EMS Communication Challenges During the Hajj Pilgrimage

Introduction and Research Question

The Hajj pilgrimage is the largest annual gathering in the world, attracting millions of Muslims each year. As the global Muslim community grows to well over one billion, the number of pilgrims to Makkah — sometimes spelled Mecca — continues to increase as well. The sheer volume of people presents significant challenges for EMS staff. The population of Makkah province is currently seven million people, a figure that rises sharply during Hajj season (Arab News, 2012). In 2012, more than 3.5 million men and women attended, and those numbers are expected to climb to as many as ten million by the year 2020 (D'Alessandro, Edd & Al Mubarek, 2013). This mass gathering creates a range of concerns for EMS professionals, from acute injuries related to crowd surges to the spread of infectious diseases to cardiac arrests. Effective communication is critical to the success of all EMS efforts at the annual Hajj pilgrimage.

As the number of pilgrims increases each year and as local infrastructure shifts in response, EMS professionals face ongoing challenges related to communication. These challenges can be loosely grouped into five categories: language and cultural barriers, inter-agency communication constraints, intra-agency communication constraints, technology challenges, and challenges related to public relations, public education, and the media. Each category presents particular opportunities for the EMS community, for primary stakeholders in Saudi Arabia, and for all participating organizations worldwide. Although some communication-related problems seem overwhelming given the sheer number of participants or the involvement of multiple organizations and government agencies, such challenges can be overcome through concerted, collaborative effort and cooperation.

Research Question: What are the communication challenges faced by the Saudi Emergency Medical Services during the Hajj season in Makkah, and in what ways can these 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 "perform 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 five essential 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 2,000 years, but since the Prophet Muhammad first led a group of pilgrims there in 630 CE, the Kaaba has become central to the Muslim faith. Today, the Kaaba is marked by an enormous black cube that Muslims believe to be the "center of the world," situated literally at the center of the vast mosque complex Masjid al-Haram (Fetini, 2009). When pilgrims visit Makkah and enter the mosque complex, they circle the Kaaba seven times in a counter-clockwise direction — a ritual that serves several spiritual functions including seeking forgiveness, guaranteeing a place in heaven, and fulfilling 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, the pilgrim also visits Arafat, Mina, and Muzdalifah, all holy sites that form part of the overall pilgrimage. A large number of pilgrims also journey to Madinah, the site of the tomb of Muhammad. The movement of people between and within these sacred sites creates tremendous crowd-related risks, particularly given that more than two million people per year now complete the Hajj (Fetini, 2009).

Dhu al-Hijja is the last month of the Muslim lunar calendar and is considered the time when "God's spirit is closest to earth" (Fetini, 2009). Unfortunately for many pilgrims, the Hajj has also proven fatal. During the 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 recurring tragedies, as people die each year and several years have witnessed death tolls in the hundreds or thousands ("Timeline of tragedies during hajj pilgrimage in Mecca," 2015). Short of completely redesigning the site or staggering visits, crowd management and disaster management must be improved using evidence-based practice. Communication is one of the most critical areas for improvement, both to minimize risks and to enhance the efficacy of emergency response services.

Notably, for eight consecutive years from 2006 to 2015, no major disaster occurred at the Hajj. If the management of the event was different in some meaningful way during those years, authorities need to understand how to best prevent future tragedies. One important tool is mathematical modeling to ascertain crowd movements and determine risks (Benedictus, 2015). Hajj naturally presents the most severe risk due to crowd density exceeding six people per square meter — a density at 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 have often involved crowd stampedes and the crushing of people. However, ancillary disasters have also occurred, including hotel collapses, injuries from the symbolic stoning of the devil in 2003, a tent fire in 1997, and in 1979, "hundreds of gunmen opposed to the Saudi government barricaded themselves inside the Grand Mosque," taking many pilgrims hostage and resulting in hundreds of deaths and injuries ("Timeline of Tragedies during Hajj Pilgrimage in Mecca," 2015).

The Hajj is not unique in experiencing mass-gathering disasters. As Benedictus (2015) notes, 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 in the world. Yet much can still 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 responds to each of the five concerns outlined in this report: 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 protocols related to their areas of specialization, minimizing problems associated with bureaucratic organizational structures. The media and social media will facilitate communication with the public and provide educational services that help prevent problems before they occur.

The model illustrates the organic flow of information and communication between the various parties involved, but must remain flexible, as each year at Hajj unique situational variables will present themselves. Variable weather, changes to local infrastructure, increasing numbers of pilgrims, shifting demographics, and infectious disease development all require EMS personnel to be flexible and responsive rather than rigid in their approach.

Specifically, the model shows how the five key components of communications strategy function as independent variables — from improving staff language knowledge to deploying communication technology to managing public relations, intra-agency communications, and inter-agency communications. When each of these variables functions properly, they can positively impact dependent variables including quantitatively measured safety improvements (such as reduced loss of life or reduced injury counts), improvements to language and cultural competencies, and technological literacy across all agencies.

Language, Cultural, and Inter-Agency Communication 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 must pay close attention to how best to communicate across linguistic and cultural boundaries. Even in multicultural environments, EMS responses may be delayed due to language barriers (Grow, Sztajnkrycer & Moore, 2007). Oliveira (2013) points out that crisis management frameworks frequently lack cultural competency standards, and that increasing cultural competence requires relatively simple training interventions that can vastly improve service delivery.

Language barriers are only a few of the many potential obstacles to effective EMS 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. EMS organizers and leaders therefore need to develop effective methods of minimizing confusion and maximizing the clarity of all services provided, within a culturally competent framework.

Some language barriers have already been partially addressed through "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 other related materials can help pilgrims prevent injuries and accidents before they occur. Cultural barriers to communication may be even more pressing than language barriers. Issues such as refusing treatment, not trusting doctors, preferring traditional healers, or wanting the input of family members will all inhibit the actions of EMS personnel who wish to respect cultural norms while still delivering immediate and effective medical interventions. Similarly, body language and especially physical contact between male and female providers and patients may be problematic for some devout pilgrims whose cultural norms restrict cross-gender touching (Dees, 2007).

Emergency responders in Saudi Arabia do not operate under a single organizational umbrella. Rather, EMS personnel may fall under the auspices of several different agencies, including the Minister of the Interior (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 EMS personnel. With so many different organizational players, communication problems are virtually inevitable. Furthermore, the Hajj does not take place only in Makkah, but also in Mina, Muzdalifah, and Arafat. Each region has municipal leaders and protocols, and some 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 personnel also need to interact with local police and fire departments, which in turn must communicate effectively with each other. An interview with the EMS general director during 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). To effectively coordinate EMS services during Hajj, the government of Saudi Arabia has promoted the development of both permanent and temporary health care facilities along with their support staff and materials (Eltahir, 2000). Still, communication barriers related to chains of command and protocols regarding mass injuries — including the need for triage — persist. Identification of specific ailments and assessment issues may need to be handled by specialized medical staff, whereas responding to infrastructure-related disasters might fall to a different department. Effective communication and coordination ultimately require role clarity and a dedicated team of coordinators.

Conclusion

Effective emergency planning, coordination, and interventions depend on the most robust and well-integrated communications systems possible. The Hajj, with its two million-plus international visitors each year, presents special challenges that can be addressed through effective planning and evidence-based practice. Although Saudi Arabia has improved its technological capabilities regarding emergency services, there is still a long way to go before events like the 2015 Mina stampede can be prevented or crises responded to with greater effectiveness. Many of the challenges faced by Saudi authorities and Hajj event planners stem from inadequate training of staff to meet the needs of the diverse pilgrim population. Language barriers, cross-cultural communication constraints, and ineffective intra-departmental communications are among the most pressing areas for improvement.

To address the shortfalls of the current emergency communications systems, Saudi Arabia can take cues from what works in mass-event risk management in other countries — such as freeing up radio bandwidths, improved communications training for personnel, and, perhaps most importantly, a standardized system of communication in terms of both technology platforms and protocol, procedures, and languages. Hajj event coordinators also need specific systems in place for pre-planning and for public relations strategies in the event of an emergency.

Interoperability is the current priority concept in providing the most effective emergency response services. Because the Hajj is such a large-scale event, attracts an international crowd with every possible demographic need, and takes place across multiple jurisdictions in Saudi Arabia, interoperability is especially relevant here. Coordinators need to map out and conceptualize which agencies are responsible for which tasks and ensure that leadership and organizational culture are consistent and effective. Similarly, information management depends on standardized systems that prevent problems linked to either too much noise or insufficient sharing of intelligence that can be used to prevent or mitigate problems. The Hajj is many thousands of years old and will continue to be central to the lives of more than a billion Muslims worldwide. The future should witness meaningful improvements to Hajj safety.

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