Muslims may now be the second largest religious group in the U.S. Good health care for Muslim patients means culturally aware and religiously sensitive care. Such care requires commitment, willingness to honor differences, and openness to exploring diversity—even within America's Muslim population. When, for example, a Muslim woman visits a Western-trained, white, male doctor, she may be uneasy with practices taken for granted in that setting. Depending on the individual and the circumstances, different cultural and religious issues come into play.

Consider Mrs. A, a 50-year-old Bosnian refugee who emigrated to the U.S. in 1997 to escape the war in her country and to live with her eldest daughter. Over the past two months she has become sleepless, irritable, unfocused, and anxious, distancing herself from friends at her suburban mosque; she now attends only midday Friday prayer services. Repeatedly she hears sermons about the attacks of September 11, 2001, and about threatening messages left on the mosque's answering machine. After one Friday service Mrs. A was so distraught that her daughter brought her to Dr. Albert for medical attention. A thoughtful family physician, Dr. Albert was able to learn, despite the language barriers and her agitation, that the hostility some Americans now feel toward Muslims has rekindled Mrs. A's horrible experiences in Bosnia.

Dr. Albert sees Mrs. A as manifesting classic symptoms of post-traumatic stress disorder. Before referring her to a colleague in psychiatry, Dr. Albert performs a physical exam. He does so cautiously because he is aware that in many Muslim countries men and women relate differently than they do in America. From Mrs. A's daughter Dr. Albert learns of the Islamic conventions about modesty and standards for interaction between unrelated males and females. Thus, he learns it is not rude when mother and daughter decline to shake his hand, not a cause for offense when they request a female doctor, and not unusual when they insist that parts of Mrs. A's body, such as her head and arms, be covered.

He also learns that the decision-making unit among immigrant Muslim groups is usually the family, not the individual. Thus, Mrs. A's husband and their extended family may wish to have a say in planning her treatment for post-traumatic stress. Dr. Albert may extend his efforts to learn how to give culturally and religiously attuned care by conferring—with Mrs. A's permission—with her imam (religious leader) or a lay leader of her mosque regarding religious and other community resources.

Another Muslim patient—Mrs. B, a 26-year-old African-American Muslim, six months pregnant, and suffering from bronchitis—calls for different sensitivities. She explains her understanding of the fasting obligations of Ramadan, which concern Dr. Albert because of her pregnancy and her illness. Turning to a respected Muslim leader he seeks information about treatment in general, and more particularly during Ramadan. He learns that in prescribing medication for Mrs. B's cough and congestion, he must be sensitive to Islamic prohibitions against the intake of pig products and alcohol. The gelatin coating on some pills contains pork extract, and cough medicines often include alcohol. Finally, the exemption of pregnant women from the Ramadan fasting requirement has important implications in this case.

In the "new religious America" recent immigration has created a "complex religious reality of encyclopedic dimensions."¹ Islam is the largest and, given current events, arguably the most significant of America's "new" religions, although Muslims have actually been part of America throughout our history. Scholars suggest that many African slaves who were brought to this country practiced Islam in their homelands. African-American Muslim movements founded in the U.S. date back to the early 1900s. Arab and Bosnian Muslims began their immigration around the turn of the twentieth century. Many other Muslim immigrants, including Asian Indians, Pakistanis, and African national groups, have arrived since the 1960s. Many theological distinctions can also be found within the American Muslim community, such as the broad branches of Sunnis, Shi'ites, and Sufis, plus subgroups within each branch.

The U.S. Muslim population numbers perhaps 7 million and is steadily increasing. Thus healthcare professionals can expect to treat more patients like Mrs. A and Mrs. B. While it is impossible to become expert in all the ethnic and theological differences within the American Muslim community, it is important to start with the awareness that Muslims' beliefs and traditions may be quite different from those of Christians and Jews. The list below offers general guidelines about how Muslim beliefs and practices can touch upon medical practices.

These guidelines are important starting points for developing a keen attentiveness to difference. In addition to these actions, however, the physician and the patient will need to teach one another what it means to be sick, what treatments are culturally sanctioned, who makes decisions, and how those decisions are to be made. Physicians and other providers can sharpen their ability to ask respectful questions that will facilitate greater sensitivity to and understanding of cultural and religious beliefs and practices among Muslim patients. Quality health care committed to the whole person demands no less.