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THE MECCA PILGRIMAGEIts Epidemiological Significance and Control

By WASFY OMAR, M.B., Ch.B.(Cairo), Dip. Hyg., D.T.M. & H.(Camb.)

The Islamic faith demands that Moslems, atleast once in their life, should perform the pil-grimage to Mecca, provided they can do so. It isnot enough to visit the holy places in the Hedjazat any time of the year. Merit can be acquiredby only participation in the mass demonstra-tions of faith decreed to take place every year onthe tenth day of Zilhidge, according to theMohammedan calendar. No sacrifice is too greatfor any Mohammedan to fulfil this sacred duty.Some indeed devote their whole life to the attain-ment of this sacred mission.The great majority of pilgrims are from the

middle and poor classes. Some are extremelypoor; they have nothing but faith in their heartsand a stick in their hands; they walk from theirhome countries, sometimes for years, beggingtheir way to the Hedjaz. Others can afford onlythe expenses of their outward journey. Thisdestitution of the pilgrims led many governments,supported by the international sanitary conven-tions, to take certain measures to prevent thedeparture of any pilgrim unless he first pays forhis return ticket.

Every year, three months before the date pre-scribed, thousands of Moslems from every partof the world converge in large numbers on Mecca.In the early years the majority came by caravanacross the Arabian deserts, Asia and. Africa fromthe north, south, east and west. Now the majoritycome by sea and a great number travel by air.*

Wherever they arrive in the Hedjaz, all thepilgrims converge on Mecca. The small sacredtown becomes gradually crowded with them. Onthe ninth day of Zilhidge, 'the day of Arafat,'they all assemble at Mount Arafat. There, abouthalf a million Moslems gather for the consecrationof the pilgrimage. Mount Arafat is a bleak, openhill, about I2 miles east of Mecca. Here, cladonly in the symbolic garb of purity, an unstitched

* In the 1951 pilgrimage, 12,687 arrived to the Hedjazby air. The number of pilgrims arriving by air greatlvincreases year by year.

white sheet, the pilgrims must pass their first dayof pilgrimage.

In the evening of the same dayt, hey move toMozdalifa, about four miles from Mount Arafat.Here, they camp for the night, and the next daythey proceed to Mouna, about two miles furtheron to Mecca, where they stay three or four daysunder tents erected in these sacred valleys of thedesert, devoting themselves to their religiousceremonies.The pilgrimage ceremonies at Mouna are

characterized by one of the most importanttraditions; the celebration of the sacrifice ofofferings. Thousands of animals (camels, sheep,etc.) are slaughtered in the camp. The hugequantity of meat, which cannot possibly be con-sumed by the pilgrims, is either left on the groundor incompletely buried, and within a few hoursunder the burning sun, this creates a big sanitaryproblem.On the twelfth or thirteenth day of Zilhidge, the

pilgrims move to Mecca to fill again the sacredlittle town to overflowing and to live necessarily inconditions of appalling overcrowding. Their de-votions include one important function: everypilgrim must drink of the holy water of the Zam-Zam well; moreover, some pilgrims take withthem for distribution to their nearest and dearestat home, tins full of the holy water. The Zam-Zam well is a shallow, open well from which thewater is drawn by buckets. This water has alwaysbeen liable to contamination with germs of in-testinal infectious diseases. This is why it isstressed that the drums containing Zam-Zamwater, carried by returning pilgrims, be regularlysteam disinfected at the Tor (Egypt) QuarantineStation,t on the return of the pilgrims. They

t According to the provisions of articles 135, 140,14I and 142 of the International Sanitary Convention(Paris, I926), all ships carrying pilgrims from the portsof the Hedjaz and going north must call at Tor quaran-tine stations to undergo sanitary measures of medicalexamination, observation, disinfection, etc., before thevare allowed to proceed on their voyage.

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must be destroyed if an outbreak of cholerahappens to occur in the Hedjaz, a precaution whichwas found necessary after the isolation of choleravibrios from water drums at the Tor CampLaboratory.*With the return of the pilgrims to Mecca, the

pilgrimage ceremonies come to an end and themass begins to break up and disperse.

The Sanitary Dangers of the PilgrimageThe conditions under which the pilgrimage to

Mecca is performed, particularly by pilgrims whoare not well provided with this world's goods, areso rigorous as to be a severe strain on even thestrongest. A large number of the pilgrims whoproceed to Mecca are old and infirm; some ofthem desire to undertake the pilgrimage only withthe object of dying in the Holy Land.t A pilgrimwho is in ill health is more liable to be a focus ofinfection than one who is in robust health. It wasfound by experience that while deaths amongpilgrims on their outward voyage are comparativelyrare, the mortality after the pilgrimage ceremoniesand on their return voyage is very high even in theabsence of epidemics. The mortality in the 1924pilgrimage was 4 per cent. among the Egyptiansand 22 per cent. among the Javanese.The Arabic (lunar) year does not correspond

exactly to the Christian year, but is i i daysshorter. Thus, the date fixed in the Arabiccalendar for the pilgrimage, ninth of Zilhidge, doesnot fall on a fixed day according to the Christiancalendar, but falls in every succeeding year on adate ii days earlier. The pilgrimage may be,therefore, at any time of the year. This mieansthat pilgrims are subjected to the severest climaticconditions ranging, according to the date of thepilgrimage, from the merciless winds of a desertwinter to the fiercest heat of summer. It is notsurprising that heat stroke claims many victimsunder these conditions. In last year's pilgrimageas many as 753 deaths were recorded in one day atMouna; most of these were due to heat stroke.

The Mecca Pilgrimage and EpidemicsPilgrimages in general, involving the collection

in one place of large numbers of people, havealways been, even with the utmost sanitary pre-cautions, a potential source of serious epidemics.

* According to some reports, the origin of the terribleepidemic of cholera which broke out in I902 has beenaitributed to the fact that a pilgrim had poured someZam-Zam water into the well of his home village(Mousha, in Upper Egypt); and that from this theepidemic started.tThis led many countries to submit their pilgrims

to a medical examination before allowing them toproceed to the Hedjaz.

During the Mecca pilgrimage, there is a hugegathering of people of different races, the majorityof whom come from countries where many of thepestilential diseases are endemic.The Mecca pilgrims, travelling sometimes under

precarious and unhealthy conditions and beingliable to carry with them the germs of cholera,plague, smallpox, etc., from their home countries,have, by their agglomeration, often made of theholy towns of Islam a dangerous centre from whichepidemics of pestilential diseases spread all overthe world. Any epidemic disease could start thereand spread to the home countries of the returningpilgrims.

Malaria, dysentery and other water-borneepidemic diseases have always been commonamong returning pilgrims. Until vaccination ofpilgrims was made compulsory by most of thecountries, smallpox was very common. The lastoutbreak occurred in I949 when 545 smallpoxcases and I98 deaths were recorded.The great plague pandemic of I896 menaced

the pilgrimage for the first time and it reappeared inJedda in the following year. The infection wasthought to have been introduced by pilgrims'caravans from Sanaa (Yemen), where plague wasprevalent. Only a few cases appeared among thereturning pilgrims. After I897 plague was de-clared in the I898, I899, 1900, 1907, 1909, 1910,1913-14 and I9I8 pilgrimages. None has been re-ported from the Hedjaz since I9I8.Although plague has been considered in all the

international sanitary conventions on equal lineswith cholera, experience showed, that it hasnever been of the same epidemiological im-portance in pilgrimage as cholera. In all these' infected' pilgrimages, plague appeared mainlyamong the inhabitants of the Hedjaz. Victimsamong pilgrims were few. The preventive anti-rat and quarantine measures which are taken at thepresent time in ships can be considered a sure safe-guard against the spread of plague.Of all the diseases which have attacked or

threatened the pilgrimage, none has been so seriousand so disastrous as cholera. The wide spread ofcholera through the Mecca pilgrimage to Europeand to the rest of the world was the first alarmwhich led to international agreements putting thepilgrimage under effective sanitary control. Withpilgrims coming from areas in which the disease isendemic and subjected to conditions ofliving which could light up an infection or favourits spread, it is not surprising that cholera has beenthe worst enemy of the pilgrimage.The fourth big pandemic of cholera, to quote

one example, arose through the pilgrimage of I863.Cholera, brought by pilgrims from Java, broke outfirst in Mecca. After the pilgrimage and the dis-

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persion of the pilgrims, infection was carried byAfrican pilgrims on their return to their owncountries. Cholera appeared, thus, in Egypt andin all the ports of the Mediterranean, whence itreached, by means of emigrants, the Senegal andNorth America, Brazil and Paraguay.

In I83 i, a fatal year, cholera appeared atMecca, it is thought, for the first time. BetweenI83I and i865 eight epidemics occurred in theHedjaz (I831, I840-4I, I846, I850, I855, I856,i859 and I865).* Fifteen more epidemics ap-peared during the period I866-1912 (see TJable).Since I912, cholera has not been reported from theHedjaz. Before i866 pilgrims used sailing vesselsin their voyage to the Hedjaz. The voyage waslong and the number of pilgrirms was not great.After I866 steam navigation was utilized to carrypilgrims from India and Egypt to the Hedjaz.It diverted to its profit the conveyance of numerousMoslems, to the prejudice of caravans which weretrue ' itinerant quarantine,' enabling with theirslowness any epidemic to fade out in the desert,and so no infectious .disease was carried to thepilgrims' home countries.

After the last three outbreaks of cholera in theHedjaz in I910, I91I and I9I2, the disease ap-peared in I927 in Iraq and in I947 in Egypt, butin both cases it neither appeared in, nor originatedfrom the Hedjaz.A study of the available epidemiological data

may lead to certain conclusions:(i) The cholera outbreaks occur mainly during

the pilgrimage period, i.e. one or two months duringwhich the ceremony days fall.

(2) The epidemics reach their maximum on thedays of the ceremonies at Arafat and Mouna, whenthe agglomeration of all the pilgrims takes place.

(3) As the epidemics occur at a fixed periodaccording to the lunar (Arabic) calendar, whichdoes not correspond with the Christian calendar,this means that the epidemics may occur in anymonth of the Christian year (January to December),at any time in any of the four seasons of the year.Cholera outbreaks have occurred in winter as wellas in summer, evidence which excludes atmosphericconditions as a factor in the epidemiology ofcholera in the Hedjaz. A study of the records ofthe cholera epidemics in the Hedjaz shows, how-ever, that the winter epidemics are longer and morefrequent than the summer epidemics.

(4) The cholera epidemics occurred usually ingroups from I855 to i866, from i88i to I883,from I890 to I895, and from 1907 to 19I2. This

* According to some sources 13 epidemics, toothers 12occurred during that period. It is agreed that cholera didnot exist in the Hedjaz before 1831. It is not endemicthere, but was always traced to imported sourcesof infection.

probably means that cholera existed in the Hedjazin endemic form between these years and was re-vived in epidemic form in the following pil-grimages.

How Does Cholera Enter the Hedjaz?Since cholera. was introduced to the Hedjaz in

I83I by pilgrims, it seems that it has returnedalways with them. It arrives before the feast,reaches its maximum activity during the cere-monies and drops sharply with the dispersion ofthe returning pilgrims. It arrives in the Hedjaznearly always by sea and from the south. Ex-ceptionally it may come by the land routes. InI846 and I872 it was introduced by land from thenorth (Iraq), and in I859, I890, I89I, I893 and1902 by small caravans from the south (Yemenand Assyr).

In the early epidemics of cholera in the Hedjaz,infection could be introduced by a case among thepilgrims coming from a country where cholera wasprevalent. In its early years, the quarantinebarrier in the Sanitary Station of KamaranIslandt was probably not entirely efficient.

In I926, however, four cases of cholera werelanded from a pilgrim ship coming from Calcuttaand were isolated at Kamaran Sanitary Station.No cholera appeared in the Hedjaz that year.This incident seems to support the precedingconclusions and may be taken as an evidenceof the efficient part which may beplayed by a quarantine barrier in preventing thespread of infection if such a barrier functionsproperly. At the present time a great number ofpilgrims travel by air and may arrive in theHedjaz from their infected countries within thedanger (incubation) period. The role of choleracarriers in the transmission of cholera becomes ofmajor importance, particularly the incubatingcarrier. The other two types of cholera carriers,the contact (or healthy) carriers and the con-valescent carriers, do not seem to play a significantpart in the transmission of cholera.Some authors believe that the vibrios from a

contact carrier are not dangerous because they are'mutants,' and there is evidence that during con-valescence an increasing proportion of the vibriosexcreted by convalescent carriers are in process oflosing their pathogenicity.

tAccording to the provisions of articles I22-I2~(Intemational Sanitary Convention, 1912) and articles127-130 (Intemational Sanitary Convention, 1926),quarantine measures of inspection, isolation, disinfec-tion, etc., are taken on all pilgrim ships coming fromthe south and bound for the Hedjaz, which must put inat Kamaran Sanritary Station before. being allowed toproceed to Jedda.

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272 POSTGRADUATE MEDICAL JOURNAL May 1952

CHOLERA EPIDEMICS IN THE HEDJAZ (I866-1912)

Duration ofDEATHS FROM CHOLERA epidemic in Date of

Years of Mcathe FeastPilgrimage In In In In other |_Mecca theof

Mecca Jedda Medina areas Total From To Sacrifices

I866 .. .. Information incomplete (very small outbreak).

I871-72 .. Information incomplete (infection introduced by land route from Kerbela).

I877-78 .. 787 I86 IOI 343 1,415 Dec. 24 Jan. i i Dec. I4

I88i .. .. 2,473 121 283 1,4I5 4,292 Sept. i6 Jan. 30 Oct. 31

1882 .. .. 324 12 254 32 622 Oct. 23 Nov. io Oct. 21

I883 * * 455 I I82 - 648 Oct. I4 Nov. 12 Oct. 12

I890 .. .. 2,538 1,337 46I 103 4,439 July 28 Aug. 22 July 28

I89I .. .. 2,942 256 9 3,207 July I I Aug. 20 July i6

1893 * | 30,336 2,408 250 - 32,994 June 8 July 19 July 23

1895 306 - - | 306 April 22 May 22 June 2

1902 . . . 4,000 314 399 666 5,379 Feb. 20 April 8 Mar i9

1907-08 .. 4,745 379 260 224 5,608 Dec. I4 Feb. 7 Jan. 13

I9IO-II . 1.42 19 657 37 855 Dec. 26 Jan. 27 Dec. 12

I91 .. .. 1,536 311 117I 2,0I8 Sept. 2 Dec. 21 Nov. 30

1912 .. .. 3,339 417 142 - 3,898 Sept. 22 Dec. iI Nov. i9

The International Sanitary Control of theMecca Pjlgrimage

For the last 70 years the sanitary problemsconnected with the Mecca pilgrimage have' beenrecognized as being of great international im-portance. The Hedjaz has, on several occasions inthe past, proved to be the corridor through whichvarious infectious diseases, mainly cholera, havespread from eaft to west. Consequently, sinceinternational sanitation became a subject for dis-cussion between the nations of the world, it hasbeen realized that special precautions should beadopted with respect to the Mecca pilgrimage.The first international health conference was

held in Paris in i85I. Many other conferencesfollowed, but unfortunately all failed to reachagreement. As a result of the early conferences,however, some of the countries concerned,without being bound by any international agree-ment, applied some of the recommendationssuggested by these conferences with regard to theMecca pilgrimage. The first measures wereapplied in i858. Ships carrying returning pilgrimsand having on board cases or suspected cases ofcholera had to be put under quarantine for ten

days. This period was reduced to five for shipswith no such cases.

In I895 it was recommended that a medicalofficer should on board every pilgrim ship.The number of pilgrims who could be carried bya ship was fixed according to its tonnage afterthe I864 conference.

Cholera continued to break out in the Hedjaz.It was only after the I892 conference that theFirst International Sanitary Convention wassigned and the Mecca pilgrimage was dealt withfor the first time under international agreement.A comprehensive study of the problem was made

and a certain number of measures were prescribed.It was agreed that pilgrim ships should be pro-vided with a disinfection stove and that theyshould carry a qualified doctor on board.Quarantine control was imposed on all ships re-turning north after the pilgrimage. The TorQuarantine Station in the Gulf of Suez waschosen for this purpose. All ships coming fromthe Arab Coast of the Red Sea and carryingpilgrims should call at El-Tor Station, where thepilgrims are put under observation for a period of15 days if the ship carries an unclean (for cholera)

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Mav I52z OMAR: The Mecca Pilgrimage 273

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bill of health, and for a period of three to four days,if the ship carries a clean bill of health.The same measures were also applied to the

Egyptian caravans returning from the Hedjaz.The organization of the El-Tor Station ,was

dealt with in the 1892 convention as regards per-

sonnel, equipment, disinfection stoves, sanitation,provision of food and water supply.

Further measures were added in the i894Convention. It was prescribed that 'pilgrims arenot allowed to proceed to the Hedjaz unless theydeposit a sum of money to cover the expenses oftheir voyage and the maintenance of their familiesduring their absence; that all pilgrims are sub-mitted to a medical examination at their homeports of departure; tnat no cholera or evendiarrhoea cases are allo'wed to leave; that allpilgrims are disinfected before embarkation; thatif the port of departure is infected with cholera,all pilgrims are put under observation for a periodof five days before embarkation.' A detaileddescription was also included on the sanitaryequipment of a pilgrim ship as well as the measuresof sanitary control of these ships before and duringthe voyage. 'All pilgrim ships coming from thesouth had to put in at Kamaran Sanitary Station,where the pilgrims are submitted to quarantinecontrol before rpoceeding to the Hedjaz.' Medicalexamination and disinfection of returning pilgrimshad also to be made at the Hedjaz ports of de-parture (Jedda and Yambo).A new convention was signed in I897. The

preceding conventions dealt only with the probtlem of cholera. Measures similar to those agains-cholera were added in the i897 Convention forplague. Six years later a new convention wascirawn up (Paris, I903) followed by a second one in19I2. No cholera has appeared in the Hedjazsince 1912. In I926 the last InternationalSanitary Convention was signed in Paris. Theselast three conventions contained nearly the samepilgrimage provisions as those in the precedingconventions with little modifications.

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274 POSTGRADUATE MEDICAL JOURNAL May 1952

The I926 Convention was, however, supple-mented with two agreements:The Anglo-Dutch Agreement (1926) on the

control of the pilgrimage traffic from the 'southat Kamaran Quarantine Station, and the MiddleEast Arab Countries Agreement (I929) on theprincipal measures to be taken' to ensure healthconditions and security for the pilgrims, of thisregion.

In the second agreement, vaccination againstsmallpox and anti-cholera inoculation were madecompulsory for all pilgrims before they left theircountries for the Hedjaz. Provision of ' specialpilgrimage passports ' and the compulsoxy use ofdetermined itineraries by the pilgrims on their wayto and from the Hedjaz were also decided upon bythe countries signing the agreement.Having among its functions the administration

of the existing sanitary conventions, the World'Health Organization considered it necessary torevise and consolidate all the conventions in forceat present, and drew up, in the light of recentadvances in epidemiology and prevention, 'new' sanitary regulations ' to replace them. TheseW.H.O. ' International Sanitary Regulations' willcome into force in October 1952. In view of thespecial epidemiological significance of the pil-grimage, it was found advisable to maintain therules governing its health control in the new

regulations, with certain modifications of thepilgrimage provisions in the convention of 1926.

Since a large nuMmber of pilgrims now travel tothe Hedjaz by air, special provisions had to bedrawn for the sanitary control of the pilgrimage bythis means. The standards with which ships andaircraft carrrying pilgrims must comply have beencollected in Appendlx B ofthe regulations. Accord-ing to these regulations, pilgrims must bevaccinated against cholera and smallpox, and avalid certificate of vaccination against yellow feveris also required from those coming from a localarea infected with yellow fever or from a yellowfever endemic zone.The Kamaran Quarantine Station which has

until now been responsible for the sanitary controlof pilgrims coming by sea from the south, will beclosed; its functions will be taken over by thequarantine station now under construction atJedda.

In the case of non-infected pilgrimages, pilgrimships returning northwards will be submitted tosanitary control at Suez instead of Tor as was thecase under the I926 Convention.

Plague, cholera, yellow fever, smallpox, typhusor relapsing fever may cause a pilgrimage to beconsidered to be infected, in which case sanitarycontrol of the returning pilgrimage has to be madeat Tor and Jedda Stations.

NOTESSPharmaceutical Specialities (May & Baker)

Ltd., announce that ' Phenergan' brand pro-methazine is now available in the form of 2 percent. cream. This product is indicated in thepalliative treatment of skin conditions of anallergic and sensitization type, either alone or inassociation with systemic antihistamine therapy.It is a powerful antipruritic application in allconditions characterized by intense itching andmarked pain and has proved valuable in the earlytreatment of superficial burns and scalds where itsapplication appears to limit blister formation andoedema.

In allergic disorders and dermatological con-ditions 'Phenergan' cream should be rubbed ingently and, if possible, a further quantity spreadon gauze should be applied under a light bandage.In burns and scalds the cream should be applieddirectly to the injured area.'Phenergan ' promethazine cream is available in

containers of i oz. and I lb.

In our issue of November I951 we published anarticle on ' Resection with Restoration of Con-tinuity in the Treatment of Carcinoma of theRectum and Rectosigmoid 'by Mr. J. C. Goligher.It was explained by the author that this paper wasbased on a collective series of cases treated bycertain members of the Surgical Staff at St.Mark's Hospital. Unfortunately they were notactually nominated and Mr. Goligher would like usto rectify this omission and state that the surgeonsconcerned were Messrs. C. Naunton Morgan,0. V. Lloyd-Davies, H. R. Thompson and him-self. He would also like us to make it quite clearthat the great majority of the cases in the seriesreferred to were patients of these colleagues, twoof whom have already reported on their ex-periences with this type of operative procedure(Lloyd-Davies, 0. V., i948, Proc. Roy. Soc. Med.,41, 822. Lloyd-Davies, 0. V., 1950, Proc. Roy.Soc. Med., 43, 706. Morgan, C. N., I950, Proc.Roy. Soc. Med., 43, 701).

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