Your Hair or Your Service: An Issue of Faith for Sikh Healthcare Professionals During the COVID-19 Pandemic

Abstract

Sikh healthcare professionals make up a small but significant proportion of the workforce in the United Kingdom. The COVID-19 pandemic has presented healthcare staff across the country with challenges relating to safe clinical practice whilst wearing personal protective equipment (PPE). Practising Sikhs are mandated to keep their hair unshorn and have been negatively impacted by some standard PPE requirements. This article aims to raise awareness of this issue and provide suggestions on how this conflict can be resolved.

Introduction

Twelve percent of the British Sikh population work in the healthcare sector in the UK (British Sikh Report, 2020). A significant proportion of these professionals are practising Sikhs with a distinct physical appearance including unshorn hair and the presence of a turban. For Sikh healthcare professionals, strict personal protective equipment (PPE) protocols as a result of the current COVID-19 pandemic have raised challenging issues for employers and employees alike. It is important for all members of the healthcare team to have an awareness of the integral role of unshorn hair in the life of a Sikh and the implications this may have in the workplace.

Background

The initial phase of the COVID-19 pandemic brought with it national concern about stocks of appropriate PPE, with frequent amendments made to the guidance which was being issued to healthcare staff regarding what constituted adequate protection (Burki, 2020; Thomas et al., 2020). During this time it became clear that some PPE posed a problem for practising Sikhs with beards. Surgical masks often failed to provide an adequate seal and there were reports of Sikh healthcare professionals failing fit tests for FFP3 masks (Sandaradura et al., 2020). Whilst other options such as powered air-purifying respirators (PAPRs) hoods did exist, these were not always readily available and there was a cost implication for trusts, with some PAPRs hoods costing in the region of £475 (Midlands PPE, 2020).

Reports began to emerge of Sikh healthcare professionals feeling under pressure to remove their facial hair in order to conform to the PPE requirements necessary for them to continue frontline work (Sheridan et al., 2020). Cases of doctors cutting their hair and removing their turbans were reported in the national press (Alaa Elassar, 2020). Practising Sikh healthcare workers often faced an impossible choice; abandoning a mandatory part of their identity in order to play their part in the battle against COVID-19. With alternatives sometimes not readily available through NHS trusts, some Sikh doctors attempted to fundraise in order to privately purchase appropriate PPE (JustGiving.com, 2020). Others designed novel ways to use PPE which worked around beards and turbans (Singh et al., 2020). These examples serve to illustrate the willingness to serve the needs of patients whilst continuing to maintain their religious codes of conduct. Sikh volunteers similarly took part in endeavours to sew scrubs for healthcare professionals and provided free food from Sikh kitchens to contribute to the national effort against the crisis (Leeds Cares, 2020; The National, 2020).

However, it became clear to Sikh workers on the frontline that the understandable and rightly vocal national call to arms was overshadowing a hugely significant issue of appropriate PPE given their distinct physical appearance; an identity deeply rooted in centuries of historical precedent and symbolism.

A unique identity: philosophy and history

Founded in 1469 by Sri Guru Nanak Dev Ji, the Sikh faith is based on three principles; meditation on God, honest earning and sharing with the needy. The faith was formalized with an initiation ceremony in 1699 by Sri Guru Gobind Singh Ji. All Sikhs at this time were directed to maintain a unique physical identity which includes unshorn hair. Initiated Sikhs today continue to follow this command (The Sikh Reht Maryada, 2004). As such unshorn hair has high spiritual significance in the Sikh tradition; it symbolizes devotion to the Guru’s instruction, wholehearted acceptance of one’s natural physical appearance and the maintenance of this identity so that a Sikh can be easily recognized and relied upon to be of service to others.

Whilst facial hair is a feature of many religions to varying degrees, Sikhism is distinct in its requirement for initiated devotees to maintain this at all costs and without compromise. Historical precedent and agreed codes of conduct point to unshorn hair as being a key and unwavering requirement of the faith, to the extent that wilful abandon from this requirement is treated with gravity for initiates, requiring Dharmic atonement (Khalsa, 2020). Regarded akin to a jewel, the unshorn hair is commonly covered in the traditional form of a turban. The maintenance of this physical identity is applicable at all times as historical examples from epidemics and times of crises highlight (Singh, 1843).

Sikhs in various occupations within the UK have undergone gruelling political and legal struggles in order to protect their right to wear unshorn hair within a turban at their place of work (Hambler and Seifert, 2016). This struggle continues to this day in countries where secularism takes priority over freedom of religious expression (Rahi, 2005). Instances of forceful removal of hair may have grave effects on the mental well-being of an initiated Sikh, with examples from history indicating that some may, in extreme circumstances, choose death over the abandonment of their Guru’s command to keep their hair (Singh, 1843). Whilst unusual, this demonstrates the potent pride that initiated Sikhs carry for their unique appearance which underlines the honour and professionalism harboured in their daily work.

The issue on the frontline

Guidance was released in 2020 advising any clinician undertaking aerosol generating procedures to wear a FFP3 mask following a fit test. The presence of facial hair compromises the formation of an adequate seal thereby posing an obstacle for the large number of Sikh healthcare professionals working in Accident and Emergency, Intensive care, Anaesthetics, Respiratory medicine, and Oral surgery. It has been suggested that PAPRs hoods are used as an alternative. However, due to the aforementioned cost implication, NHS trusts have had to weigh this up against the impact of redeployment which risks losing a number of highly skilled individuals whilst placing additional burden on other team members (Sheridan et al., 2020). Redeployment as a result of religious requirements can negatively impact the individual and may harm relationships within a team.

In light of this some Sikh doctors compromised choosing to cut their hair and remove their turbans in order to use FFP3 masks when working (Alaa Elassar, 2020). This was widely praised in mainstream and social media, a response which brought to light several issues. The justification used to defend the decision to remove hair was based on the need for Sikhs to serve the community. However, there was little recognition of the importance of a Sikh’s code of conduct whilst undertaking this important service. The personal decision to compromise this aspect of faith undermined the choice of others who felt that this was a compromise too far. The portrayal of the compromise in the media did little to highlight the significance of unshorn hair in the life of a Sikh, instead celebrating these individuals as modern-day heroes who were willing to sacrifice the requirements of their faith in the face of a pandemic (despite historical precedent). Conversely articles highlighting the redeployment of Sikhs who refused to compromise in fact failed to acknowledge the failure of NHS trusts to provide safe equipment for their employees, nor did such articles openly celebrate these Sikh healthcare workers upholding their faith. Such attitudes stem from lack of awareness and cause significant damage to Sikh healthcare professionals attempting to assert their rights whilst fulfilling the obligations of their faith which empower them to excel as healthcare professionals.

Whilst awareness of the historical and spiritual significance of unshorn hair is essential, several practical steps can be taken to ensure that clinical employees can continue to work safely. All team members should have mandatory training related to equality and diversity. Within any definitively multicultural workspace such as the NHS, having a basic awareness of different religions and any faith based requirements can help hugely in maintaining the needs of all staff members. Line managers can encourage positive working relationships within teams to foster a culture in which employees are able to voice concerns around working safely if these are not initially detected. As the pandemic has progressed, risk assessments have been introduced to address the comparatively higher risk posed by COVID-19 for staff from Black, Asian and minority ethnic (BAME) communities (NHS England, 2020). Additionally, the implementation of BAME networks and BAME Champions across trusts in the NHS can have a positive role to play in supporting staff members to discuss specific faith requirements. Medical procurement teams should proactively obtain alternatives to FFP3 masks rather than this being the responsibility of the employee to arrange. The development of local pathways are recommended to support accredited fit testers in their role when liaising with clinical healthcare staff who fail fit testing.

Conclusion

Whilst PPE stores have become well established as the pandemic has progressed, important lessons need to be learned regarding the issue of unshorn hair for Sikh healthcare professionals contributing to clinical work. An increased awareness of the integral role that unshorn hair plays for Sikhs will aid in ensuring that Sikh workers continue to be valued by the health service and in turn can utilize their skills and work ethic in the battle against COVID-19 and future pandemics.

Conflict of interest

There are no conflicts of interest to declare.