Who should perform Hijama?

Who should perform Hijama?

Who should replace the Barber Surgeon of the 1800's?

This is a question that is widely discussed, debated and even argued about in the practical sphere of hijama (wet-cupping) therapy. Is hijama something that should be exclusively practiced by qualified doctors or is it something that can be done at home by family members and lay people alike? This is a question that patients and practitioners are continuously asking.


What is at stake?  
Firstly, it must be highlighted that our health, whether we recognize it or not, is our greatest possession, second to only one thing, our spirituality (imaan). These two assets are entrusted to us by Allah and when combined they amount to more than any amount of wealth that any human being can possess on the face of the earth. Once this basic principle is understood, the gravity of placing this trust (amaanah) in the hands of someone else can truly be fathomed.


As hijama is a method of treatment that can have an influence on both ones physical and spiritual health, the importance of deciding on who can, and who can not, be entrusted with these assets is a serious matter.


How do we decide?

In all cases which we go to seek advice, help or assistance from another person, we knowingly or unknowingly put our trust in them in some shape or form. When we go to a mechanic to fix or service our car we entrust them with our vehicle. We go to an accountant to manage our accounts and we entrust them with our financial affairs. We go to a plumber to maintain or improve our boiler and we entrust him with it. In all these cases we are entrusting an individual with an asset and there are always risks that we may lose that asset or that it may become damaged beyond repair. This relative risk is taken by the person entrusting the asset, only after making some basic judgments, “Is this person competent in the task that I am entrusting them with? How proficient is their knowledge in the subject area? Are they of trustworthy?” And so on.


Many of these judgments are made on a daily basis by each of us and are based on some principles of common sense. When we seek advice in any area we would always prefer to go to the person who has the most knowledge, understanding and competence in that field. This is also an Islamic principle as Allah the almighty says 'Ask the people of Knowledge if you do not know' (Quran 16:43). This is why we do not go to an accountant to fix our car, or to a plumber to do our accounts. Although the plumber may be a nice person, be punctual with his prayers, be good with numbers and be willing to take on the extra work, it is obvious that he lacks the many years of training to take on a public limited company’s (Plc) accounts and do it as effectively as a chartered accountant. The risk for failure in this task is obviously greater with the plumber than with the accountant.


The obvious choice.

When dealing with our health it is obvious that we go to the people who have the most knowledge and understanding of health and fully appreciate how the body works. This is why we call the paramedics when we are having a heart attack and not the builder. Although this is obvious, there are many factors related to the practice of hijama that can make the subject of the 'obvious choice' somewhat unclear. This lack of clarity has allowed many people with or without adequate healthcare training to take up this practice. One of the major reasons for this is that other than being a healthcare intervention, hijama is also considered a religious practice. However, some may argue and point out that circumcision is also a religious practice and yet it is almost always performed by a medical doctor. 


If you were given the choice of a qualified dentist or a renowned barber to remove your wisdom teeth, you would clearly choose the dentist, not only because he has more experience but because you know that he will have a detailed understanding of how your whole body works and therefore, in theory, there should be less risk of a complication during or following the procedure. In the famous hadith narrated by Tirmidhi, Allah’s messenger (PBUH) told the bedouin to tie his camel and then put his trust in Allah. This means that we are responsible for taking all precautions and avoiding risks where possible with our life choices.


Would you take a risk if it could be avoided?

From both the Islamic perspective as well as a rational point of view, when such a valuable asset as health is at stake there should be no risks or chances taken if they can be avoided. By ensuring that you are entrusting your health in the hands of someone who has dedicated many years of study in the field of health such as a doctor, you are taking the initial steps in minimizing the risk of harming the physical health that Allah has entrusted to you. In an ideal world the people that we would all go to for hijama therapy should be trained and qualified health professionals who have studied health and medicine and also have a good understanding of how hijama works with both its physical and spiritual applications.


The need

With a growing awareness of prophetic medical practice and a global religious revival many people are turning to hijama as a means of gaining physical and spiritual benefit. Coupled with statistics that demonstrate minority groups in the west as having the poorest level of health, hijama is now something that is of great need and demand. If given the choice people would almost always choose to be treated by a qualified and trained health professional but this option is often not available.


The Problem
Very few health professionals trained in a field of medicine appreciate, understand and unfortunately in some cases, believe in hijama. The root of this problem lies deep within the history of Muslim physicians practicing medicine. Unfortunately the abandonment of hijama as a mainstream medical practice took place not only in the western world in the late 1800’s but also by what were then mainstream medical practitioners in the Muslim world too. The compliance of every single Muslim physician from that era until today in the neglect of this sacred prophetic medical practice and religious instruction is what has allowed the procedure to become dis-attached from the medical professions and an alienated practice today.


Who is responsible?

The historical survival and current revival of hijama has to be accredited to none other than the traditional practitioners and the lay people who have kept the practice alive until now. It is these people alone who saved this practice from being a forgotten ritual myth through the many years of neglect from other fields. It is also these people more often than not who are responsible for introducing, and in some cases even teaching the concepts of hijama to health professionals. Although many become angered at the thought of untrained hands performing what is considered in a medical context a minor surgery, they must realize that blame does not lie with the lay practitioners. If hijama had been kept within the sphere of mainstream medical practice by Muslim physicians during the time of its demise in the western world, it could have been preserved as a medical procedure in its appropriate clinical context without the need of lay people having to take it into their own hands. Similarly, it could be argued that if the dental profession hand not been embraced by the medical world and recognized as an integrated part of health care, barbers would still be pulling out teeth today in the same way as they did in the past. Many will agree that eradication of the profession does not result in the eradication of its need.


Who can we turn to?

The situation we are currently in provides us with practitioners of scientifically backed understandings of health and medicine with no or very little understanding and practical skills in hijama therapy. On the other hand it provides us with practitioners with a wealth of experience in the practical skills of hijama and some understanding based on anecdotal experience but with no or very little understanding of health and medicine and in some cases of infection control too.


Layman Vs Professional

Given the situation we are in, it may be the case that hijama treatment provided by a doctor with little experience may not give the best possible results as it will require time for him/her to build up a bank of clinical experience and understanding to treat clinically diagnosed cases in the best possible way. This is something that all health professionals have the capacity to build if given the opportunity through clinical contact, communication and mentorship with other practitioners. This scenario also allows the implementation of a screening process in which patients not suitable for hijama or with possibly more serious conditions can be referred to other areas of healthcare and specialty in the appropriate time frame, therefore allowing for the improvement of the patient's health as a whole.


The second scenario entails an experienced but lay practitioner providing treatment that may or may not be effective depending on his/her ability and experience, but may potentially risk the patient's health due to their lack of understanding of some fundamental principles in medicine such as blood volume, pressure and infection control. There is also a chance that the practitioner may lack the ability to recognize pathological processes or symptom patterns which may put the patient at greater risk of not receiving the correct treatment in the correct time frame. Although this may not always be the case, as many practitioners are competent in these areas, there is still no standard in terms of the level of training, education and understanding required by the therapists making it practically impossible to determine who can safely practice hijama.


Towards finding a solution

The solution to this problem may seem apparently obvious; either the lay practitioners of hijama increase their understanding of health and medicine to include anatomy, physiology, pathology, infection control and general diagnosis in order to manage patients in a primary care setting or Muslim doctors actively re-embrace this practice as an integrated part of medical care, thus allowing patients to receive the best possible treatments in the safest possible setting. There are however many obstacles and hurdles that make both of these solutions impractical and extremely challenging ambitions.


Firstly in order to provide training for lay practitioners to undergo a course in medical science it would require the establishment of sophisticated and organized teaching institutions with dedicated staff that are able to provide full time teaching to full time students. Considering many of these practitioners undertake hijama on a part-time basis or as a hobby, this would appear to be problematic from the onset as the level of commitment to be trained to a primary healthcare standard would be lacking in many of the candidates, not to mention the financial implications of such training. Another problem would be the requirement of some form of regulation through legislation in order to allow these practitioners to be recognized as primary care providers. Even to the most hardline protagonists of this goal within the field, it would appear to be an extremely difficult task to achieve, especially in the western world.


The admittedly more practical way of attaining the most competent hijama practitioners would be to teach doctors and health professionals already trained to work in a primary health care setting. This solution is by far the most feasible option but unfortunately can not be achieved without difficulties. 


Firstly, there is a fundamental lack of belief in the practice of hijama among many Muslim health professionals globally. Sadly, hijama has been described by many Muslim physicians as being, “outdated”, “unscientific” and even “medieval”. These statements have obviously been made out of shear ignorance and without reviewing both the religious or scientific literature.


Of the practitioners who have religious conviction in the practice there is also a practical hindrance. Many are engaged in full time practice as consultants, GPs, dentists, opticians, physiotherapists etc. This prevents these health professionals from taking the basic skills of hijama learnt through training and turning them into clinical experience. Not only is there a time element to this problem, there is also an issue with financial compatibility. If a health professional is to take time out to work as a hijama practitioner he/she would need to be paid the equivalent wage in order for the work to be both feasible and sustainable. This wage could range from £40-£300 per hour depending on the professionals specialty and cannot always be matched by the fees a hijama patient would be expecting to pay.


If this issue was overcome and a health professional came to a satisfactory rate of pay, it would require a degree of business acumen and organizational skill not accustomed to all health professionals to make the situation work. As hijama is currently a practice that is in the private health sector, health professionals would need the motivation, dedication and capital to set up their own practices in order to have a widely available service. The time and commitment involved in such a task would almost certainly require a compromise of the individual’s regular duties or occupation. These factors are some of the reasons why very few health professionals trained in hijama are capable of offering services on a full time basis.


The Current Situation

With almost no qualified health professionals openly and consistently providing this service as a result of the issues listed above, traditional practitioners and lay people alike are increasingly taking the opportunity to meet the demands of the people.


This in the short term can be seen as a positive outcome as the need of the patients is met and the lay practitioners are often receiving income equal to or greater than that which they would be generating from their usual occupations. Although the intentions of the practitioners and the patients may be correct to begin with, inevitably the risks are greater than what may have initially been perceived. In such situations mishaps, accidents and mistakes are inevitably going to occur. Qualified professionals are not void of faults or infallible in any way but the liability is greater with the untrained person as they actively take greater risks simply by not having a detailed understanding of how the body works and what the consequences of their actions may have on each patient. This understanding is demonstrated to be one of concurrence with Islamic teachings as the Prophet (pbuh) stated; "Those who practice tibb (medicine), but are not Knowledgeable in this profession are responsible for their actions." Narrated by Abu Dawud.


At this juncture, it may be noteworthy to highlight potential underlying ethical issues in the practice of hijama due to the fact that there are no governing bodies or institutions for patients to go to in the event of necessity. Cases in which practitioners overstep boundaries or misuse their position of trust and authority for personal and/or financial gain are now becoming common place in the UK.


When dealing with health professionals patients do have some security in this regard as practitioners are in most cases bound by their individual governing bodies and ethical codes which require both criminal record checks and mental health declarations before registration. In the event of misconduct there are significant consequences for the practitioners and their careers are potentially at stake providing a huge deterrent to foul play.


Unfortunately in the cases of non-professionals practicing hijama there is no safeguard for patients whatsoever and members of the public are left vulnerable to being mislead, overcharged and exploited with relatively no consequence to the practitioner. In extreme cases patients are being diagnosed with spiritual ailments such as “possessions”, “black magic” and “jinn” even though the practitioners have no authority or qualification (ijazah) to give such diagnosis in these fields. Regrettably, hijama itself is being used as a medium for diagnosis and predictable physiological reactions to poor patient management such as fainting, nausea and vomiting are being used as proof of supernatural interventions. Practitioners have even been reported to claim that bubbles, steam and/or streaks in the cups are also signs of such diseases even though these phenomena can be intentionally created on demand with very little effort. Although the majority of lay practitioners in the UK may be practicing with good intentions and are God fearing (have taqwa) it must be highlighted that this is the furthest extent to their liability.


Unfortunately what we are left with is a situation in which the best medicine known to mankind is not readily accessible to patients unless they are willing to make a compromise and seek care from individuals with an unknown level of competence or efficacy, effectively taking a gamble with their health and on occasions substantial proportions of their wealth. This issue is one factor that stops many people from resorting to this prophetic practice and receiving its benefits and astonishing results.


A Practical Solution:

A practical solution to the current problem must involve both the lay practitioners and health professionals in a way that is most beneficial to the patients while being sustainable for the providers.


Clinic set ups that allow health professionals to work within a team of lay practitioners would be ideal as this would allow patients to be assessed, screened and managed by an appropriately qualified and regulated health professional whilst allowing the treatments to be administered by a hijama technician (lay practitioner) under guidance. Appropriate training in screening, clinical hygiene and safe practice could improve the efficiency of the practice and could gradually include the implementation of a triage system that allows the more experienced hijama technicians to take on a partial role in the management of straight forward cases whilst referring all other cases on for consultation with the primary health care practitioner.


This set up not only allows the health professional the capacity to simultaneously manage a larger number of patients making it more financially sustainable but also embraces the lay hijama practitioners into a professional clinical setting in which they can comfortably practice with the support of a qualified health professional. Similar setups are seen in hospital wards in which doctors and nurses develop relationships in which they both complement and learn from each other whilst maintaining separate and distinct roles.


When void of the ability to refer on to a health professional, lay practitioners practicing alone are left in positions where they are expected to have knowledge or treat conditions beyond their scope of training, understanding and practice. Such situations either results in a humble and considerate practitioner refusing to treat complicated cases or an ignorant and over confident practitioner taking on the case and risking the health of the patient.


In situations where there are not facilities in place to offer such a structured system of care, a pairing or mentoring provision should be arranged so that lay practitioners are not left in situations where they feel pressured to practice or manage patients beyond their scope. Even if this scheme would involve a fee that the lay practitioner pays for the support, it would be within the interest of both the practitioners, patients and the health professionals to work together, as it would increase patient safety, practitioner credibility and reduce the chance of major errors or mishaps that could adversely tarnish the profession as a whole. The system itself could be a form of self regulation as each professional would have a pool of practitioners that they had contact with and the responsibility of mentoring. This inadvertently has the potential to create a degree of accountability as if there was to be a complaint against the practitioner it could be made to their corresponding mentor, allowing an avenue for complaints to be addressed, investigated and resolved. A degree of standardization could also be implemented at this level by ensuring that all practitioners underwent a basic standard of training provided by the mentor and covering essentials in infection control, first aid, patient screening and record keeping.




Unfortunately the majority of hijama training providers and courses both in the UK and abroad do not supply a follow-up or mentoring structure to their training, leaving the newly qualified practitioners alone to manage complicated patient cases without any guidance. Unfortunately, the majority of these courses are designed/created by individuals with no health backgrounds whatsoever hence the void of any clinical reasoning and lack of emphasis on medical science, pathophysiology, clinical anatomy or diagnosis. Even at the level of verification, there is currently no register or available database of people qualified through a particular organization to check and verify claims of qualification, to many, this makes the actual courses themselves worth very little on both the level of knowledge and credibility.


In order for there to be a platform on which both health professionals and lay practitioners can work together, there needs to be a mutual understanding and recognition by which both parties recognize and learn from the skills of each other. Ideally, a standardized protocol of practice needs to be adopted so that there is a framework to the techniques and methods employed as part of the hijama therapy. Once this is established the safety and screening guidelines need to be laid down by the health professional and patient management methods can be discussed and arranged between the two practitioners depending on their level of experience.


In concluding, the importance of mutual cooperation by all stake holders in the field of hijama can not be overemphasized. Only through this conjoined effort can the hijama profession progress in its knowledge, practice and understanding.


May Allah Grant us all the ability and sincerity to take this practice forward in the best possible manner and revive this sunnah, providing benefit to the people for the sake of pleasing Allah. Ameen.


By Dr Rizwhan Suleman Mchiro

Edited by Nurudeen Hassan BSc (Hons) MRes

Hijama Centres UK

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Website: www.hijamacentres.co.uk

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