Pre-existing Health Concerns and Their Management in Ramadan and Mass Gatherings
Insight into key religious practices and their implications for health is important for professionals who care for Muslim patients in different sectors of healthcare systems. In this chapter, we focus on two religious practices of importance for many Muslims around the world: observing the fasting period during the month of Ramadan and travelling for pilgrimage. We set out with a brief discussion of the multidimensional notion of health and an overview of how religious practices may shape the ways in which Muslims perceive and manage health and disease. This is followed by an outline of the meaning, rules, and practices related to firstly fasting during Ramadan and secondly travelling to attend the Islamic pilgrimage. Finally, taking a practice-oriented approach, we tease out practicalities and recommendations for healthcare professionals caring for Muslims wanting to observe the fasting period and/or attend mass gathering in the context of the Islamic pilgrimage.
KeywordsChronic disease Ramadan Fasting Hajj Travel Mass gatherings Healthcare
The extent and type of pre-existing health concerns that need to be managed either during the fasting period in the month of Ramadan and/or when preparing for and attending mass gatherings differ immensely between individuals, groups, and contexts. Despite the great diversity in health status across different ethnic and religious groups in different countries, shaped by complex interplays between genetics, health behaviors, and exposure to individual and structural adversity across the life course of the individual (Marmot 2017; Ottersen et al. 2014; Vos et al. 2013), some practicalities associated with caring for Muslim patients/citizens wanting to observe the fasting period and/or travel for pilgrimage are relevant to many healthcare professionals in different healthcare sectors (Gatrad and Sheikh 2008; Sadiq 2008). From a clinical point of view, there is often a need for disease-specific approaches taking into consideration also the increasing number of people living with multi-morbidity. For the purpose of this chapter, we will, however, focus on insights and recommendations that are of relevance to patient-provider encounters irrespective of the specificities of the underlying disease and its treatment modalities. Thus, while pre-existing health concerns naturally vary substantially among Muslims, attempts to tease out ways of managing health concerns must be based on principles of person-centered care, shared decision-making, and evidence-based medicine (Barry and Edgman-Levitan 2012; Rashid 2015).
Notions of Health
While great diversity in health status and associated needs for counselling and treatment to manage disease exists among the world’s Muslim population, there are also shared values uniting Muslims based on tenets of faith and the role of Islam in managing different aspects of life, including illness (Kristiansen and Sheikh 2012; Padela et al. 2012). Health is a multidimensional concept that covers the physical, mental, and social well-being of people, thus incorporating complex and ever-changing aspects related to how we feel and engage with others around us (World Health Organization 1948). While comprehensive in scope, this notion of health may meaningfully be expanded to encompass also the capacity to cope with the changing realities of human life, and some might add that spiritual dimensions are also for many people part of a healthy life (Huber 2011; Huber et al. 2016). Correspondingly, within the Islamic tradition, the Arabic concept of al-afiyah is commonly used to describe a very multidimensional concept of health that encompasses safety from disease, grief, and troubles, thus emphasizing the dimensions covered by the WHO’s concept of health and adding spiritual well-being (Ahmed 2008).
The Relationship Between Religion and Health
Muslims have in common a worldwide religion based on a set of core beliefs, as outlined in the Qur’an and the Prophetic traditions (Sunnah). However, the meaning carried by religious identity and the ways that faith shapes health and disease naturally differ between people and even within the life course of any individual person. These are informed by personal beliefs and interpretations of the tenets of faith, but variations are also shaped by a wide range of individual and context-related factors such as ethnicity, culture, and the behavior and values of people in one’s social circles (e.g., family and friends) and life experiences. Across the life course of a person, importance bestowed to faith may vary, and for people living with severe illness, there may be a particular need for trying to make sense of illness and death through religious grand narratives (Kristiansen et al. 2014, 2016).
For those Muslims who engage actively with their religious beliefs and practices, Islam often has a considerable influence on the ways in which they perceive and manage health and disease (Ahmed 2008; Padela et al. 2012). A large body of literature based on both Muslim majority and minority contexts around the world illustrates the importance of faith, often in combination with ethnicity, socioeconomic position, and gender, for health behaviors such as diet or alcohol; health-seeking behaviors including screening, adherence to treatment plans, and medication intake; and coping with illness and death, thereby highlighting both shared experiences in how religion shapes health overall and the great diversity caused by individual, social, and larger societal factors (Bhopal 2013; Ghouri et al. 2006; Ingleby et al. 2012; Inhorn and Serour 2011; Kristiansen and Sheikh 2017; Laird et al. 2007; Padela and Curlin 2013; Sheikh and Gatrad 2008). An overview of this complex field of research is beyond the scope of our chapter; however for healthcare professionals, a basic understanding of the role of faith for observing/practicing Muslims may be helpful as it enables a more open dialogue on how to manage health when either fasting during the month of Ramadan or attending mass gatherings, more specifically the Islamic pilgrimage to Mecca.
Briefly, among Muslims, religion may be reflected or translated into a wide range of practices, including the five daily prayers, dietary practices such as fasting during the month of Ramadan, and an avoidance of substances and practices that are considered to be forbidden (e.g., drug abuse or extramarital sex). In addition, Islam encourages Muslims to be physically active, to avoid excessive eating, to reflect regularly upon and seek to restore mental and spiritual well-being, and to be constructive members of society (Ahmed 2008; Kristiansen and Sheikh 2017). These practices have the potential to decrease the risk of adverse health outcomes through promoting healthy lifestyle choices and fostering mental health. In its approach to public health, Islam builds upon the principle that public interests often take precedence over private ones, thus emphasizing the need also to take measures to promote societal well-being (Rathor et al. 2011).
In the following sections, we will discuss more detailed, practice-oriented approaches to managing health concerns, firstly in Ramadan and secondly for those who wish to attend mass gatherings during the Islamic pilgrimage.
Managing Health Concerns in Ramadan
The Fast of Ramadan
Although the practice of fasting is shared across different religious and cultural groups, the Muslim fasting period during the month of Ramadan is perhaps the most widely observed fasting practice with implications both for the health status of patients/citizens and for healthcare provision. Here, we will briefly outline the meaning of fasting and overall rules taking as a starting point mainstream understandings of fasting among Muslims. However, it is important to note, again, the huge diversity in the understanding and/or approach to religious practices, including also the fasting period. Therefore, any discussion on fasting should be based on individualized approaches in a dialogue with patients/citizens and relatives when relevant.
The Meaning and Rules of Fasting
According to Islam, the month of Ramadan has a special status as it was during this month that the revelation of the Qur’an began. The month of Ramadan is dedicated to reaffirming the message brought to mankind through prophets, and it is a month of reflection, blessing, and moderation for most Muslims (Sadiq 2008). Fasting is a deeply embodied spiritual experience that can be hard to capture adequately in words, including when discussing health aspects of the practice with healthcare professionals. As it is a spiritual exercise shared in communities across the world, fasting often represents an inward journey reaffirming a consciousness of the divine based on moderation, willpower, and principles of sincerity. It also cultivates and strengthens a spirit of social belonging, unity, and equality within Muslim communities as the ritual is observed in the same manner at the same time across the world.
The practice of fasting is guided by rules regarding how it is observed, when it takes place, and who should engage with it. While fasting, Muslims abstain from all food, drink, and intimate relations in the period from dawn to sunset. Unlike fasts in many other religious traditions, the Ramadan fast also involves abstinence of water and smoking. In the period from sunset to dawn, Muslims eat and drink according to the common regulations regarding what are considered lawful foods and drinks. However, in the spirit of the Ramadan, overeating is discouraged, and many Muslims spent the evening and night hours in prayers, often at local mosques, or in reading from the Qur’an.
Fasting takes place during the ninth month of the Islamic calendar, which is based on a lunar cycle, and hence the Islamic year is around 9–10 days shorter than the solar year. This means that the precise dates of the Ramadan vary from year to year and that for Muslims the Ramadan will fall during all seasons of the year during the course of a lifetime. With Muslims living across the globe, timings of fasting differ widely with those living in extreme latitudes experiencing summer fasting periods that span more than 19 h a day in the summer months and substantially shorter fasts if Ramadan falls during the winter months. According to some scholars, it is considered permissible for those Muslims to fast for the length of time of neighboring regions with more normal cycles of day and night; however this is still a disputed subject with Muslims following different rulings (Sadiq 2008).
Children under the age of puberty
People considered unable to comprehend the nature and purpose of fasting, e.g., due to cognitive disabilities
Older individuals who are too frail to be able to fast
Those who are acutely unwell and who will experience an exacerbation of their health condition if fasting
People with chronic diseases who may experience detrimental health effects if fasting
Travellers with a set minimum limit of approximately 50 miles that may feel harmed by fasting
Pregnant and nursing women concerned about their own health or that of their child
While these categories are generally agreed upon, healthcare professionals often encounter patients falling into one of the mentioned groups who insist on fasting despite both rulings and recommendations from relatives and, e.g., physicians (Mir and Sheikh 2010; Mygind et al. 2013; Salti et al. 2004). The spiritual and social dimensions of fasting may be felt to be more important for the individual Muslim than discomfort or potential negative health effects caused by the practice. Therefore, while many groups are exempt from fasting, it is still good practice to discuss the attitude to fasting and potential strategies for managing health issues even for those who may clearly be allowed not to fast (Abolaban and Al-Moujahed 2017; Mir and Sheikh 2010; Mygind et al. 2013).
In general, the overwhelming majority of Muslims fast. In Muslim majority countries, fasting structures around, e.g., working hours may be adjusted to accommodate for fasting times and the prayers taking place during evenings and nights. In countries with Muslim minorities, such as many Western countries, people may choose to adjust daily life on more individual bases, e.g., by scheduling vacation to fit the last 10 days of Ramadan that takes on special importance as days of intense prayers and spiritual reconfirmation of faith and by postponing outpatient appointments (Sadiq 2008). This raises some demands for organizational efforts to educate both staff and patients about how to responsibly and adequately reconcile concerns related to health, health-seeking behaviors, and the practice of fasting for the benefit of all parties involved (Abolaban and Al-Moujahed 2017; Sadiq 2008).
Fasting and Health
As outlined above, Muslims may be exempt from fasting if they fall under one of these categories. For some, this exemption is temporary as their health condition may be acute or they may be in a temporary situation, e.g., while pregnant, breastfeeding, or travelling. Once the situation leading to exemption from fasting has passed, people are required to make up for missed days of fasting. For those who are in a permanent situation leading to exemption from fasting, fasting may be substituted by providing food for poor people, most often in countries afflicted by hunger, war, and poverty (Sadiq 2008). For chronically ill patients and older, frail patients, this is often the option of choice; however as mentioned, patients may feel that the emotional, social, and spiritual costs of not fasting are hard to cope with despite these rather clear rules of exemption (Mygind et al. 2013).
For some citizens/patients, it is harder to determine whether fasting should be observed or not. This may be the case for those who are not sure if fasting may be harmful for their health condition or those who do not feel well but are not properly diagnosed yet. Here, patients are recommended to seek a doctor’s opinion related to the likely effects of fasting on their health condition, which should then be adhered to in these cases of uncertainty (Sadiq 2008). However, studies suggest that Muslim patients may feel that discussing choices and strategies related to fasting, including effects of fasting on health conditions or adjustment of medication or self-care regimens, is difficult, thus refraining from raising these concerns in clinical encounters in primary care, at hospitals, or in pharmacy settings (Mir and Sheikh 2010; Mygind et al. 2013). This may both be due to a perception that non-Muslim healthcare staff may fail to appreciate the importance of fasting from a religious point of view and therefore may be inclined to discourage fasting (Mir and Sheikh 2010). Also, some may feel that the physical dimensions of health, which may deteriorate in the fasting period, are not of the same importance as the more spiritual and social dimensions of health and well-being and that the trade-off between feeling physically unwell and potentially worsening treatment outcomes in the long run is not worth missing the spiritual dimension of Ramadan. Raising such spiritual, emotional, and social issues in healthcare encounters may be difficult for patients, relatives, and healthcare providers (Abolaban and Al-Moujahed 2017; Ali et al. 2016; Amin and Chewning 2014).
Investigating the health effects of fasting has been the subject of a number of scientific studies, mostly within the field of diabetes but with examples related to also, e.g., cardiovascular diseases, chronic kidney disease, and Parkinson disease (Abolaban and Al-Moujahed 2017; Almalki and Alshahrani 2016; Amin and Chewning 2014; Bragazzi 2014; Chamsi-Pasha et al. 2014; Damier and Al-Hashel 2017; Myers and Dardas 2017; Salti et al. 2004). As changed eating, drinking, medication, and sleeping patterns during Ramadan may have complex effects on disease trajectories depending on the type and severity of the underlying disease, any multi-morbidity the patient may have, general well-being, functional capability, etc., it is beyond the scope of this chapter to give a detailed overview of specific health effects and their underlying causal mechanisms. Readers are referred to scientific literature for more in-depth insight into disease-specific and stratified approaches to patient education and management related to Ramadan fasting for patients with diabetes, cardiovascular diseases, respiratory disorders, renal diseases, or gastrointestinal diseases (Abolaban and Al-Moujahed 2017; Almalki and Alshahrani 2016; Bragazzi 2014; Car and Sheikh 2004; Ghouri et al. 2012; Hassan et al. 2014; Myers and Dardas 2017).
Fasting also has implications for medication use. With medication use being a part of treatment regimens for many diseases, and multi-morbidity leading to increasingly complex drug interactions at times not adequately attended to by healthcare professionals across clinical settings, the issue of regulating medication during fasting period is of key importance for many patients. Any oral intake of medication – or any other substance – through the mouth nullifies the fast. At times, dosage times of oral medication can be changed to fit into fasting timings, in particular during shorter fasting days in winter periods, therefore allowing the patient to safely combine medication intake with fasting practices. Other options would be to switch from short-acting to longer-acting agents that may be feasible for patients with, e.g., respiratory, endocrine, or rheumatic disorders. As stated above, medication intake and timing considered to be necessary for the patient automatically leads to a dispensation not to fast, and this should be discussed with patients and relatives that may have different understandings of the need for medication. Some Muslims believe that medication may also be taken by other routes than orally without any consequences for fasting; however the use of specific types of medication routes during Ramadan is a disputed area. Healthcare professionals may feel a need to seek out additional, specific counselling from the body of Muslim scholarly literature; however often consensus may be hard to find, and shared decision-making based on the particular patient and his/her overall health situation is advisable (Sadiq 2008).
Taking care of health while fasting – advice for Muslims
Drink ample amounts of water between sunset and dawn to avoid dehydration
Maintain a well-balanced, healthy diet that is rich in fibers and low in salt and glycemic index
Exercise is encouraged
Adhere to recommended sleep durations appropriate for different age ranges
Take advantage of the changing lifestyle patterns during Ramadan to quit smoking or other harmful health behaviors
Attend planned necessary healthcare appointments
Raising the issue of fasting in clinical encounters – advice for healthcare professionals
Ideally, issues related to fasting during Ramadan should be integrated into health education programs for patients of Muslim faith
Meanings of Ramadan and intentions to fast should be raised in encounters with Muslim patients, in particular with patients living with long-term conditions and/or multi-morbidity. Discussions should take place at appropriate timings, most importantly prior to the month of Ramadan, and in the patient-provider encounters where disease management is most firmly anchored. This could be in, e.g., community care settings, pharmacies, primary care settings, in- or outpatient settings, or the context of patient support associations
Open questions aimed at elucidating meanings of faith in general and Ramadan fasting in particular should be used, thus adhering to general principles for person-centered, engaging, and holistic healthcare practice
Managing Health Concerns During Mass Gatherings
The Significance of Religious Journeys in Islam
While mass gatherings occur in many places and situations, at times raising concerns for the safety and well-being of attendants, religiously inspired/motivated mass gatherings are often of particular importance for participants and for healthcare providers. In Islam, the journey to Mecca, known as the Hajj, is mandatory for Muslims once in a lifetime provided that the health and financial circumstances of the person allow for this travel (Gatrad and Sheikh 2008). Significant numbers of Muslims from all around the world travel to Mecca to perform the Hajj that lasts for 5 days and, as was the case for Ramadan, follows the Islamic lunar calendar, this varying in exact timings from year to year. Although Hajj is required only once for each person, many perform the pilgrimage several times as this journey represents an important spiritual exercise leading to both reaffirmation of faith and a sense of community with fellow Muslims across different ethnic backgrounds, socioeconomic position, or geographical origin. A lesser pilgrimage, known as Umrah, is performed more often and may take place at other times of the year (Gatrad and Sheikh 2008).
Rituals and Health Risks During Pilgrimage
A number of rituals are carried out while on Hajj, some of which may be strenuous in particular on those who are not in good health and the frail and elderly (Gatrad and Sheikh 2008). However, for all Muslims, the pilgrimage is likely to be physically demanding because of the setting (the hot desert climate of Saudi Arabia), the large numbers of people present at the same time leading to risks of overcrowding, the long walking distances, and the limited sanitation facilities – at least for those not staying in the expensive hotels built in and around Mecca. Long days of prayer, lack of shade, and lack of access to routine facilities such as healthcare may also compromise health conditions for some Muslims.
Health problems during pilgrimage differ according to the individual situation, health status, and functional ability; however some common health concerns are related to the risks of sunburn, lack of acclimatization to the heat causing heat exhaustion and heat stroke, injuries, or, although rarely, risks of stampede or fire accidents caused by the huge numbers of people living in the same area. Outbreaks of infectious diseases also represent an important health risk, in particular due to the many people travelling on Hajj from countries with large burdens of communicable disease and with suboptimal vaccination statuses (Gatrad and Sheikh 2008; Memish 2010; Shafi et al. 2008). Influenza, pneumonia, SARS, and MERS are some diseases that may spread in the overcrowded context of pilgrimage, despite attempts to enforce vaccination coverage and timely responses to unexpected symptoms among pilgrims (Al-Tawfiq et al. 2014; Gatrad et al. 2006; Gatrad and Sheikh 2008; Shafi et al. 2008).
In particular, those with pre-existing health concerns at times coexisting with frailty and/or older age should take appropriate measures to decrease their risks of either worsening of their health status or adverse outcomes caused by the risks mentioned above (Chamsi-Pasha et al. 2014; Memish 2010).
Although Muslims are not required to embark on neither the Hajj nor the Umrah if their health is poor, often people are determined to travel for the spiritual meanings of the journey, also among patients who are severely ill and at times in terminal phases of their illness. Healthcare providers should therefore not assume that discussing ways of minimizing health risks prior to, under, and after pilgrimage is not relevant for very ill and/or older patients.
Managing health concerns during Hajj/Umrah – advice for Muslims and healthcare providers
Discuss current health status, its prognosis in the foreseeable future, and likely effects of adverse exposures on health during the pilgrimage
If advisable to travel, ensure appropriate vaccination coverage
Discuss strategies to lower risk of heat exhaustion and sunburn, in particular related to the use of sun block, minimal sun exposure (e.g., by travelling at night, keeping heads covered at day), consuming large volumes of fluids, increasing dietary salt intake, and responding to early symptoms of heat exhaustion and heat stroke (e.g., fatigue, headache, vomiting, delirium)
Ensure medication prescriptions covering the travel period and discuss potential restrictions on or permissions to take medications into Saudi Arabia
If possible, travelling to Mecca in advance of the Hajj is advisable to ensure acclimatization to the harsh desert climate
Raise possibility of having an accompanying partner (e.g., spouse, relative, friend) to assist in particular older or frail pilgrims
Advise related to appropriate footwear able to withstand foot injuries and burns, in particular for diabetic patients with neuropathy
For women, delaying menstrual bleeding through, e.g., oral contraceptive pills or contraceptive vaginal rings may be relevant as menstruation is considered a state of ritual impurity that hinders women in performing the Hajj
Bringing a simple travel pack with common remedies (e.g., analgesia, salt tablets, bandage, antiseptic cream, and water sterilization)
Being aware of pilgrim health facilities and knowing how to access these
Religious practices related to fasting during the month of Ramadan and travelling for pilgrimage carry important meanings for many Muslims, but they also have implications for health and healthcare practices. Although the nature of pre-existing health conditions to be managed during Ramadan or mass gatherings differs substantially, a basic understanding of the possible role of faith is important as this opens up for more open, person-centered care and shared decision-making in encounters between Muslim patients and healthcare professionals.
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