For 1.8 billion Muslims worldwide, Ramadan 2020 brought unique challenges, as it coincided with the global covid-19 pandemic and implementation of social distancing measures. The Ramadan month of fasting requires adult Muslims (with exemptions) to abstain from food and drink from dawn to sunset. However, this year, there was considerable debate about whether fasting would be safe during the pandemic; particularly with a higher than expected disease burden and severity of covid-19 in ethnic minority populations.¹ Furthermore, traditional Ramadan communal practices came to a standstill, giving a sense of loss to the community.

Covid-19 produces mild symptoms in most people; however, some can develop severe or critical illness, leading to starvation ketosis, severe dehydration and rapid clinical deterioration, particularly in those with diabetes and cardiovascular disease (seen at higher prevalence in the ethnic minority communities).² This year, UK Ramadan fasts were 17-18 hours long, making sufficient fluid intake in the remaining hours difficult. Patients with symptoms due to covid-19, such as fever, loss of taste and fatigue, are at higher risk of dehydration although the link between dehydration and outcome in covid-19 is still emerging. Muslims were therefore advised that, should they experience symptoms of covid-19 or dehydration,³ they should break their fast, rehydrate and follow NHS guidelines.⁴

Furthermore, the NHS employs almost 1.5 million staff, of which approximately 21% are from ethnic minorites.⁵ These healthcare professionals are more likely to have higher risk of exposure and severity of covid-19, and those wearing PPE for long periods of time are at increased risk of dehydration; the latter can be extended outside of covid-19 to surgical staff wearing surgical gowns and masks. Stratification can help identify those at risk of severe covid-19⁶ and this was extended to help avoid Ramadan fasting in at risk individuals.

Whilst, many Muslims were anxious regarding the safety of fasting, preliminary findings from a recent South Asian Health Foundation’s “Ramadan during covid-19” survey suggest that most Muslims continued to fast as they usually do.⁷

Adhering to infection control guidance and social distancing⁸ was imperative during lockdown. Traditionally, Ramadan gives a sense of community, with communal evening meals and nightly congregational prayers at the mosque. With social distancing and closure of places of worship, many felt isolated, particularly as the covid-19 pandemic had already been taxing for mental health;⁹ with worry about contracting the illness, risk to loved ones and cancelled plans, as well as financial strain and social isolation all contributing to anxiety.

Muslims across the world responded to this challenge, finding new ways of upholding the principles of the month, whilst following covid-19 guidance. Previously, some Muslims have “fasted” from social media during Ramadan; this year was different.

The World Health Organisation highlighted the pivotal role of technology in overcoming some of the difficulties of Ramadan during the pandemic, with many Muslims incorporating video-calls to loved ones and vulnerable members of the community into part of their daily routine.¹⁰ Islamic organisations worldwide streamed nightly prayers, while scholars shared knowledge and encouraged individual worship in unison with others globally, through videos. Other initiatives such as “virtual iftars”, where Muslims across the nation would break their fast “together”, allowed Muslims to feel simultaneously socially and spiritually connected.¹¹ While the vast majority of Muslims surveyed by the South Asian Health Foundation had socialised less during Ramadan, perhaps surprisingly, most found the month less challenging and experienced less low mood than usual during this time.⁷

For many Muslims, adhering to social distancing was most difficult during the Eid celebrations, which is usually a time focused on gathering family and friends, and attending the mosque. In recent years, public Eid prayers in parks across the UK have drawn crowds of thousands of worshippers.¹² Instead, this year households performed Eid prayers at home in isolation for the first time, dropping off food at the homes of loved ones rather than sharing meals together.

Undoubtedly, this Ramadan was unlike that of any experienced in the lifetime of most Muslims. Many adapted to the situation with new and creative ways to engage with the wider Muslim community; ultimately remaining a time of reflection and connection, despite the disruption of this shared experience.

S Hanif, Fifth Year Medical Student, University College London, UK.

W Hanif, Professor of Diabetes, University Hospital Birmingham. UK.

Kamlesh Khunti, Professor of Primary Care Diabetes & Vascular Medicine, University of Leicester, College of Life Sciences, Diabetes Research Centre, UK.

Sarah N Ali, Consultant Physician, Department of Diabetes & Endocrinology, Royal Free Hospital, London, UK.

Competing interests: none declared. 

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