The fifth pillar of Islam, Hajj – a pilgrimage to Mecca in Saudi Arabia – is something all Muslims must perform at least once in their lifetime, as long as they’re physically and financially able. Mecca is the holiest city in the Muslim faith and the Kaaba, a cube-shaped building set within the city's Great Mosque which is considered the House of God, is the focal point.
Hajj takes place over five to six days in the twelfth month of the lunar Islamic calendar each year. In 2023, it occurs from 26 June to 1 July.
Millions of pilgrims visit Mecca around this time. In 2019, before the Covid pandemic, there were almost 2.5 million visitors, with 1.9 million from outside Saudi Arabia. The Hajj was limited to small numbers of Saudis in 2020 and 2021, with one million foreign and domestic pilgrims in 2022. However, this year there will be no restriction on numbers and the age limit of 65, imposed in 2022, will be removed. There will also be no Covid-related restrictions.
The sheer number of people, along with the nature of the pilgrimage, pose unique challenges for authorities and assistance companies. As the lunar calendar is shorter than the Gregorian one, the dates of Hajj also change each year, adding to the preparation challenges. However, with careful planning and controls, authorities can limit the risks to pilgrims and facilitate getting help to them if necessary.
A risky business
There are a range of health and safety risks for pilgrims, who carry out numerous rituals in and around Mecca over the course of Hajj. These include walking counter-clockwise around the Kaaba seven times, walking and running between the hills of Safa and Marwah seven times, and travelling to the plains of Arafat. These rituals are physically demanding, especially in the Saudi Arabian heat, which can reach well over 40 degrees in the summer. The crowds also pose health problems.
“The huge volume of people in one place results in close contact, so diseases such as flu and, more recently, Covid-19 can spread,” said Lara Helmi, Managing Director of CONNEX Assistance, which operates in the Middle East and has offices in Cairo and Dubai.
“There’s also the risk of heat exhaustion when walking long distances, especially for the elderly. A large portion of pilgrims are of a certain age or elderly, so with them comes heart disease and other pre-existing conditions, as well as mobility issues.”
This year there will be no restriction on numbers and the age limit of 65, imposed in 2022, will be removed
A study published in 2019 that reviewed previously published literature on the health risks at Hajj found the most common cause of death were pre-existing cardiovascular diseases, at 66 per cent.
All pilgrims are at risk from the extreme weather, overcrowding and the strenuous nature of Hajj, but the elderly and disabled, and those with chronic illnesses, are particularly vulnerable.
The Saudi Arabian government takes responsibility for the health of all pilgrims during Hajj, providing them with free healthcare, regardless of what travel insurance they have or whether it covers pre-existing medical conditions. Medical standards are also high.
In July 2022, the Saudi Arabian Ministry of Health reported that by the fourth day of Hajj, its hospitals and healthcare centres had provided services to more than 97,000 pilgrims in Mecca and elsewhere, including performing 10 open-heart surgeries and diagnosing nine stroke cases virtually.
If patients choose to go to a private hospital - rather than relying on Ministry of Health-run services, where they can get private treatment for pre-existing conditions with the right insurance - assistance companies such as CONNEX can step in to provide transport.
Pilgrims from outside Saudi Arabia are also now required to buy a health insurance policy as part of their visa, covering accidental death and permanent disability, repatriation in the event of death, flight cancellation and delays, and Covid treatment and quarantine costs with cover of up to 100,000 SAR (around £21,500).
Although attitudes to women are very different in Saudi Arabia than other parts of the world, there are no specific risks at Hajj, and women now have greater freedoms in the country than in the past.
In October 2022, it was announced that women no longer need a male guardian to perform Hajj or Umrah – a shorter, voluntary version of the Hajj pilgrimage that takes place all year round.
As well as making it easier for infectious diseases to spread, overcrowding can cause fatal stampedes and crushes. Sadly, there have been numerous incidents at Hajj over the years, resulting in thousands of people losing their lives.
The deadliest was in 2015, when more than 2,400 pilgrims are estimated to have been killed in a stampede in Mina outside the city of Mecca, where pilgrims stay in air-conditioned tents and perform the Stoning of the Devil ritual on three or four consecutive days. The exact cause of the stampede has never been determined.
There are a range of health and safety risks for pilgrims
The Stoning of the Devil, which involves throwing stones at one of three walls (previously pillars) that represent Satan, has historically been particularly dangerous because of the crowd sizes, especially on days four to six of the Hajj when pilgrims throw stones at all three walls. Many of the stampedes have occurred at this ritual.
However, authorities have now put extra measures in place. “I would say that there is a very small possibility of experiencing a stampede now,” said Mohamed Abdo, Managing Director of LGA Assistance – another assistance company operating in the Middle East, based in the UAE.
“The way Saudi Arabia has prepared for the Hajj in recent years has been excellent,” he added. “They have been able to perform road expansions annually in the Grand Mosque, and in the stoning area and Arafat, and the Ministry of Hajj and Umrah has formed crisis management committees. They also deploy a large number of army, air force and police personnel to secure the area.”
Helmi said authorities have also used simulators to determine where police and other personnel need to be to avoid stampedes and put strict controls in place to prevent overcrowding.
“Mecca itself is closed down about a week before Hajj,” she commented. “Only residents and pilgrims with permits are allowed there, so this limits the numbers coming in and out. During pilgrimage, people are limited to certain areas and have to stay in assigned groups in assigned locations. It’s organised by allowing a certain number of individuals in one area, with a certain number in another.”
All mass gatherings are a challenge, but the Hajj is particularly risky due to the huge numbers that attend and the small number of areas they visit. Other fatal incidents include fires among the tents – which are now fireproof – traffic accidents, violence during protests, terrorist bombs, a hotel collapsing and a crane falling into the Grand Mosque. Abdo stated there have been improvements in the preparations for Hajj every year, though, which has made it safer.
The Saudi Arabian government takes responsibility for the health of all pilgrims during Hajj
Having to play the long game
Assistance companies and the authorities face many of the same obstacles when attempting to help pilgrims in need.
The size of the crowds and levels of traffic in Mecca – and at other pilgrimage sites – make it difficult to reach people quickly. Although the Saudi Ministry of Health sets up medical points and emergency centres specifically for Hajj in places such as Mina and the Great Mosque area, medical services are put under great strain and government hospitals have high occupancy.
“The main challenge we face is the availability of resources in the area,” said Helmi. “All the road ambulances could be out at the same time, with unavailable doctors and overwhelmed hospitals, meaning we can’t get a medical report to send to the insurance company. Everything takes longer and more effort.”
The effect on the supply of medical services and the extra time and resources involved in assistance ultimately affects cost.
The government can be difficult to communicate with
LGA Assistance has also had problems dealing with the authorities. “The government can be difficult to communicate with,” said Abdo. “Afterhours you can’t get anyone to help you, even during Hajj, as government offices and decision-makers finish work.
One way assistance companies deal with Hajj is to have a strong presence on the ground. Although LGA Assistance was already handling Hajj cases, it’s opening a permanent office in Mecca, as well as in Riyadh and Jeddah, for the first time this year. All three offices are set to open in the first quarter of 2023, in plenty of time for Hajj.
“We have a very strong network of private medical facilities within Mecca and other nearby cities, but opening an office in Mecca means we’ll be able to deploy our own doctors and medical team,” said Abdo. “We won’t have to use agents, which often cost too much and don’t give good-quality service. If we do it ourselves, we can be sure the service will be high quality.”
CONNEX Assistance has people in Mecca all the time to deal with Umrah, but sends a team there for the Hajj period since the volume of pilgrims is so much larger.
We have our own direct network throughout the Middle East; in Saudi Arabia since 2003,” said Helmi. “We work with all the major hospitals and clinics, and ambulatory services, and have several licensed doctors on call for house visits and even telehealth consultations.”
The authorities provide lots of help for pilgrims, including special facilities for disabled and older people, such as wheelchairs, canes for the blind and visually impaired, and transportation for those who can’t walk easily. There are also specialist companies that provide services to people with additional needs to help them perform Hajj. However, it’s clear that assistance companies play a crucial role in helping to keep pilgrims safe.