¶ … 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 (Mecca) also grows. 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 10 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 report will explain the specific communications challenges faced by EMS professionals and EMS leaders and then provide a set of cohesive evidence-based solutions.

Background and Literature Review

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. 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. 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...

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.

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.

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…