key: cord-0915927-et1qsiww
authors: Tan, Min Min; Musa, Ahmad Farouk; Su, Tin Tin
title: The role of religion in mitigating the COVID-19 pandemic: the Malaysian multi-faith perspectives
date: 2021-04-30
journal: Health Promot Int
DOI: 10.1093/heapro/daab041
sha: a22ffdd587fda0d694a14a11180370c27c8602a1
doc_id: 915927
cord_uid: et1qsiww

Social distancing is crucial in breaking the cycle of transmission of COVID-19. However, many religions require the faithful to congregate. In Malaysia, the number of COVID-19 cases spiked up from below 30 in February 2020 to more than a thousand a month later. The sudden increase was mostly linked to a large Islamic gathering attended by 16,000 near the capital, Kuala Lumpur. Another large COVID-19 cluster was from a church gathering in Kuching, Sarawak. Within a few weeks, Malaysia became the worst hit country by COVID-19 in Southeast Asia. While religious leaders have advised social distancing among their congregants, the belief that “God is our shield” is often cited for gathering. There is a need to promote sound decision-making among religious adherents so that they will not prioritize their loyalty to the subjective interpretation of religion over evidence-based medicine. Malaysia, a multi-cultural and multi-faith country, is an example of how religious beliefs could strongly influence health behaviours at individual and community levels. In this article, we detail the religious aspects of COVID-19 prevention and control in Malaysia and discuss the possible role of religious organizations in encouraging sound decision-making among religious adherents in mitigating this crisis. We make recommendations on how to promote a partnership between the healthcare system and religious organizations, and how religion and faith could be integrated into health promotion channels and resources in the response of COVID-19 and future communicable diseases.

via contaminated surfaces (World Health Organization, 2020a) . Since this disease is transmitted among people in close contacts with each other, WHO recommends a social distancing of 1 m (World Health Organization, 2020a). However, keeping the recommended social distance is difficult when population density is high, for example, during mass gathering.

Mass gathering is characterized by a gathering of at least 1000 persons to that exceeding 25 000 at a specific location for a specific purpose, or a gathering of large number of people that could strain the planning and response resources of a community, state or nation (World Health Organization, 2008) . However, this definition only takes into account crowd size, which is one of the descriptors of mass gathering. Arbon (2007) suggested the following more comprehensive definition: "mass gathering is a situation (event) during which crowds gather and where there is the potential for a delayed response to emergencies because of limited access to patients or other features of the environment and location." Mass gathering is a common feature in many religions. The annual Hajj pilgrimage may have two to three million Muslims from around the world gathering at Mecca, Saudi Arabia (Shafi et al., 2008) . The Lourdes pilgrimage at France may gather five millions pilgrims every season (Gautret and Steffen, 2016) . The Kumbh Mela pilgrimage in India, occurring once every 3 years alternately along the banks of four holy rivers, is the largest religious gathering in the world and may have over 120 million pilgrims from across the world (Memish et al., 2019) .

Religious mass gatherings often involve international travel where communicable diseases might be brought into or out of the host country. In addition, crowding of people in a specific time and site may lead to the spread of infectious diseases due to close contact among attendees. Outbreaks of respiratory and gastrointestinal diseases are not uncommon during religious mass gathering (Abubakar et al., 2012) , and have been reported during Hajj and Kumbh Mela (Abubakar et al., 2012; Memish et al., 2014 Memish et al., , 2019 .

Smaller religious gatherings such as prayers and worship services at houses of worship may involve hundreds to thousands of attendees and carry significant risk of transmission of infectious diseases. In 2005, there was an outbreak of measles among unvaccinated children after a church gathering of 500 in Indiana, USA, where the index case was a 17-year-old unvaccinated girl who had just returned from Romania (Parker et al., 2006 ). An outbreak of salmonellosis occurred at a church festival in 2012 attended by 200 Christians in Rwanda (Nzabahimana et al., 2014) .

To help curb the spread of COVID-19, many religious mass gatherings around the world have been cancelled. Saudi Arabia has suspended the year-round Umrah pilgrimage to Mecca in early March and all international flights to the country, and restricted movement of its citizens within the country (AlJazeera, 2020; BBC News, 2020a) . The suspension of Umrah was put in place before the holy month of Ramadan in April 2020, a period that is considered favourable for the pilgrimage. Hajj, the fifth pillar of Islam, which would have begun on the 28th of July in 2020, had also been cancelled by Saudi Arabia for all international pilgrims, except to a very limited number of citizens of the country (BBC News, 2020b). Worldwide, gatherings for Tarawih prayers at mosques during Ramadan have been replaced with prayers at home. Pope Francis's Holy Week and Easter services at St. Peter's Basilica, Vatican City, were held in April 2020 without public attending and were broadcasted live (The Straits Times, 2020). Other protestants churches around the world had replaced their in-person Easter services with live broadcast. Many houses of worship around the world have suspended their regular physical worships and prayers and switched to online streaming.

Religion might facilitate or hinder the adherence to public health measures to prevent the spread of COVID-19. On one hand, religion could mediate adherence to preventive measures through the moral principles of doing no harm and protecting the interest of fellow citizens, and compliance to authorities such as the government; on the other hand, people who are more religious might perceive greater divine support and hence feel invincible to COVID-19 (DeFranza et al., 2020) . In this article, we detail the religious aspects of COVID-19 prevention and control in Malaysia and discuss the possible role of religious organizations in encouraging sound decision-making among religious adherents in mitigating this crisis. We will suggest recommendations on how to promote a partnership between the healthcare system and religious organizations, and how religion and faith could be integrated into health promotion channels and resources in the response of COVID-19 and future communicable diseases.

Malaysia is a multi-faith country. According to Article 3 of the Federal Constitution of Malaysia, "Islam is the religion of the Federation, but other religions may be practised in peace and harmony in any part of the Federation" (Federal Constitution, 2010) . Article 12(2) of the Federal Constitution also states that it is lawful for the Federation to further the cause of Islam. Hence, the Department of Islamic Development Malaysia (Jabatan Kemajuan Islam Malaysia, JAKIM), a federal government agency, receives an annual budget allocation of RM1 billion (USD241 109) to further the cause of Islam (Vivegavalen, 2018) . And in addition to civil courts, in Malaysia, there are Syariah Courts, which have limited jurisdiction over Muslims.

Islam is practiced by 61.3% of the Malaysian population (Department of Statistic Malaysia, 2011). The second largest religion practiced in Malaysia is Buddhism (19.8%), followed by Christianity (9.2%) and Hinduism (6.3%). While all Malays are legally Muslims, the majority of Chinese (83.6%) and Indians (86.2%) are Buddhists and Hindus, respectively. The indigenous people are mostly Christians (46.5%) and Muslims (40.4%) (Department of Statistic Malaysia, 2011). In view of the religious and cultural diversity, religious mass gatherings are not uncommon in Malaysia, and the recent COVID-19 outbreak in the country brought to light that religious gatherings are one of the public health concerns in the country.

The first confirmed COVID-19 cases in Malaysia were reported in 25 January 2020 and involved three Chinese-nationals from Wuhan arriving the country via Singapore (Elengoe, 2020; Reuters, 2020a) . In the following month the number of positive cases remained low and they were mostly confined to imported cases. However, the number of COVID-19 cases in Malaysia spiked up from below 30 in February to more than a thousand a month later. Within a few weeks, Malaysia became the worst-hit country by COVID-19 in Southeast Asia. The sudden increase was linked to an international Islamic event that took place from 27 February to 1 March 2020 at Sri Petaling, Kuala Lumpur, and attended by 16,000, including 1500 foreigners from 30 countries such as Cambodia, Vietnam, the Philippines, India, South Korea, Brunei, China, Japan, Thailand etc. (Mat et al., 2020; New Straits Times, 2020) . During the event, the participants congregated during prayers and sermons, sat close together, ate from one tray and shared sleep area within the mosque's hall. About 48% of the COVID-19 cases in Malaysia up to May 2020 was directly linked to the religious event, and the related cluster remains the largest in Malaysia (The Sun Daily, 2020). In addition, in Southeast Asia, at least 73 COVID-19 cases in Brunei, 10 in Thailand, and 22 in Cambodia were linked to this religious gathering (Beech, 2020) . The Ministry of Health had urged the participants to attend COVID-19 testing. However, while many were cooperative, some refused to be tested, citing that they prefer to rely on God to protect them (New Straits Times, 2020) . Working with the police, the Ministry of Health Malaysia traced about 5000 participants to their house addresses (Aziz, 2020) .

Another large COVID-19 cluster in Malaysia was from a Christian leadership seminar, in Kuching, Sarawak (Malaysian state on Borneo) in late February 2020. About 100 participants attended the seminar. The event has been identified as the source of 117 of the 371 COVID-19 cases in Kuching (Tawie, n.d.) . The first COVID-19 death from this cluster involved a pastor from another church who attended the seminar. The participants of the seminar or people who were in contact with the participants were urged to attend COVID-19 testing. About 190 people were traced and tested (The New Sarawak, 2020).

The Ministry of Health had taken steps in preparing for COVID-19 outbreak since early January 2020 before it was declared a global health emergency by the WHO on 31 January 2020 (World Health Organization, 2020b), such as increasing surveillance of influenza-like illness and severe acute respiratory infection in the country, initiating thermal screening at airports, preparing reagents to detect coronavirus in the Institute of Medical Research, stockpiling of personal protective equipment at the Ministry of Health facilities etc. (Shakirah et al., 2020) . While there was no ban on Chinese-nationals from entering Malaysia (The Star, 2020a), all inbound passengers from Wuhan were required to attend COVID-19 screening. Travellers with symptoms were examined at quarantine centres and suspected patients were referred to the nearest Ministry of Health facility.

Despite public outcry and advice from the Ministry of Health, religious mass gatherings were still being organized and many religious organizations still had their regular prayers and worship services, even though some of the gatherings were not associated with the spread of COVID-19 (Dermawan, 2020) . On 16 March 2020, the prime minster declared movement control order (MCO), a full lockdown, under the Prevention and Control of Infectious Disease Act 1988 and the Police Act 1967, starting from 18 March to 31 March 2020. MCO was extended later till 3 May 2020. During MCO, social distancing was enforced, and all mass movements and gatherings, including religious, sports, social and cultural gatherings, were banned. All houses of worships were closed. International travel was banned and foreigners were not allowed into the country.

Alternatives to physical religious gatherings have been offered by various religious organizations in Malaysia during MCO. Friday prayers at the mosques were suspended and replaced with Zuhr (noon) prayers, the second of the five daily prayers, at home. Ramadan Bazaars (evening markets during the fasting month) were also cancelled throughout the country (Dzulkifly, 2020) . Tarawih prayer, an additional prayer performed at night during Ramadan were performed at home instead of the mosques. The Malaysian Buddhist Consultative Council encouraged Buddhists to have e-Wesak celebrations on 7 May 2020 at home (Malaysian Buddhist Consultative Counsil, 2020). The Hindu new year prayers on 14 April 2020 were live streamed (Alagesh, 2020) . Online services for Easter and the weekly worships were available for Christians (The Star, 2020b; Vinesh, 2020) . For Chinese who were observing Qing Ming (Chinese Memorial Day), they were commemorating their ancestors at home instead of visiting their tombs (中国报, 2020) . Wedding ceremonies at houses of worship were cancelled and replaced with simpler ceremonies at home (Zikiri, 2020) .

The violation of MCO carried a maximum fine of RM1000 (USD234) or six months imprisonment or both. However, there were cases of illegal religious gatherings. In Muar, Johor, 116 immigrant workers were arrested while preparing their Friday prayers on the rooftop of the factory where they worked (Tan, 2020) . In another case, the Malaysian deputy health ministry and a cabinet member from Perak were fined after having a meal at an Islamic religious school in Perak. A wedding was held illegally at a Hindu temple during MCO and the priest, bridegroom and chairperson of the temple committee were fined (Timbuong, 2020) .

Unfortunately, the time-lag between the large international Islamic event and the implementation of MCO allowed COVID-19 to spread to other parts of the country, as the participants went home and attended their local mosques for prayers and participated in other social activities whilst being unaware that they were infected. A number of COVID-19 sub-clusters linked to the religious event have been identified, including the madarasa (religious schools) sub-clusters at Pahang, Penang and Selangor, and Melaka (The Edge, 2020); a sub-cluster in Rembau district, Negeri Sembilan, where a participant attended a meeting at a school; and two sub-clusters in Simpang Renggam, Johor (Astro Awani, 2020).

The enforced movement control order (EMCO) was implemented from 27 March 2020 for 14 days if a large cluster was found in a specific location. During EMCO, all residents in the involved areas would be screened for COVID-19, and none of them were allowed to leave their houses and non-residents were not allowed to enter the area. EMCO was implemented in a Tahfiz school (schools producing 'huffaz', plural of 'hafiz' or memorizer of the Qur'an) in Sungai Lui, Hulu Langat, Selangor, from 30 March to 13 April 2020, where one of the madarasa sub-clusters was identified, and in Simpang Renggam from 27 March to 14 April 2020.

The reduction of positive and active cases of COVID-19 around mid-April prompted the government to relax MCO, and conditional movement control order (CMCO) was implemented from 4 to 11 May 2020, which was then extended to 9 June 2020. However, during CMCO, religious gatherings were still banned. CMCO was replaced with recovery movement control order (RMCO), which took effect in 10 June 2020 until 31 March 2021, where there were less restrictions. While religious mass gatherings were still banned, gathering of with limited number of congregants (not more than 30-40 people or one-third of seating capacity, depending on state's ruling) were allowed at mosques and selected suraus while complying to standard operating procedures such as social distancing, performing ablution at home, using own's prayer mat, no gathering after prayers etc. (Hassan, 2020) . Non-Muslim houses of worship were allowed to open at one-third of their seating capacity and physical contact such as laying of hands, communion service are not allowed (Malay Mail, 2020) . MCO was re-imposed on 13 January 2021 in several states in Malaysia due to increased number of cases.

Like government health services, religious communities in Malaysia have never experienced such pandemic of communicable disease and were caught off guard by the sudden increase of COVID-19 cases in the country. Given the importance of religion in Malaysia, the suspension of religious gathering in the entire country was unprecedented and many were unprepared for the sudden change of their religious routines.

Research has shown that health promotion and disease prevention measures without due consideration of cultural and religious context will be met with resistance and rendered ineffective (Manguvo and Mafuvadze, 2015) . In the case of COVID-19 outbreak in Malaysia and many countries, the challenge is to implement preventive measures that are religiously acceptable by the diverse religious groups where religious traditions across the many faiths would require the faithful to congregate either in mosques, churches or temples (VanderWeele, 2020) . In addition, many people turn to religions for psychological relief during times of crisis such as COVID-19 to cope with worries, stress and anxiety related to disease prevention measures such as lockdown, restricted travel and social distancing (Counted et al., 2020; Li et al., 2020; Thomas and Barbato, 2020) . In view of the importance of religion in the spread of COVID-19, we would like to recommend the following on how to promote a partnership between the Ministry of Health and religious organizations in Malaysia.

In this article, we use the term religious organizations to describe (i) places of worship such as mosques, temples, churches etc. and (ii) organizations that are formed to promote the interests of a specific religion or its adherents, such as faith-based organizations that provide social services. Many of the religious organizations in Malaysia are also members of larger umbrella organizations. Gunderson and Cochrane (2012) suggests a move away from a needs-based health promotion approach (diagnosing what is lacking in a person, family, local community, or society) to an asset-based approach that examines what are already available for public health. Since religion is considered important by many Malaysians, more effort should be made to map religious health asset in the community available for health promotion. Religious health assets include the tangible (e.g. houses of worship, faith-based non-governmental organizations [NGOs], etc.) and the intangible (e.g. compassion, credibility of religious leaders, religious practices etc.) assets (African Religious Health Assets Programme, 2006; Gunderson and Cochrane, 2012; Kramer et al., 2012) . Participatory Inquiry into Religious Health Assets, Networks and Agency is an example of religious asset mapping framework developed by the African Religious Health Assets Programme to map religious assets in Zambia and Lesotho and has now been adapted to other settings (de Gruchy and Olivier, 2007) .

One of the most important religious health assets would be religious leaders. For the partnership between the Ministry of Health and religious organizations to work in Malaysia, there is a need for the government to identify and engage community religious leaders in the planning of health promotion programs. Congregants generally look up to their religious leaders, trust them and have close relationship with them (Pew Research Center, 2019). Religious leaders usually have deep and trusted relationship with their congregants and connection with disadvantaged and vulnerable members who might not be reached by the routine health services and health promotion programmes.

People's attitude towards public health messages are shaped by their religious beliefs and how their religious leaders respond to the messages. Thus, religious leaders have a strong influence on the health behaviours of their congregants. Religious leaders are in a good position to instil rationality among their congregants, that there is no conflict between preventive measures for communicable diseases and religious beliefs. For example, during the initial Ebola outbreak in West Africa in 2014, preventive measures such as the banning of traditional burial practices, which involved touching and washing the deceased and were a major transmission route of Ebola virus, were ineffective because they were against traditional cultural and religious beliefs (Featherstone, 2015) . When Imams and clergy were engaged later in the response to Ebola outbreak in Sierra Leone, they identified passages in the Qur'an and Bible to support new burial practices (World Health Organization, 2014). As they began participating in the new burial practices, resistance ceased and the number of Ebola cases dropped drastically.

Religious leaders are skilful in public speaking and communications. They influence thinking and shape social values and social responsibility through their preaching. When religious leaders preached against social distancing during COVID-19 outbreak and cited that God is our shield, their congregants defied the ban on religious gatherings. During the initial implementation of MCO in Malaysia, many religious adherents strongly opposed the ban of religious gatherings (Ismail, 2020) . Even during MCO, there were still illegal religious gatherings. This phenomenon of irrationality is not only peculiar to this country, but global in nature

The role of religion in mitigating the COVID-19 pandemic and span across many religions (AFP, 2020; Halbfinger, 2020; Reuters, 2020b ). An online survey of 525 participants worldwide found that people who had higher level of religious orthodoxy were less likely to trust in science and less likely to comply with COVID-19 preventive measures (Plohl and Musil, 2020) . However, the religious adherents were more likely to comply with social distancing when their religious leaders urge them to do so. In the USA, while most states have exemptions for religious gatherings, many religious leaders have cancelled worship services (Dias, 2020) . In Bali, Indonesia, religious leaders cancelled the Ogoh-Ogoh Carnival, a mass gathering which was part of the celebration of Nyepi (Day of Silence) (Ikhwan and Yulianto, 2020) . In Malaysia, while the banning of religious gatherings was a federal government order and there was no exemption, religious leaders in the country were cooperative and made official announcements about the need of social distancing among their congregants and suspended inperson religious gatherings (Francis et al., 2020; Shan, 2020; World Health Organization, 2020c) .

Religious organizations in Malaysia could also play a role in disease monitoring, as all mosques and most non-Islamic houses of worship in Malaysia were registered with the government. Many religious organizations such as Christian churches, keep a record of membership. Even in other religious organizations where there are no official membership records, it is possible to keep track of the congregants, since they tend to attend the same religious congregations regularly. Within a congregation, people form smaller and more personal groups where they share similar interest. The close relationship among congregants would facilitate community engagement and mobilization. During the Ebola outbreak in West Africa, community leaders, including religious leaders, were more successful in case finding and monitoring than their government counterparts (Marshall, 2016) .

Because of the close and trusted relationship between religious leaders and their congregants, religious organizations are well-placed to reach out to the vulnerable and disadvantaged groups which are living in conditions that are not conducive to prevention of communicable diseases and who have been overlooked by the healthcare system. During the COVID-19 outbreak in Malaysia, many religious organizations and faith-based humanitarian NGOs provided relief items and hygiene products to vulnerable groups such as people from low socio-economic background, the urban-poor and the rural communities, prisoners, migrants and refugees (MERCY Malaysia, 2020; World Vision Malaysia, 2020) . These religious organizations could be mobilized in identifying possible COVID-19 cases among vulnerable groups and refer them for healthcare services. Faith-based humanitarian NGOs represent one large potential religious asset in the country and could be tapped into for future health promotion.

Refusal of religious adherents to be screened for COVID-19 because of religious teaching or stigmatization was common. The members of the Shincheonji Church, which accounted for almost 50% of all COVID-19 cases in Korea, believed that their spirit and bodies are immortal and this may have led them to refuse testing even when they had symptoms (Kim et al., 2020) . In Malaysia, there was immense stigma against Tablighi participants, especially those who were tested COVID-19 positive. Many Tablighi participants were afraid to attend COVID-19 testing for fear of social consequences. Similarly, the Good News Fellowship Church where another large COVID-19 cluster was found has been subjected to media misrepresentation that the 600 congregants were responsible for the spread of the disease while only 100 participants attended the seminar. Religious leaders could play a role in encouraging and providing spiritual and mental support to their congregants to attend COVID-19 testing or seek medical help when there are symptoms. For example, they could quote the Holy Scriptures regarding seeking medical care when one is sick (Featherstone, 2015) .

Amidst the COVID-19 outbreak, misinformation about COVID-19 was shared extensively in social media. About 20% of misinformation was spread by prominent public figures such as politicians but it attracted 69% of social media engagement (Brennen et al., 2020) . Religious leaders, because of their prominent role, could play a part in dispelling COVID-19 misinformation. The Ministry of Health could work with religious leaders in countering misinformation and disseminate scientifically correct and religiously acceptable messages to the congregants. Since religions teach honesty, it could be used as a resource to encourage truthful sharing of information. A study of found that a simple accuracy reminder at the beginning of the study increased the likelihood that the participants would share true information related to COVID-19 (Pennycook et al., 2020) .

Religion and spirituality become more important in time of adversity. A recent study showed that during the current COVID-19 outbreak, there was a 50% increase of Google search for prayer in 95 countries around the world, including the most secular countries such as Denmark (Bentzen, 2020) . The increase was the highest ever recorded, and included people from all continents and religious denominations. The rising prayer intensity was mostly explained by the increased need for religious coping. Given the importance of religion and spirituality during a pandemic, we recommend the integration of religion and spirituality into healthcare setting through the setting up of multi-faith chaplaincies to provide spiritual support to patients and their families, and healthcare personnel. The current COVID-19 pandemic has revealed the importance of chaplaincy (Barber, 2020; Cadge, 2020) . The provision of spiritual support by professionally trained and accredited spirituality guidance officers to patients in government healthcare facilities has been proposed previously (The Star, 2019). However, to our knowledge, only very few hospitals in Malaysia provide chaplaincy services for patients, for example, the National Heart Institute, a corporatized government healthcare facility, and Penang Adventist Hospital, a Christian private hospital (Penang Adventist Hospital, n.d.; Whitehead, 2019) .

Distrust towards medical doctors and the healthcare system is not uncommon in many populations around the world (Mascarenhas et al., 2006; Kennedy et al., 2007; Tokuda and Inoguchi, 2008; Ragnarsson et al., 2009; Choy and Ismail, 2017) . Compared with hospitals and other clinical settings, religious settings are less threatening and provide a more supportive environment for health promotion where people are more open to their religious leaders than healthcare personnel. In a study conducted in the USA, about 25% of participants who ever sought help for mental disorders did so from a clergy member and the proportion was higher than that of psychiatrists (16.7%) or general physicians (16.7%) (Wang et al., 2003) . The distrust towards doctors and healthcare system may undermine outbreak control. In addition to provision of chaplaincy services, conducting spirituality assessment may improve doctor--patient relationship through building trust (Saguil and Phelps, 2012) . While religion is widespread in Malaysia, spirituality is rarely assessed in clinical setting. In a study conducted at a Malaysian government hospital which included 280 patients and 50 doctors from diverse religious backgrounds, 79% of the patients reported an increase in faith due to illness and preferred to have religious counsellor to help them rather than psychiatrists; however, the majority of them could not recall being asked by their doctors about religious issues. Among doctors, only 52% of them reported discussing religious issues with patients irrespective of religious/spirituality background (Rathor et al., 2009) .

Another way to integrate spirituality into clinical setting is to include religion, spirituality and health in medical curricula. Many medical schools in Western countries have started to include courses on religion, spiritual and health into their curricula. In the USA, in 1994 only 17 of the accredited medical schools offered courses on religious and spiritual issues as applied to medicine (Fortin VI and Barnett, 2004) ; in 2012, more than 100 were doing so . In the UK, about 59% of medical schools provided some form of teaching on spirituality (Neely and Minford, 2008) . In Brazil, about 51% of medical schools out of 86 who responded to a survey offered specific spirituality and health courses or had some form of teaching content related to spirituality and health . In Southeast Asia, it is unknown how many medical schools have included religion, spirituality and health in their curricula. In the universities (located in Malaysia and Myanmar) where the authors are or were affiliated to, medical students were trained to inquire about religious and spiritual beliefs of patients during assessment.

On the other hand, some non-essential religious or cultural practices that are incompatible with code of medical ethics might be medicalized, such as virginity testing (Crosby et al., 2020) and female circumcision (Serour, 2013) . In addition, unlike religion, which is well-defined, there is no widespread agreement on the definition of spirituality (Koenig, 2018) , which might have different connotations in Asian countries than in the West, were most studies on spirituality are conducted. Thus, it is important to develop an awareness of the multi-faceted definition of spirituality and the complex interplay between religion, culture and medical practices among medical students. In an Asian setting, the inclusion of religion and spirituality in the medical curricula should focus on the influence of religion and culture as one of the social determinants of health.

The Ministry of Health should consider funding religious organizations in health promotion. Religious settings are one of the very few where people from diverse background gather regularly, thus, it presents an ideal channel for health promotion especially in rural and semi-rural communities where there is a lack of access or resources. In fact, many faith-based health promotion programmes have been shown to be effective in improving health and modifying health behaviours (DeHaven et al., 2004; Lancaster et al., 2014; Yanek et al., 2016) . However, in times of crisis such as COVID-19 outbreak, most resources are directed to government facilities rather than religious organizations that provide care. Without strong governmental support, the capability of religious organizations in addressing COVID-19 effectively might be limited. In a recent case study of two rural faith-based healthcare facilities in Africa, while strategies to identify suspected COVID-19 cases and to isolate them have been developed, the shortage of supply of ventilators, personal protective equipment, nasal swabs etc., lack of healthcare workers and low number of beds meant that these healthcare facilities might be rapidly overwhelmed if the number of cases increases (Vilakati et al., 2020) .

Because of their simpler administrative structure, religious organizations have the flexibility to adapt rapidly to a health emergency. In the USA, the first community quarantined due to COVID-19 outbreak was a Modern Orthodox Jewish community in New York State (Weinberger-Litman et al., 2020) . During the quarantine, more community members reported that they completely trusted COVID-19 related information from their local community organizations (schools and synagogues), compared with that from government agencies, and the local community organizations were the primary source of COVID-19 information during the initial stage of the outbreak. The majority of the participants (80.6%) reported that their religious community had provided various community support during the quarantine, which included tangible support such as delivering food items and helping to run errands; social support especially for elderly through Zoom meetings and phone calls; informational support through calls and hotlines to help the community members stay informed about COVID-19; and religious and other communal support such as online prayer, religious classes and gatherings.

The above example in the USA shows the important role of religion during a pandemic and how religion could mitigate the negative impact of a pandemic. Religious organizations remain an underutilized asset in health promotion in Malaysia, especially during a health emergency such as COVID-19. Given the importance of religion and the prominent role of religious leaders in the country, a long-term engagement with religious organizations holds great potential of community outreach. Past studies have shown that religious leaders have significant influence on the types of health-related activities being offered in their congregations Baruth et al., 2015) , and moderate the effectiveness of faith-based health promotion programmes (Peterson et al., 2002) . Thus religious leaders should be included as active participants in public health planning. While religious leaders are significantly involved in offering faith-based health counselling, however, they may lack self-efficacy (Fallon et al., 2013) . To address this issue, religious leaders should be trained in disseminating correct public health information. In rural and hard-toreach areas in Pakistan and Bangladesh, the United Nations Children's Fund (UNICEF) provided the Imams with public health messages about hygiene and infection so that they could customize the messages and deliver them during their sermons in the mosques (UNICEF, n.d.) .

During an outbreak of communicable disease, there is a need to "refrain from using religious teachings to undermine evidence-informed public health practices" and also a need to "refrain from using secularist ideology to undermine effectiveness of faith-based groups' work in health" (Duff and Buckingham, 2015) . Religious organizations should not preach against public health measures such as social distancing, disclosing contact and possible COVID 19 symptoms, and there is a need to encourage sound decision-making among the believers so that they will not prioritize their loyalty to and subjective interpretation of religion over evidencebased medicine. Meanwhile, the importance of religion in terms of health should not be downplayed and religion should not be blamed for the spread of disease. We hope this article would invite closer partnership between the healthcare providers and religious organizations in respective countries worldwide.

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The delay in confirming COVID-19 cases linked to a religious group in Korea

Religion vs. Spirituality. Religion and Mental Health: Research and Clinical Applications

The philosophical assumptions, utility and challenges of asset mapping approaches to community engagement

Obesity interventions in African American faith-based organizations: a systematic review

The impact of COVID-19 epidemic declaration on psychological consequences: a study on active Weibo users

Spirituality and health in the curricula of medical schools in Brazil

Spirituality in medical education: global reality?

Religious activities at non-Muslim houses of worship allowed with new SOP, says ministry

E-Wesak announcement

The impact of traditional and religious practices on the spread of Ebola in West Africa: time for a strategic shift

Responding to the Ebola epidemic in West Africa: what role does religion play? Bekerley Center for Religion

Hypothesized predictors of patient--physician trust and distrust in the elderly: implications for health and disease management

A single mass gathering resulted in massive transmission of COVID-19 infections in Malaysia with further international spread

Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events

Hajj: infectious disease surveillance and control

MERCY Malaysia fights coronavirus disease (COVID-19)

Current status of teaching on spirituality in UK medical schools

How Sri Petaling tabligh became Southeast Asia's Covid-19 hotspot

Food borne outbreak of salmonellosis at a church gathering, Rwanda

Implications of a 2005 measles outbreak in Indiana for sustained elimination of measles in the United States

2020) Fighting COVID-19 misinformation on social media: experimental evidence for a scalable accuracy nudge intervention

Most congregants trust clergy to give religious advice. Pew Research Center's Religion and Public Life Project

Key elements for church-based health promotion programs: Outcome-based literature review

Modeling compliance with COVID-19 prevention guidelines: the critical role of trust in science

Young people's understanding of HIV: a qualitative study among school students in Mankweng

Religion and spirituality in specific clinical situations in medical practice: a cross-sectional comparative study between patients and doctors in a tertiary care hospital in Malaysia

Malaysia confirms first cases of coronavirus infection

Preacher who says Christians immune to virus appears in Myanmar court. Free Malaysia Today

The spiritual assessment

Medicalization of female genital mutilation/cutting

Hajj: health lessons for mass gatherings

The COVID-19 Chronicles of Malaysia

Temples prohibited from conducting speal prayers during the movement control order (MCO)

Johor police: Seven more from Sulawesi 'tabligh' event have returned via Johor, Malay Mail

Sarawak identifies main Covid-19 cluster, Malay Mail

Covid-19: MoH detects four subclusters related to tabligh assembly at Sri Petaling Mosque. The Edge Markets

Bad press for good news fellowship church over unfair Covid-19 link. The New Sarawak -Bold

Health Ministry wants professionally trained 'spiritual guidance' officers

Wuhan coronavirus: no plans to stop Chinese tourists for now

Church to proceed with Good Friday celebrations online, The Star Online

Coronavirus: Vatican cancels public participation at pope's Easter events

48% of nation's Covid-19 cases linked to Sri Petaling tabligh event

Positive religious coping and mental health among Christians and Muslims in response to the COVID-19 pandemic

Temple priest, bridegroom fined RM1k over wedding during conditional MCO, The Star

Trust in the mass media and the healthcare system, interpersonal trust and self-rated health: a population-based study in Japan

Religious leaders play key role in battle against COVID-19

Love of neighbor during a pandemic: navigating the competing goods of religious gatherings and physical health

The neglected role of faith-based organizations in prevention and control of COVID-19 in Africa

Christians go digital in accordance with the MCO ahead of Easter, The Star Online

June 4) Malaysia --secular or Islamic? Malaysiakini

Patterns and correlates of contacting clergy for mental disorders in the United States

A look at the first quarantined community in the United States: response of religious communal organizations and implications for public health during the COVID-19 pandemic

Malaysian hospitals should hire 'Islamic chaplains' for spiritual support, say experts. Salaam Gateway -Global Islamic Economy Gateway

WHO director-general's opening remarks at the media briefing on COVID-19-11

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Q&A on coronaviruses (COVID-19)

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WHO partnered with faith-based organizations in Malaysia to make Wesak Day as colourful and meaningful as ever

Novel coronavirus (COVID-19) appeal

Project Joy: Faith based cardiovascular health promotion for African American women

No photographer, no wedding dress, no problem: newlywed shares last minute solemnisation ceremony during MCO

The authors would like to acknowledge the support of Prof. Mohamed Shajahan Yasin, the Head of School of Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, during the writing of this manuscript.

There are no ethical concern. FUNDING This work was supported by the John Templeton Foundation (60839), 'Religion and physical and mental health among elderly in a predominantly Muslim and multicultural community: the causal linkages'.

The authors declare no conflict of interest.