¶ … Hajj is the largest gathering in the world, attracting millions of Muslims each year. As the Muslim community worldwide grows to well over one billion, the number of pilgrims to Makkah (which is sometimes spelled Mecca) also grows The sheer numbers of people itself presents challenges for EMS staff. The population of Makkah province is currently seven million people, which increases during hajj (Arab News, 2012). In 2012, there were more than 3.5 million men and women in attendance but those numbers are expected to climb to as many as ten million by the year 2020 (D'Alessandro, Edd & Al Mubarek, 2013). The mass gathering presents a number of concerns for EMS professionals, from acute injuries related to crowd swells to the spread of infectious diseases to cardiac arrests. Effective communication is critical for the success of all EMS efforts at the annual Hajj pilgrimage. As the number of pilgrims increase each year, and as the local infrastructure shifts in response to those increases, EMS professionals face ongoing challenges related to communication. These challenges can be loosely grouped into five categories including language and cultural barriers, inter-agency communication constraints, intra-agency communication constraints, technology challenges, and also challenges related to public relations, public education, and the media. Each of these individual challenges presents particular opportunities for the EMS community, for primary stakeholders in Saudi Arabia, and for all participating organizations around the world. Although some of the communication-related problems seem overwhelming in light of the sheer number of participants in the Hajj or due to the involvement of multiple organizations and government agencies, such challenges can be overcome effectively through concerted, collaborative effort and cooperation. This project will explain the specific communications challenges faced by EMS professionals and EMS leaders and then provide a set of cohesive evidence-based solutions.

Research Question

What are the communication challenges faced by the Saudi Emergency Medical services during Al hajj season in Makkah city and in what way can the 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 "preform 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 essential five 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 2000 years, but since the Prophet Muhammad first led a group of pilgrims there in the year 630 CE, the Kaaba has become central to the Muslim faith. Now, the Kaaba is marked by an enormous black cube that Muslims believe to be the "center of the world," and which is literally in the center of a vast mosque complex Masjid al-Haram (Fetini, 2009). When pilgrims visit Makkah and enter the mosque complex, they will circle the Kaaba cube seven times in a counter-clockwise direction, a ritual that serves several spiritual functions including forgiveness, guaranteeing a "place in heaven," and also the fulfillment of 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 in Makkah, the pilgrim also visits Arafat, Mina, and Muzdalifah, all holy sites that are part of the overall Hajj pilgrimage. A large number of the pilgrims also journey to Madina, the site of the tomb of Muhammad. The movement of people between and within these sacred sites creates tremendous crowd-related risks, particularly considering that now more than two million people per year are completing the Hajj (Fetini, 2009).

Dhu al-Hijja is the last month of the Muslim lunar calendar year and considered the time when "God's spirit is closest to earth," (Fetini, 2009). Unfortunately for many pilgrims, the hajj might also be their last month on earth. During last year's (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 the recurring events, as each year people die and several years have witnessed death tolls in the hundreds or thousands ("Timeline of tragedies during hajj pilgrimage in Mecca," 2015). Save for completely redesigning the site or staggering visits, crowd management and disaster management need to be improved using evidence-based practice....

Communication is one of the most important areas that can be improved, in order to minimize risks and improve the efficacy of emergency response services.
For eight consecutive years from 2006 to 2015, no major disaster occurred at the Hajj. What was done differently, if anything, during those eight years? If the management of the event was somehow different, authorities need to know about how to best prevent the problems from occurring again. One of the things that Saudi disaster planners can do is use mathematical modeling to ascertain crowd movements and determine risks (Benedictus, 2015). Hajj naturally presents the most severe risk due to crowd density more than six people per square meter, a density in 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 at the Hajj have often been related to crowd stampedes and the crushing of people. However, ancillary disasters like hotels collapsing, being hit by stones during the symbolic stoning of the devil in 2003, a tent fire in 1997, and terrorist-type attacks have also occurred such as in 1979 when "hundreds of gunmen opposed to the Saudi government barricaded themselves inside the Grand Mosque," taking many pilgrims hostage and leading to hundreds of deaths and injuries ("Timeline of Tragedies during Hajj Pilgrimage in Mecca," 2015).

The hajj is certainly not the only mass event during which stampedes and other disasters have occurred. As Benedictus (2015) points out, 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 around the world. Yet much can 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 will respond to each of the five concerns outlined in this report including 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 protocol related to their areas of specialization to minimize problems related to bureaucratic organizational structures. The media and social media will help by facilitating communication with the public and providing educational services that aid in preventing problems before they occur.

A conceptual model also illustrates the organic flow of information and communication between the various parties involved. However, the model must remain flexible as each year at hajj unique situational variables will present themselves. Variable weather, changes to the local infrastructure, increasing numbers of pilgrims in attendance, shifting demographics of the attendees, and infectious disease development will all ensure that EMS personnel need to be flexible and responsive rather than rigid in their approach to communication.

Conceptual Models

This model illustrates how communications systems work to improve safety at the Hajj. The model shows how the five key components to communications strategies all work together as independent variables: from improving staff knowledge of language to communication technology to public relations, intra-agency communications, and inter-agency communications. When each of these variables working properly, they can impact dependent variables including quantitatively measured safety improvements (such as reduced loss of life or reduced numbers of injuries), improvements to the language and cultural competencies, and to technological literacy across all agencies.

Language and Cultural 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 need to pay close attention to how to best communicate across linguistic and cultural boundaries. Even in multicultural environments, EMS responses may be delayed due to language barriers (Grow,, Sztajnkrycer & Moore, 2007). Oliviera (2013) points out that crisis management frameworks frequently lack cultural competency standards, and that increasing cultural competence requires simple training interventions that can vastly improve service delivery. Language barriers are only a few of the many potential obstacles to effective EMS delivery of care and services. Perceptions…