without necessarily consulting with them or with their healthcare providers? If it is the former, then, perhaps, it might be more prudent to start at a local strategic level. If the latter, then, perhaps, it might be worthwhile to consider this: one should command respect, not demand it, as 'Good Medical Practice' (GMC, 2006) and good common sense will tell us! Recent changes with regards to Multifaith rooms and provision of halal and kosher food for patients shows the committment of the NHS to provide facilities for faith groups and should be welcomed. Certain practices of faith like prayers, fasting, halal food and circumcision are some tenets of the Islamic faith that needs to be respected by the wider society, similarly as Christmas, Lent, Easter, Diwali etc., are respected. Competing interests: Member and presently, General Secretary,of the Muslim Doctors and Dentists Association MDDA)UK.
Education is the key 16 January 2007
Ghaleb W El-Farouki, Senior House Officer St George's Hospital, London SW17 Send response to journal: Re: Education is the key	Thanks to Sheikh and Esmail for articulating two different views in an equally-convinsing manner; perhaps the answer lies somewhere in-between (1). Though I agree that identity does not solely depend on religious belief and that, consequently and additionally, those affiliated with a single religion do not all live their lives in the same way, there remain issues that are more relevant to certain religious groups than others. In a diverse and tolerant society, we must aim to respect and accommodate all groups of people where that does not infringe on the rights of any other group. Whether or not we end up having special services for this or other religious groups, there are more basic ways in which their concerns can be effectively addressed. A simple and cost-effective start would be to incorporate issues that are sensitive and special to Muslims in teaching delivered at medical and nursing schools. The Official 2005 Report of Jehovah’s Witnesses (JW’s) Worldwide listed the total number of JW’s at the time in Britain at around 127,000 ; in other words, a medium to small minority (2). Yet, you would be hard-pressed to find a medical trainee in this country who does not appreciate the attitude of Jehovah’s Witnesses to receiving blood products, the professional dilemmas that ensue and the ways in which these can be managed. The reason is that this topic periodically features in lectures and tutorials, especially as it encapsulates some basic tenets of medical ethics, such as autonomy, benevolence and the concept of following the patient’s best interests. On the other hand, knowledge about Muslim issues and those of other more sizeable religious minorities is still lacking. If we are to truly follow a patient-centred approach, we should be aware of religious differences especially where these affect our work. Only when we acknowledge and respect everyone’s beliefs can we say that we treat all our patients equally. 1) Sheikh A, Esmail A. Should Muslims have faith based health services? BMJ 2007; 334: 74-5.(13 January.) 2) 2005 Report of Jehovah’s Witnesses Worldwide, from the Website of the Watch Tower Bible and Tract Society of Pennsylvania, 2006 (http://www.watchtower.org/statistics/worldwide_report.htm). Competing interests: None declared
Re: "Faith" -based hospitals in the United Kingdom 16 January 2007
Sankar K. Das, Consultant Geriatrician (retd) St. Helier and St. George's Hospital SW17 0QT, Dr. M.S. Kataria Send response to journal: Re: Re: "Faith" -based hospitals in the United Kingdom	Sir, The current British system of health care came into force in 1948. The origin of this novel idea of free health care was introduced to the British Parliament by Mr Aneurin Bevan in 1946/48, as a Labour Party member. His main idea for the NHS was to provide a medical service financed chiefly by taxation, where every individual citizen of Great Britain, of all ages, would be looked after uniformly by the State, irrespective of colour, creed and financial situation. Unfortunately, Professor Sheikh’s theory of Faith specific health care in NHS hospitals is beyond all imagination. What I gather from the article, the main theme is based on religious grounds rather than on the basis of illness. Furthermore, it may be noted that increasing cases of in -born errors of metabolic disease and genetically based problems are emerging in all communities, including Islam. Such long-term medical problems are cared for best within the community as primary care, instead of in NHS hospitals. In my 30 years experience as a Consultant Specialist of Geriatrics around the world, I have only come across one hospital that specially catered for faith related issues, either in the UK or any other country. This exception was in the USA, where some Jewish homes cater for elderly Jewish patients who require long-term management only. These hospitals were managed by private, blue shield companies and not by the taxpayers of America. In my opinion, faith specific health care is not a right, but a choice. If required, it should be managed exclusively by the private sector and should only be paid for by those that wish to use it. The needs of a minority of community members should not be allowed to burden the already strained services of the NHS and the taxpayers of the UK, especially for a service that most will never use! Competing interests: None declared
Faith based services may be helpful 17 January 2007
Ahmed Mohammed Iqbal, Medical Student City Hospitals Sunderland, SR4 7TP Send response to journal: Re: Faith based services may be helpful	Dear Editor, I read with considerable interest articles by both Professor Sheik and Professor Esmail BMJ Jan 2007. I am in agreement with Professor Sheikh in that Muslims or members of any other religion for that matter may attribute a significant proportion of their personal identity to the religion they practice. As highlighted by Professor Esmail however, it is difficult to define who exactly a Muslim is given the heterogeneity of the British Muslim population and in light of other factors namely; gender, religious sect, ethnic origin, social class and level of faith which may also play a role in defining ones personal and religious identity. Nevertheless, Muslims are a sizeable ethnic minority and Islam is a complete way of life for possibly a significant number of these individuals. It follows then, in order to provide holistic care, the NHS ought to take into account and cater for the distinct needs of its Muslim patients should they wish for such care. This is only possible through appropriate allocation of funds for such services. An example would be a well regulated male infant circumcision service. Clearly, such faith based services should not only be limited to Muslims and other faiths require due representation based on demand for a particular service. Very much on the contrary to Professor Esmail I would like to argue that failure to recognize and respond to faith based health care needs marginalizes and to a certain extent stigmatises religious groups there by exacerbating pre- existing health inequalities. This inevitably may be to the detriment of society as a whole as a neglected and uncared for community is unlikely to contribute positively. Competing interests: None declared
Individualized Medicine 17 January 2007
Adrian Mondry, Locum Consultant in General Medicine Horton General Hospital, Banbury OX16 9AL Send response to journal: Re: Individualized Medicine	Sir, An individual’s decision to identify with a social peer group does not alter the fact that all humans share the same basic physiology, and that physiological variations are based on material rather than spiritual differences. Health outcomes are influenced both by ethnicity and social standing, and genes and environment interact in complex ways [1]. “Ethnicity” is a medically more relevant fact to individualize hard, evidence based medicine than faith [2]. “Ethnicity”, however, is notoriously hard to define [3], and population subgroups of the same “ethnicity” may show quite distinct gene polymorphisms [4, 5], leading to distinct health risks and, possibly, distinct needs for therapy. Thus, “hard science” rules out the need for specific, faith based health care. What about sociology, often thought of as a “soft science”? Again, we see that much less than by faith, health is influenced by an individual’s social standing, and access to health services [1]. There is a large body of evidence that shows disparities in chronic diseases within predominantly Muslim communities in Northern Africa and the Arabic peninsula [6- 9]. As such, it is not obvious at all that a faith based health service will do anything to improve public health in Britain. Lastly, as an active medical professional within the NHS, I find that the number of Health professionals of Muslim faith is quite considerable. At the time of writing, 2/4 physicians in my firm are, at least nominally, of Muslim faith. Maybe I’m too naďve, but doesn’t this bode well for those of our patients who expect cultural sensitivity? [1] Ramirez S. Race and Kidney Disease Outcomes: Genes or Environment? J Am Soc Nephrol 16: 3461-3463, 2005 [2] Spielman RS, Bastone LA, Burdick JT, Morley M, Ewens WJ, Cheung VG. Common genetic variants account for differences in gene expression among ethnic groups. Nat Genet. 2007 Jan 7; [Epub ahead of print] [3] Bloche MG. Race-based therapeutics. N Engl J Med 2004, 351:2035- 2037. [4] Mondry A, Loh M, Liu P, Zhu AL, Nagel M. Polymorphisms of the insertion / deletion ACE and M235T AGT genes and hypertension: surprising new findings and meta-analysis of data. BMC Nephrology 2005, 6:1 [5] Splawski I, Timothy KW, Tateyama M, Clancy CE, Malhotra A, Beggs AH, Cappuccio FP, Sagnella GA, Kass RS, Keating MT. Variant of SCN5A sodium channel implicated in risk of cardiac arrhythmia. Science. 2002 Aug 23;297(5585):1333-6. [6] Ibrahim M. Epidemiology of hypertension in Egypt. Saudi J Kidney Dis. Transplant. 1999;10(3):352-6. [7] Jaddou HY, Bateiha AM, AI-Khateeb MS, Ajlouni KM. Epidemiology and management of hypertension among Bedouins in Northern Jordan. Saudi Med J 2003;24(5):472-6. [8] Zubaid M, Suresh CG, Thalib L, Rashed W. Differential distribution of risk factors and outcome of acute coronary syndrome in Kuwait: three years' experience. Med Princ Pract 2004;13(2):63-8. [9] Hasab AA, Jaffer A, Hallaj Z. Blood pressure patterns among the Omani population. Eastern Mediterranean Health Journal. 1999;5(1):46-54. Competing interests: None declared
Poor health not related to religious faith 18 January 2007
Michael Crawford, Consultant Anaesthetist Hairmyres Hospital, East Kilbride, G75 8RG Send response to journal: Re: Poor health not related to religious faith	Aziz Sheikh argues that because many Muslims inhabit inner city areas, have low income and poor health, there should be faith based health systems in place for them. This argument has no merit, unless it is the faith which is causing the ill-health. In Glasgow like most British cities , over the course of the last 150 years there have been immigration waves involving Irish , Italians, Poles, Lithuanians, displaced Jews, Pakistanis and more recently Poles. Mainly they have come and worked and lived initially in the inner city areas. Suffering ill-health as a result of poverty and deprivation did not result in specific health services for these individuals, but improvements in the health service in general, in education and social interventions, along with the work ethic of the immigrants produced positive results in their health and economic status Measures such as this suggestion would only lead to further division in society and increased isolation for Muslims. Competing interests: None declared
"Et tu BMJ" 18 January 2007
Adedeji T Odelola, Consultant Psychiatrist Birch Hill Hospital, Rochdale OL12 9QB Send response to journal: Re: "Et tu BMJ"	“Et tu BMJ” It doesn't matter whether or not muslims have faith based services. The issue here appears to be one of yet another attempt to mischievously start a "debate" designed to place the spotlight on muslims unnecessarily. One can't help but be reminded of the recent attempt by Jack Straw to pick on muslims wearing the veil, disguised as an invitation to debate. It would be easy to understand concerns about the BMJ’s complicity in a thinly "veiled" agenda of racism and religious discrimination. In 1999, the Psychiatric Bulletin started a similar "debate" with an article on Roast Breadfruit psychosis- a Jamaican cultural phenomenon which refers to the adoption by black people of white values. I expressed the view then that the "Bulletin's" so-called focus on this issue, in the wake of the then report on the murder of Stephen Lawrence, reflected the journal's own prejudice and was bound to cause offence. There similarly does not seem to be any important purpose that the current articles serve. Both authors in the BMJ “head- to- head” debate make roughly the same points about configuring services where possible to take account of the needs and sensitivities of muslims. It appears that by deliberately encouraging discussion about services exclusively for muslim people, what the BMJ has done is to hold up muslim people as needing to be separate, leaving them open to being talked about, and inevitably verbally denigrated. It was immediately provocative that the cover of the January issue of the BMJ bore the picture of a muslim woman wearing the veil. The question needs to be asked- why wasn't an image of a muslim man or mosque used if it had been necessary to refer to muslims? and why couldn't the headline have read: Should Sikh people have faith based services? In the current post "9/11" climate, there is already enough negative focus on the muslim faith. Doctors from minority ethnic groups are currently battling against harsh discriminatory initiatives such as the recent abrupt "changes to the immigration rules for postgraduate doctors", and the current intense anxieties about competition for limited places arising from the slip-shod “modernisation of medical careers” process. These are both issues that certainly cry out for the BMJ’s active engagement. It is unfortunate that the BMJ has chosen rather to risk causing offence to a section of its’ readership. References Esmail, A., Sheikh, A. (2006), Head to Head: Should muslims have faith based services. British Medical Journal, 334, 74-75. Hickling, F.W. and Hutchinson, G. (1999), Roast Breadfruit Psychosis: disturbed racial identification in African-Caribbeans, Psychiatric Bulletin, 23, 132-134. Maharajh, H.D. (2000), Afro-Saxon psychosis or cultural schizophrenia in African-Caribbeans, Psychiatric Bulletin, 24, 96-97. Competing interests: None declared
Use faith, but not necessarily faith-based 18 January 2007
M Justin S Zaman, Clinical Research Fellow /Honorary Specialist Registrar in Cardiology/Trustee University College London/Newham University Hospital/South Asian Health Foundation Send response to journal: Re: Use faith, but not necessarily faith-based	As part of my work as a trustee for the charity South Asian Health Foundation, I host regular meetings in community centres, mosques and temples to answer any questions and also to educate communities about heart disease. Using faith to advocate health can help communities such as South Asians to overcome their higher disease risk from conditions such as coronary disease and improve their (often-lower) knowledge levels about its causes. Using the fact that the Quran has for instance many references to 'healthy' food (and less on 'halal' surprisingly despite its publicity) and not over-eating helped me greatly in my talk last week at a mosque in Newham. This advice I believe is culturally more appropriate than advising them to join a gym. This can work for many cultural groups. An evangelical church in the area uses its distinct form of worship to advocate health. We as doctors in clinic often tailor our consultations with the patient (perhaps sub- consciously)according to their social class, ethnic background, age, gender.. As long as we are aware how we can use a patient's background in a sensitive and positive way to improve their health, we can provide an individualistic service to that patient. It is however difficult for doctors to be aware of everyone's cultural background - I had little awareness on evangelical worship for instance. However, opportunities do exist within ethnic, religious and cultural settings to improve health, without the need to necessarily set up new services. In this way, the community/faith/ethnic group is in control of their own health. By undertaking specific health promotion within specific environments where members of that specific group choose to go, we as doctors go to our patients, not vice versa. This helps to prevent stereotyping - as not everyone who is labelled a Muslim in hospital necessarily has the same degree of belief. Ben Hart’s point is particularly valid here. Most NHS professionals I think are aware that patients are individuals, and respect cultural and religious viewpoints, and perhaps we could all be educated better on how we can use a patient's faith to improve our consultation. However, by setting up faith-based services, we have to consider whether we are ignoring others that are not from that faith, and how - logistically - we can provide 'bespoke' services. Competing interests: None declared
What role has faith in Medicine? 24 January 2007
Somasundari Gopalakrishnan, Honorary Research associate, Dept of Public Health and Epidemiology University of Birmingham, B15 2TT Send response to journal: Re: What role has faith in Medicine?	When I studied Medicine, I was proud and able to save, protect and prolong the life of many individuals. Medical professionals have the unique opportunity to deliver such health care to those who need it. I am intrigued and puzzled, why people are talking about faith based health services? Isn’t it better to discuss and find novel ways of improving the health service to all the citizens of the country? If people from different faiths demand treatment choices based on their beliefs and cultural preferences, can the National Health Service cope? If male circumcision should be available throughout the NHS, the Hindu community can demand ear piercing for their children to be done in the NHS, and so can people from different faiths can demand treatment based on their faiths. We cannot compartmentalize health care based on certain faith group beliefs. We need to plan and commission health service that takes care of people irrespective of race, ethnicity, religion or their socio-economic status. Individuals can use the private sector for their own personal health needs. It is unfair to use the NHS for such faith based treatment choices. My argument is that we need to take care of people’s demands, (i.e., if a female patient wants to be seen by a female doctor, it has to be respected, be it a female Muslim, Hindu, or Jew). We cannot stereotype the patient’s wishes! Let us focus on providing a culturally sensitive and at the same time a competent health service to meet the needs of the diverse population within the country. Competing interests: None declared
Should Muslims have faith based health services 24 January 2007
andrew peacock, Consultant Physician and Professor in Medicine Western Infirmary G11 6NT Send response to journal: Re: Should Muslims have faith based health services	Dear Sir Should Muslims have faith based health services? I read with increasing concern the contribution from Aziz Sheikh advocating special treatment for Muslims within the health service. Being married to a Muslim and having many Muslims as friends (including Aziz Sheikh) I am anxious that this concept of singling out a ‘faith based’ group for special treatment may lead to resentment towards Muslims by non Muslims within our community. While I share with many Muslims the feeling that the West, and in particular the USA and Britain, are antipathetic towards Islam, the way forward is not to further isolate Islam by turning what is an ethnic issue into a religious one. Muslims are a ‘faith community’ but only in the sense that they attend the mosque and take as their foundation the writings of the Qur’an. Traditionally, in Britain, Muslims have been known by their country of origin whether it be Bangladesh, India, Iran, Iraq, Saudi Arabia or Palestine rather than their religion. All these groups should be integrated into British society and that integration should include a sensitivity to their religion but there is absolutely no doubt that all in the NHS - the medical profession, the nursing profession and the paramedics sign up to the core belief of equitable care for everyone irrespective of faith or ethnic origin . This does not mean special care for any particular faith group although the system must be sensitive to particular needs. Clearly the issues of early burial following death, the avoidance of pork products in medicines, the availability of a place to pray in hospital are necess