Paper presented at the Second Universiti Malaya Medical Center
Conference on Medicine from the Islamic Perspective held at Sheraton Subang on 11-13 October 2002 by Professor Omar Hasan
Kasule, Sr. MB ChB (MUK), MPH, DrPH (Harvard). EM firstname.lastname@example.org. Web address: http://omarkasule.tripod.com.
Discussion of the medical benefits of saum should not distract us from
the more important considerations of its obligation as ‘ibadat and its virtues,
fadhl al saum. Saum according to Islamic
regulations has no physiological harm. Saum is practical training in five important
aspects: control of the food appetite, control of the sex appetite, behavioral self restraint, compassion for others, and
personal empowerment. Control of the food appetite prevents diseases due to malnutrition. Control of the sex appetite prevents
sexually-related diseases and conditions. Behavioral self-restraint prevents aggression that results in physical and mental
harm. Compassion for others enables a more equitable distribution of health-related resources to relieve the disease burden
of the less privileged. Personal empowerment strengths individual will to adopt and maintain a healthy life-style.
1.1 Obligation of saum
Saum is obligatory and is one of the pillars of Islam, al saum rukn al Islam[i], enjoined by the Qur’an[ii]. It has two main pillars, arkaan al saum,
intention, niyyat al saum, and abstinence from food or drink, imsaak 'an al ta'aami wa al sharaabi. The definition of saum as prohibition
of entry of anything through any of the external body orifices is figurative but is true. Food and drink through the mouth
are not allowed. Smoking and other inhalants are also forbidden. Sexual relations are strictly forbidden. All these prohibitions
operate during the day-light hours because saum is not obligatory at night. Saum is obligatory for adult, sane, and healthy Muslims who have reached puberty or
have attained the age of 15 years.
1.2 Virtues of saum, fadhl al siyaam,
The merits are many and varied. The spiritual merits are expiation of sins. The medical
merits are self control and discipline with regard to appetite for food and sex. The social merits arise from the self restraint
and self-discipline since the saum person is enjoined to desist from quarrelling,
loud talk, cruel acts, and falsities. The personal benefits are personal empowerment. Those who fast will enter jannat through the gate of rayyaan[iii]. Saum will be an intercession in the hereafter, al saum shafa’at yawm al qiyamat[iv]. Saum cleanses the body, al saum zakaat al jism[v]. The saum person has two pleasures: when he breaks the fast and when he meets his Lord, li al saim farhataan[vi]. The smell of the mouth of the person saum, huluuf fam al saim, is better
to Allah than the best of perfumes[vii]. If a person fasts the month of Ramadhan in the true belief and expectation of reward from Allah,
he is forgiven all the previous sins[viii].
2.3 Etiquette and Regulations of saum:
Among etiquettes of saum, adaab al
siyam are: intention of saum, niyyat
al siyaam, before fajr[ix] and avoiding falsehood or foolishness during saum[x]. Among recommended acts of saum, sunan al siyaam/manduubaat
al saum are: night prayer in Ramadhan[xi]. itikaaf in the last 10 days of Ramadhan[xii], dua at break-fast[xiii], generosity, al juud; joining kindred
relations, silat al rahm; recitation of the Qur'an, tilawat al Qur'an; major ablution before salat al fajr;
avoiding back-biting, ghaibat, telling lies, kadhb, and obscenities, fahsh, providing breakfast for the poor, and delaying non-urgent medical treatment. Among offensive acts of saum, makruhaat al siyaam,
is kissing for young couples or those who can not control themselves from sexual arousal[xiv]. Prohibitions of saum, muharramaat al siyaam, are sexual intercourse in the day[xv], eating and drinking in the day[xvi]. The following abrogate saum, mubtilaat
al saum, and require make-up, qadha: deliberate eating and drinking,
akl 'amdan; use of snuff or tobacco in the nose, putting water in the ear until
it reaches the ear-drum, excessive madhmadhat, excessive istinshaaq, insanity
or loss of consciousness even if temporary, any penetration by any object or material into the body cavity (intra-muscular
and intra-venous injections are excepted); vaginal coitus or any other sexual act that leads to orgasm.
1.4 Types of saum
The saum of the month of Ramadhan is obligatory.
The following are permitted non-obligatory saum: saum of Mondays and Thursdays[xvii], saum of the 9th and 10th of
Muharram, saum of 6 days in the month of Shawal[xviii], saum of 3 days in every lunar month[xix], saum of the day of Arafat for the pilgrim[xx], saum of the sanctified months, ashhur al hurum[xxi]. The following types of saum are forbidden: saum of the 2 days of eid al fitr and eid al adh-ha[xxii], saum during ayaam al tashriik[xxiii], singling out Friday as a day of saum[xxiv], continuous saum, wisaal[xxv], life-time saum, saum
al dahar[xxvi], saum of a doubtful day, saum yawm al shakk[xxvii], saum in the second half of sha'abaan[xxviii], and purposely planning to selecting saum on Friday,
Saturday, or Sunday. Two types of saum are punitive: saum of 3 days during hajj and 7 after return to home country for infraction of a hajj riteand saum of 60 days for sexual intercourse in Ramadhan.
2.0 PREVENTION OF
PHYSIOLOGICAL HARM IN SAUM
2.1 Concepts of ‘psychological’
and ‘physiological’ hunger
The purpose of saum is to achieve taqwa[xxix]through disciplining and controlling two of the most powerful human drives: food and sex. It is wrong to think that the
purpose of saum is food deprivation because in normal circumstances a person in
saum has enough nutrients stored in the body and is not at any moment in physical
danger due to food deprivation. He however feels hunger and thirst which are psychological proxies for the food drive whose
control is the purpose of saum. The psychological hunger drive is satisfied by
ingestion of food or water using the alimentary canal (from the mouth to the anus). It is not satisfied by intake of nutrients
through any other route into the body. I am therefore of the opinion that the jauf
of the fuqaha is the alimentary canal and nothing else. Saum is abrogated if any material is ingested in such a way that the drives of hunger and thirst are satisfied.
The distinction between ingestion of food and water for satisfaction
of the hunger drive and their ingestion for purposes of bodily physiological need is made very clear in the Qur’an[xxx]. Food ingested may not satisfy hunger but may fulfill physiological needs. In sham feeding experiments,
an animal ingests food by the mouth but the food does not reach the stomach being diverted by a tube to outside the body.
The animal does not feel hunger but suffers from food deprivation. Patients on intravenous feeding get enough nutrients for
their physiological needs but feel hungry because they do not eat through the mouth.
2.2 Saum has no physiological
Saum does not make the body suffer to attain spiritual benefit. The concept of ascetism in this sense
is alien to the Islamic creed. There is no spiritual advantage in punishing or persecuting the body or causing it any harm.
The rights of the body must be respected in saum[xxxi]. Decisions of non-obligatory saum should consider three types of rights: rights
of the self, haqq al nafs; rights of the family, haqq al ahl[xxxii], and rights of the body, haqq al jasad[xxxiii]. A balance is needed among these rights. A balance must also be established between fulfilling these rights and ‘ibadat.
Saum therefore results in psychological and not physiological hunger. Saum
will have to be terminated if it actually results in nutrient deprivation that harms good health in any way. Excessive hunger
or thirst that harm health are valid excuses for breaking the fast and making it up later, qadha.
Saum according to Islamic regulations has no physiological harm. Saum
during the day has almost the same duration as the normal overnight saum with the
difference that metabolism and hence nutrient requirements are lower during sleep. Saum
according to the regulations is associated with psychological hunger but does not expose the body to any significant nutrient
deprivation. Allah created the sensation of hunger as a warning to humans to start looking for the next meal. Sensation of
hunger does not indicate immediate need for food or nutrient deprivation because the body has a reasonable nutrient storage
2.3 Exemption from
saum for physiological stress
The Law provides guidelines on saum for those who may suffer from physiological imbalances. The sick, the young, the travelers, pregnant women,
menstruating women, breast-feeding mothers, and any other persons for whom saum
is an extra burden are excused from saum or are asked to fast at a different time
when they are physiologically competent. Children are told to fast from the age of 7 years but the saum of children[xxxiv]is for training but is not obligatory. The insane
and those with physical conditions that can be aggravated by saum are exempted.
The sick are allowed to break the fast and make up for lost days later[xxxv]
2.4 Etiquette of
saum for preventing dehydration and hypoglycemia
The Prophet recommended delay of suhuur, ta'akhiir al suhuur[xxxvi], hastening iftar, ta'ajiil al iftar[xxxvii]. Suhuur is delayed such that there is a very short time remaining before fajr[xxxviii]. Breakfast is hastened at sunset[xxxix]. The prophet recommended breaking the fast with dates (high sugar content) and water[xl].
2.5 Exemption of
the sick and those under physiological stress
Exemption from saum
with no make-up and no kaffaaratoccurs
in the following conditions: old age, shiekh kabiir; weakness, 'ajz; and illness with no hope of cure, maradh muzmin. The following
are allowed to break the saum and make up later: a patient with expected recovery,
al maridh[xli], the traveler, al musafir[xlii], the pregnant woman, al hublah[xliii], the breast-feeding woman or nursing woman, al murdhi'[xliv], the menstruating woman, al haidhah[xlv], and a woman in post-natal bleeding, nifaas.
2.6 Allowing activities
of normal living during saum
When undertaken according to the teachings of the prophet,
saum should not disturb the normal activities needed to work for feeding the family
or undertaking ‘ibadat. It is offensive to treat the month of Ramadhan as
a month of laziness with no productive work. The following are permitted during the day: using the tooth-pick, siwaak; use of toothpaste can be used provided care is taken not to swallow any of it; rinsing the mouth with
pure water with care being taken to avoid swallowing;washing or bathing in water
with care being taken not to swallow any water; applying kuhl, kissing a spouse
if there is no fear of sexual temptation, and washing or rinsing inside the mouth and nostrils. The Law also provides for
protection of conjugal rights of spouses[xlvi]. A guest does not fast non-obligatory fasts except with the permission of the host[xlvii]. If a person eats or drinks in forgetfulness then all they have to do is to complete the day
and the day is considered valid[xlviii]. A non-obligatory fast can be broken at any time but must be redone, qadha[xlix]. The following activities do not nullify saum: wet sexual dream[l], madhmadhat, istinshaaq[li] with no exaggeration, cooling the body such as tepid sponging, tabarrud,[lii].
2.7 Prohibition of
harmful actions in saum
The Law prohibits continuous day and night saum, wisaal[liii]and saum every day for life, siyam al dahr.
2.8 Medical guidelines
The person in saum should aim at
maintaining normal body weight or actually reducing it if overweight. Over-eating at iftaar and suhuur should
be avoided. Over-eating will cause indigestion. The diet should contain sufficient fiber to prevent constipation. Fiber and
slowly digested foods with a long stomach transit times are preferred. Enough water should be taken at night both for preventing
dehydration and preventing constipation. Adequate fluid and salt intake prevents lethargy in the afternoon caused by low blood
pressure. Hunger is a cause of headache especially later in the day. Intake of adequate calcium, magnesium, and potassium
will prevent muscle cramps. Hot places should be avoided. Attempts should be made to keep cool. Time should be allowed for
adequate sleep because inadequate sleep is a cause of headaches. Monitoring for and prevention of hypoglycemia is necessary
during saum. In non-diabetics hypoglycemia may be due to insulin overproduction
on intake of refined sugar. In diabetics it may arise due to insulin injections with inadequate dietary intake. Peptic ulcers
are aggravated by raised acid levels. Kidney stones may be due to low fluid intake. Joint pains may be due to excess solutes.
2.9 Medication in saum
The general rule is that any substance that enters the body through any of its openings, manfadh, nullifies saum. The openings are the two ends of the alimentary
canal, the mouth and the anus. All drugs that are applied externally on the skin do not nullify fating. Use of eye drops does
not nullify saum. Nose drops may nullify saum
because they could drop into the pharynx and be swallowed. Inhalants also nullify saum.
Sub-cutaneous, intra-muscular, and intra-venous injections do not nullify saum.
However nourishing injections nullify the purpose of saum. Drugs of whatever form
taken orally or anally nullify saum. Sub-lingual pills are allowed.
3.0 TRAINING IN CONTROLLING
THE FOOD APPETITE
3.1 Normal Nutrition
The human needs food to survive[liv]. Humans need different amounts and types[lv] of food depending on their gender, age, health status, and type of activity. Humans eat by Allah’s
permission. They must therefore mention Allah’s name at the start of the meal[lvi] and praise Him at the end[lvii]. The general principle of the law is that all food is halal
unless specifically prohibited. The Qur'an listed permitted food[lviii]. Humans can speculate but cannot know with certainty the reasons for Allah’s decreeing
some foods halal and others haram.
3.2 Nutrition and Disease
Malnutrition whether qualitative or quantitative has disease implications. Over-nutrition leads to obesity and related
neoplastic and cardio-vascular diseases. Obesity, defined as 120% of ideal body weight or higher, arises in cases of excessive
intake and decreased energy expenditure. It is a social and medical disease that was condemned by the prophet. It is directly
associated with coronary heart disease. It also has an indirect association through causing a rise in blood pressure. Besides
its association with disease, obesity in its extreme forms interferes with performance of physical acts of ‘ibadat such as saum, salat,
and hajj. Disease associations with excessive intake of specific nutrients have
been described by epidemiologists. Hypertension is associated with high sodium intake. Coronary Heart disease is associated
with high dietary unsaturated fats. Colon
cancer is associated with a diet of high protein and high fat. Gall stones are associated with high cholesterol and high sugar
diets. Diabetes (type 2) is associated with high fat diets
3.3 Human will and
Scientific medicine has made much progress in the control
of infectious diseases. Its record on chronic and non-communicable diseases is still poor. This is because these diseases
are related to life-style and their control requires changing human will to adopt a more healthy life-style. Human will has
in a way become the last frontier in medicine because changes in dietary and sexual habits are very difficult.
3.4 Saum in health promotion
and disease prevention:
Saum also has health benefits. It purifies the body, al saum zakat
al jism[lix]. Abundant epidemiological evidence has proved that diet is a co-factor in heart diseases and cancer. People or communities
with excessive intake of certain types of foods are at increased risk for these diseases. Tobacco is linked to lung and oral
cancers. In all such cases there is weak will power to control appetite for food or tobacco. Saum teaches appetite control. The advantages of saum should not be
looked at only as deprivation of food for a limited time. The focus should be looked on the long-term benefits that a person
undertaking saum gets from strengthening will-power and stopping eating or smoking
even if they feel like to eat more.
3.5 Saum and Control of Food
Saum has a positive impact on the individual. Saum is ‘ibadat that teaches self-control. A person in saum is able to control the food instinct, perhaps the most powerful human instinct. The sense of self-control
gained is extendable to other situations of temptation to evil or when facing difficulties. The believers eat differently
from the non-believers[lx]. They eat only when they are hungry and do not eat their fill. The meal should not be
treated as a form of entertainment. It is a necessary act of ‘ibadat to give
the body the energy and nutrients needed to undertake the human mission on earth. Satiety can be described in three states,
maraatib al ghadha: the necessary, dharurat; the needed, haajat; and the excess, fadhl. Dharurat is the minimum nutritional
intake necessary to maintain health in the best status. It represents the balance between excessive and too little intake.
Haajat is intake that is more than dharurat but which prevents the feeling of hunger. It is however recommended
not to eat to full satisfaction, shaba’u. Fadhl is the excess intake beyond the need. Waste in eating
and drinking is condemned[lxi]. Both obligatory and nafilatsaum help in controlling excess intake. A Muslim should eat only what satisfies hunger and give the rest of the
food to the needy. It is a waste to eat more than what you actually need. Most of this just passes through the alimentary
canal and is voided as waste. It is considered bad to eat whatever you desire without discrimination, sharr akl kull ma
4.0 TRAINING IN CONTROLLING
THE SEX APPETITE
Saum helps in control of the sex drive[lxii]. Saum is a general protection, al siyaam junnat[lxiii][lxiv]. It is protection for one unable to marry, al
saum wijau li man lam yastati’u an baa’at[lxv]. It is a means of instilling sexual
self-control, al saum li man khaafa al 'uzuubat[lxvi].
5.0 TRAINING IN BEHAVIORAL
Saum is an exercise and training in patience. Saum is half of patience, al saum nisf al sabr[lxvii]. It helps control of aggression. A person in saum
who is insulted does not respond in kind but just says 'I am in saum'[lxviii]. Saum helps control the tongue; a person in
saum who does not achieve this control gets not rewards from the fast[lxix].
6.0 PERSONAL EMPOWERMENT
Saum is freedom from the daily routines of life. It therefore leads
to personal Empowerment. Saum has a beneficial impact on the daily routine of life.
Saum breaks the normal routines of life that revolve around meals. It creates a
different psychological milieu that liberates the mind from the routines of life and gives it an opportunity to reflect on
the bigger issues of the creator, the good and the bad. It is surprising to many people to discover that their daily life
routines are tightly controlled by the pattern of meals. A person in saum feels
a sense of liberation in Ramadhan when the routines of daily life are changed. Ramadhan is therefore a time of stock-taking
when a person can look back in his her life when he or she is in a different mood. Saum
is empowerment. A person in saum is able to control the appetite for food and to
withstand hunger for a whole day. This is an exercise in self-control and self-discipline that empowers the person. This empowerment
can be transferred to other life activities.
7.0 TRAINING IN COMPASSION
Voluntary hunger in Ramadhan gives the rich practical experience of hunger that makes them understand and appreciate
the suffering of the poor. It teaches compassion for the poor and the hungry in a practical way. Without this obligatory saum the wealthy would never taste physical hunger. The Qur’an emphasized the
virtues of giving food to the needy[lxx]. The prophet taught the virtue of feeding others, fadhl al ‘it’aam[lxxi] especially the hungry, it’aam al jai’u[lxxii]. This can take any of the following forms: sadaqat, kaffaarat, zakat al maal, and zakaat al fitr. The prophet
taught the virtue of sharing food when he said that the food of suffices 4[lxxiii]. He also taught that food not needed should be given to the needy, man kaana ghaniyan ‘an al ta’aam faliyuwajihahu
ila ghayrihi[lxxiv]. Food security has been an important factor in the growth of human civilization. Early humans were hunter gatherers who
spent most of the waking day looking for food and even with that they could not be sure that they could get their day’s
meal. When humans settled down in communities and started domesticating plants and animals they were able to assure themselves
of food without having to search the whole day. With the problem of food security solved humans could devote energy to tasks
of building a sophisticated human civilization. The family unit must ensure food security especially since it has children
and pregnant women who are very vulnerable to malnutrition. The prophet recommended putting aside food reserves for a whole
year to ensure food security for the family. There is no true problem of food security in the world as a whole. The problem
is poor distribution. Whereas food is being wasted in rich countries, humans in poor countries are starving. Situations of
war and civil disturbance also create conditions of temporary food insecurity.