Saudi Arabia Use of Emergency Response

¶ … Hajj is the largest gathering in the world, attracting millions of Muslims each year. As the Muslim community worldwide grows to well over one billion, the number of pilgrims to Makkah (which is sometimes spelled Mecca) also grows The sheer numbers of people itself presents challenges for EMS staff. The population of Makkah province is currently seven million people, which increases during hajj (Arab News, 2012). In 2012, there were more than 3.5 million men and women in attendance but those numbers are expected to climb to as many as ten million by the year 2020 (D'Alessandro, Edd & Al Mubarek, 2013). The mass gathering presents a number of concerns for EMS professionals, from acute injuries related to crowd swells to the spread of infectious diseases to cardiac arrests. Effective communication is critical for the success of all EMS efforts at the annual Hajj pilgrimage.

As the number of pilgrims increase each year, and as the local infrastructure shifts in response to those increases, EMS professionals face ongoing challenges related to communication. These challenges can be loosely grouped into five categories including language and cultural barriers, inter-agency communication constraints, intra-agency communication constraints, technology challenges, and also challenges related to public relations, public education, and the media. Each of these individual challenges presents particular opportunities for the EMS community, for primary stakeholders in Saudi Arabia, and for all participating organizations around the world. Although some of the communication-related problems seem overwhelming in light of the sheer number of participants in the Hajj or due to the involvement of multiple organizations and government agencies, such challenges can be overcome effectively through concerted, collaborative effort and cooperation. This project will explain the specific communications challenges faced by EMS professionals and EMS leaders and then provide a set of cohesive evidence-based solutions.

Research Question

What are the communication challenges faced by the Saudi Emergency Medical services during Al hajj season in Makkah city and in what way can the problems be solved?

Background and Literature Review

For fourteen centuries, religious pilgrims have visited Makkah and Madinah in what is now the Kingdom of Saudi Arabia to "preform rituals based on those conducted by the Prophet Muhammad during his last visit to the city," (Royal Embassy of Saudi Arabia, Washington DC, 2016). Every year for five days during the month of Dhu al-Hijja, Muslims from around the world make the pilgrimage to Makkah to fulfill a religious obligation that is one of the essential five pillars of Islam. The tradition extends to the time of Ishmael, son of Abraham (Ibrahim), who built a monument at a spring known as the Kaaba (Fetini, 2009). That same site has been a place of pilgrimage for more than 2000 years, but since the Prophet Muhammad first led a group of pilgrims there in the year 630 CE, the Kaaba has become central to the Muslim faith. Now, the Kaaba is marked by an enormous black cube that Muslims believe to be the "center of the world," and which is literally in the center of a vast mosque complex Masjid al-Haram (Fetini, 2009). When pilgrims visit Makkah and enter the mosque complex, they will circle the Kaaba cube seven times in a counter-clockwise direction, a ritual that serves several spiritual functions including forgiveness, guaranteeing a "place in heaven," and also the fulfillment of a duty considered essential to the practice of Islam (Fetini, 2009). All persons fit of mind and body are considered obligated to perform the hajj at least once in their lifetime. In addition to encircling the Kaaba in Makkah, the pilgrim also visits Arafat, Mina, and Muzdalifah, all holy sites that are part of the overall Hajj pilgrimage. A large number of the pilgrims also journey to Madina, the site of the tomb of Muhammad. The movement of people between and within these sacred sites creates tremendous crowd-related risks, particularly considering that now more than two million people per year are completing the Hajj (Fetini, 2009).

Dhu al-Hijja is the last month of the Muslim lunar calendar year and considered the time when "God's spirit is closest to earth," (Fetini, 2009). Unfortunately for many pilgrims, the hajj might also be their last month on earth. During last year's (2015) hajj event, well over two thousand pilgrims died in a stampede ("Saudi Arabia Hajj disaster death toll rises," 2015). Mismanagement of the event and its crowds has been partially blamed for the recurring events, as each year people die and several years have witnessed death tolls in the hundreds or thousands ("Timeline of tragedies during hajj pilgrimage in Mecca," 2015). Save for completely redesigning the site or staggering visits, crowd management and disaster management need to be improved using evidence-based practice. Communication is one of the most important areas that can be improved, in order to minimize risks and improve the efficacy of emergency response services.

For eight consecutive years from 2006 to 2015, no major disaster occurred at the Hajj. What was done differently, if anything, during those eight years? If the management of the event was somehow different, authorities need to know about how to best prevent the problems from occurring again. One of the things that Saudi disaster planners can do is use mathematical modeling to ascertain crowd movements and determine risks (Benedictus, 2015). Hajj naturally presents the most severe risk due to crowd density more than six people per square meter, a density in which "bodies are jammed together so tightly that they can no longer choose where they go and they begin to behave like a fluid," (Benedictus, 2015). Prior disasters at the Hajj have often been related to crowd stampedes and the crushing of people. However, ancillary disasters like hotels collapsing, being hit by stones during the symbolic stoning of the devil in 2003, a tent fire in 1997, and terrorist-type attacks have also occurred such as in 1979 when "hundreds of gunmen opposed to the Saudi government barricaded themselves inside the Grand Mosque," taking many pilgrims hostage and leading to hundreds of deaths and injuries ("Timeline of Tragedies during Hajj Pilgrimage in Mecca," 2015).

The hajj is certainly not the only mass event during which stampedes and other disasters have occurred. As Benedictus (2015) points out, crush incidents in which more than ten people die as a result of being trampled during a stampede at a mass event occur once every four months somewhere around the world. Yet much can be done to improve communications and reduce both injuries and fatalities at this holy event.

Conceptual Model

The conceptual model for improving EMS communications during hajj will respond to each of the five concerns outlined in this report including language and cultural competencies, inter-agency communications, intra-agency communications, technologies, and public relations. Improving EMS will involve an interrelated and interdependent network of communications, in which technology is used to facilitate interactions between all stakeholders. Multiple agencies involved in EMS delivery will respond to protocol related to their areas of specialization to minimize problems related to bureaucratic organizational structures. The media and social media will help by facilitating communication with the public and providing educational services that aid in preventing problems before they occur.

A conceptual model also illustrates the organic flow of information and communication between the various parties involved. However, the model must remain flexible as each year at hajj unique situational variables will present themselves. Variable weather, changes to the local infrastructure, increasing numbers of pilgrims in attendance, shifting demographics of the attendees, and infectious disease development will all ensure that EMS personnel need to be flexible and responsive rather than rigid in their approach to communication.

Conceptual Models

This model illustrates how communications systems work to improve safety at the Hajj. The model shows how the five key components to communications strategies all work together as independent variables: from improving staff knowledge of language to communication technology to public relations, intra-agency communications, and inter-agency communications. When each of these variables working properly, they can impact dependent variables including quantitatively measured safety improvements (such as reduced loss of life or reduced numbers of injuries), improvements to the language and cultural competencies, and to technological literacy across all agencies.

Language and Cultural Challenges

The majority of pilgrims to Makkah are not from Saudi Arabia, but from almost 180 other countries (Memish, 2013). The diversity of the Muslim community is one of its core features. The annual pilgrimage is "the most internationally, ethnically, demographically and clinically diverse assembly today," and likely in the history of humanity (Memish, 2013). To support the needs of this diverse body of pilgrims, EMS and their ancillary organizations need to pay close attention to how to best communicate across linguistic and cultural boundaries. Even in multicultural environments, EMS responses may be delayed due to language barriers (Grow,, Sztajnkrycer & Moore, 2007). Oliviera (2013) points out that crisis management frameworks frequently lack cultural competency standards, and that increasing cultural competence requires simple training interventions that can vastly improve service delivery. Language barriers are only a few of the many potential obstacles to effective EMS delivery of care and services. Perceptions of health care, views on health and wellness, and attitudes toward rules, regulations, and authority will all vary from culture to culture and person to person. Therefore, EMS organizers and leaders need to develop effective methods of minimizing confusion and maximizing the clarity of all services provided, within a culturally competent framework.

Some of the language barriers have already been resolved by "custom-designed picture books ... used to help pilgrims communicate condition, location, and severity of an illness or injury," (D'Alessandro, Edd & Al Mubarak, 2013, p. 56). Signs and all other related material can help pilgrims prevent injuries and accidents before they occur. Cultural barriers to communication may be even more pressing than language barriers. Problems such as refusing treatment, not trusting the doctors, preferring the use of traditional healers, wanting the input of family members will all inhibit the actions of EMS personnel wishing to respect the cultural norms and values of the people they treat while still delivering immediate and effective medical treatments and interventions. Similarly, body language and especially body contact between male and female may be problematic for some devout pilgrims with cultural norms related to cross-gender touching (Dees, 2007).

Inter-Agency Communication

Emergency responders in Saudi Arabia do not operate under one umbrella. Rather, EMS personnel may fall under the auspices of several different agencies including the Minister of the Interior (which is uniquely responsible for most overall Hajj operations), the Ministry of Hajj Affairs, the Civil Defense Department, the National Police Department, the Saudi Red Crescent Authority, the Ministry of Health, and the National Guard (D'Alessandro, Edd & Al Mubarak, 2013). International organizations may also provide some EMS personnel. With so many different organizational players, communication problems are bound to arise. Moreover, the Hajj does not only take place in Makkah, but also in Mina, Musdelapha, and Arafat. Each region has municipal leaders and protocols. Some of these regions are subdivided for management purposes. Makkah in particular is subdivided into the Grand Mosque sector and the surrounding circle (D'Alessandro, Edd & Al Mubarak, 2013).

EMS also need to interact with local police and fire departments, which in turn need to communicate effectively with each other. An interview with the EMS general director in Hajj season revealed that lack of coordination between fire, police, Civil Defense, and medical departments is one of the most serious concerns among response teams (Aymen,2016) n To effectively coordinate EMS services during Hajj, the government of Saudi Arabia has promoted the development of both permanent and temporary health care facilities including their support staff and materials (Eltahair, 2000). Still, there are communication barriers related to chains of command and protocols regarding mass injuries resulting in the need for triage. Identification of specific ailments and other assessment issues may need to be accomplished by specific medical staff, whereas responding to infrastructure-related disasters might fall to another department. Effective communication and coordination entails role clarity and a dedicated team of coordinators.

Intra-Agency Communication

Within each agency, flow of communication will determine effectiveness of the response. For example, the medical director and EMS responders need to maintain an open two-way flow of communication in order for services to be delivered in a timely manner. Intra-agency communication may also be related to human resources management. As Alanazi (2012) points out, variability in staff training needs to be documented in a way that allows medical directors to allocate trained staff to appropriate response venues. Differential training and backgrounds of responders might also complicate matters because of different methods learned for triage and acute treatment interventions like first aid. The diversity of medical concerns faced at Hajj will also present challenges to each agency involved in EMS. Some teams will need to address infectious diseases, others may need to address acute injuries, while others may be working with issues related to heat stroke (Gowa, et al., 2015). The wide range of issues that can confront EMS staff simultaneously requires conscientious communication and role clarity.

Communication between responders and hospital staff also presents particular challenges. Hospitals might become temporarily overloaded, requiring the use of secondary support systems and ambulatory medical treatment centers. Teams of paramedics, physicians, and EMTs will be working together, some from countries outside of Saudi Arabia. Other issues include the communication logistics related to medical supplies such as inventory management and delivery logistics. As a preventative measure, it is also important to vastly improve health education among Hajj pilgrims. In a study directly assessing Hajj pilgrim health literacy, Turkestani (2013) found a statistically significant improvement to health education regarding things as personal hygiene and sun exposure after a brief intervention including pamphlets. A more concerted effort to improve health literacy is critical, and will entail translating health education-related documents into all of the languages represented by Hajj pilgrims in any given year.

Technology

Communications technologies can enhance the responsiveness of EMS personnel at the hajj. Some possible barriers to the implementation of technology include the use of too many different devices or operating systems. Inter-agency and intra-agency communications coordination should include a commitment to refining the technologies used so that all responders are on the same networks using related hardware and software. Geo-location can help EMS personnel respond more rapidly and minimize unnecessary deaths. Likewise, geo-location technologies can help ambulance drivers understand the fastest routes to the injured or affected parties. Different systems of transport such as Mobile Command Center buses, specialized stretchers, and specialized motorcycles for access to tighter areas provide different services depending on the situation. If personnel are insufficiently trained in how to navigate the pathways and roads during hajj, problems might arise. D'Alessandro, Edd & Al Mubarak (2013) also draw attention to the use of infrared and satellite technologies to aid responders.

Currently, there is a special 3-digit telephone number active only during Hajj season and which anyone can access (D'Alessandro, Edd & Al Mubarak, 2013). The support staff at hospitals need to know how to use these communications technologies and to effectively and accurately let responders know their current hospital capacity, such as available beds, doctors, and medical equipment. Likewise, technology should be used for logistics and supply delivery systems before and during the hajj pilgrimage.

Public Relations

One of the greatest communications challenges during hajj is communication with the public before and during hajj. Pre-arrival communications can be instrumental for preventative action. A more concerted effort at educating the public about potential dangers and how to minimize risk and accident will help in the future. With so many different countries and agencies involved in planning hajj, it may be difficult to develop a cohesive public relations strategy. Skilled communications and public relations consultants might help to minimize these problems. The media can also be used as an effective information dissemination tool, and can participate by publishing guides to hajj safety. Social media can offer pilgrims updates and current information on risks. Partnerships with international organizations can help improve public relations during hajj.

Recommendations

"Language and Cultural Challenges"

1. Hire new safety and rescue personnel from different countries, maximizing the number of languages spoken and also enhancing cross-cultural awareness.

This critical step can be undertaken in the most efficient and effective way by first mandating all pilgrims register prior to the Hajj with their language and country of origin. This will provide emergency services personnel with raw data they can use to build a specialized workforce unique to each year's event. The data will help inform how many personnel with be needed, as well as determine the language and cultural distribution needed for human resources.

2. Provide in-depth training for all personnel, related to cultural sensitivity and the ability to use communications tools and technologies such as translation software or video chat with a translator.

Investing in comprehensive training programs will pay off in reduced costs associated with fewer casualties. Training personnel not only in how to use technology and communications protocols, but also in cultural sensitivity can promote safety and maximize the responsiveness of all personnel.

"Inter-Agency Communication"

1. Develop a set of standard operating procedures, holding regular training for personnel. The standard operating procedures can be distilled into a reference guide that can be accessed using personal handheld devices.

2. Strengthen organizational culture and leadership, making prevention and responsiveness a priority. Create a culture of safety that encourages compliance and synchronizes all staff.

"Intra-Agency Communication"

1. Form strategic partnerships with stakeholder organizations, with interoperability central to all decisions. Maintain ongoing communications during the Hajj to promote risk management skills and prevent disasters. For example, intelligence and law enforcement can provide information critical for use by emergency personnel.

2. Identify a few key communications modes and rely on those methods. Standardize communications between multiple stakeholder agencies. Maintain a dedicated "base camp" of communications that can rout calls appropriately, liberating valuable human resources on the field to concentrate on their acute needs (United States Department of Justice, 2006).

"Technology"

1. Expand the range of radio frequencies used for emergency communications. Hire specialized staff to monitor radio communications and perform required maintenance on the systems. Ensure that there are adequate backup systems and redundancy.

2. Replace all aging equipment with updated hardware and software. Develop new software solutions that can help workers with specific issues such as access to victim medical records, even from other countries, translation software, and video communication software. Imaging software might also help facilitate communication during a crisis.

"Public Relations"

1. Incorporate a media strategy into the pre-planning and planning stages (Technical Response Planning, 2012). With a stable and reliable media strategy and a group of trustworthy media allies, Hajj emergency managers can provide updates and receive information about related events in a timely manner.

2. Craft media messages carefully, with attention paid to creating a sense of calm and reducing panic. Express empathy and make sure messages are delivered in multiple languages to respect the diversity of the pilgrim base. Provide honest and realistic data and information.

Barrier 1: One of the recommendations was to hire new safety and rescue personnel from different countries. Ostensibly, this would maximize the number of languages spoken among EMS responders and reduce communication errors. This could also help enhance cross-cultural awareness. However, this recommendation will face considerable barriers, such as how the Saudi government will arrange for work permits for so many individuals from so many different nations. This recommendation may also present national security threats. One suggestion for overcoming these barriers would be to work with partner organizations who can pre-screen individuals. A second suggestion is to have the government of Saudi Arabia establish a unique temporary work permit classification specifically for Hajj.