Original Research
Health Systems & Mass Gathering Medicine

The Fundamental of Hajj Demand for Health Care Services Within Congestion in Makkah

Background: The Hajj Pilgrimage and Public Health

The Hajj pilgrimage to Makkah (Mecca) in Saudi Arabia represents one of the largest annual mass gatherings in human history. Each year, approximately two million Muslims from over 140 countries converge on the holy city to perform the fifth pillar of Islam. This extraordinary concentration of people — from diverse geographic origins, age groups, and health backgrounds — creates a unique and formidable public health challenge that demands careful planning, robust healthcare infrastructure, and evidence-based management strategies.

For Malaysia, the Hajj holds particular significance. As a Muslim-majority nation, Malaysia sends tens of thousands of pilgrims each year through Lembaga Tabung Haji (TH), the government-established institution responsible for managing the pilgrimage for Malaysian citizens. The Malaysian government invests substantial resources in preparing pilgrims for the health challenges they will face, deploying medical teams to Makkah, and providing healthcare services throughout the pilgrimage period. Understanding the health needs and healthcare demands of Malaysian pilgrims is therefore essential for optimising these investments and ensuring pilgrim safety.

This study, published in the Malaysian Journal of Public Health Medicine, investigated the types of health problems experienced by Malaysian pilgrims and their healthcare service requirements during the Hajj, with particular attention to the role of extreme congestion in driving health demand.

Study Methodology

The researchers conducted a cross-sectional survey involving 379 Malaysian pilgrims during the 2013/1434H Hajj season. Four hundred questionnaires were distributed at the Abraj Janadriyah Hotel in Makkah, which accommodated more than 3,000 Malaysian pilgrims, achieving a response rate of 93%. The survey was conducted after pilgrims had completed their Hajj rituals, enabling comprehensive reporting of health experiences throughout the pilgrimage.

The respondent profile was balanced between genders (49.6% male, 50.4% female) with a mean age of 52 years. This age profile is typical of Malaysian Hajj pilgrims, many of whom undertake the pilgrimage later in life after years of financial saving through Tabung Haji. The older age demographic is epidemiologically significant because it is associated with higher rates of pre-existing chronic conditions including cardiovascular disease, diabetes, and respiratory disorders — all of which can be exacerbated by the physical demands of the Hajj.

Health Problems During Hajj

Respiratory disease emerged as the dominant health problem, affecting 77.5% of the Malaysian pilgrims surveyed. This finding is consistent with the global Hajj health literature, which has consistently identified upper and lower respiratory tract infections as the most common illness among pilgrims. The combination of extreme crowding, exposure to millions of individuals from diverse geographic origins (each carrying their own respiratory flora), dust from construction activities, and the physical exhaustion of the rituals creates an environment highly conducive to respiratory pathogen transmission.

The types of respiratory conditions reported ranged from common upper respiratory tract infections (cough, sore throat, rhinitis) to more serious lower respiratory tract infections including pneumonia. Community-acquired pneumonia during Hajj has been identified in international research as a leading cause of hospital admission and, in some cases, mortality — particularly among elderly pilgrims with pre-existing chronic conditions.

Health problems were reported with varying frequency across different pilgrimage locations. The highest incidence was associated with activities in Mina, where 79.0% of pilgrims experienced health problems. Mina is the site where pilgrims spend several days in extremely dense tent encampments during the stoning ritual at Jamarat. The confined spaces, limited ventilation, and prolonged close contact with thousands of other pilgrims create ideal conditions for disease transmission. Activities at Arafah accounted for 30% of health problems, while tawaf (circumambulation of the Ka’aba) and sa’i (walking between the hills of Safa and Marwah) accounted for 16% and 6% respectively.

The Congestion Factor

Extreme congestion is a defining characteristic of the Hajj experience and a major driver of health problems. During peak ritual periods, population densities can reach 7 persons per square metre — a level of crowding that creates significant physical, environmental, and psychological stresses. The congestion contributes to health problems through multiple pathways: facilitating respiratory pathogen transmission, increasing the risk of heat-related illness by limiting air circulation, elevating the risk of crush injuries and stampede-related trauma, and creating psychological distress including anxiety and claustrophobia.

The Saudi government has invested billions of dollars in infrastructure improvements to manage congestion, including the expansion of the Grand Mosque, the construction of the multi-level Jamarat Bridge, and the development of the Makkah Metro system. Despite these investments, the sheer scale of the gathering continues to pose challenges. The study’s findings underscore that congestion management is not merely a logistical issue but a direct public health intervention — reducing crowding reduces disease transmission, heat illness, and injury risk.

Healthcare Service Demand and Preferences

Malaysian pilgrims expressed strong demand for specific types of healthcare services. Quality health personnel and quality medicines emerged as the most frequently cited needs. These findings suggest that pilgrims value both the competency of healthcare providers and the availability of effective medications, particularly for the respiratory and other infectious conditions that dominate the Hajj illness profile.

The study also captured suggestions for improving healthcare management during Hajj. Pilgrims recommended enhanced health education programmes delivered before departure, better hygiene promotion during the pilgrimage, and improved coordination between Malaysian Hajj health services and Saudi Arabian medical facilities. The recommendation for pre-departure health education is particularly noteworthy, as evidence suggests that pilgrims who receive comprehensive health preparation — including vaccination, instruction on hand hygiene, and guidance on recognising warning symptoms — experience fewer health complications during the pilgrimage.

Pre-existing Conditions and Vulnerability

The mean age of 52 years among respondents highlights the vulnerability of the typical Malaysian pilgrim population. Many pilgrims undertake the Hajj with pre-existing cardiovascular, metabolic, or respiratory conditions that may be stable in their normal living environments but become destabilised under the physical stresses of the pilgrimage. The combination of prolonged walking (often covering 5–15 kilometres daily), extreme heat (Makkah summer temperatures can exceed 45°C), sleep deprivation, dietary changes, and emotional intensity creates a cumulative physiological burden that can overwhelm the compensatory mechanisms of individuals with chronic disease.

Cardiovascular events, including myocardial infarction and heart failure, are recognised as leading causes of death during the Hajj globally. Malaysian Hajj health services typically include pre-departure medical screening to identify high-risk pilgrims, but the effectiveness of this screening in preventing adverse events during the pilgrimage depends on the thoroughness of assessment and the availability of appropriate medical support in Makkah.

Implications for Malaysian Hajj Health Management

This research provides fundamental data for the continuous improvement of Malaysian Hajj health services. The findings support several strategic priorities: strengthening pre-departure health education with specific emphasis on respiratory infection prevention; ensuring adequate supplies of antibiotics and respiratory medications in Malaysian clinic facilities in Makkah; deploying medical personnel with competencies in managing respiratory infections, heat-related illness, and cardiovascular emergencies; and advocating within international Hajj health forums for improved congestion management as a public health intervention.

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