December 12, 2011 (San Diego, California) — The use of aspirin reduces the risk of recurrent venous thromboembolism (VTE) by more than half when compared with placebo, according to the results of a new study [1]. Investigators say the reduction in VTE risk, which was achieved without an increased risk of bleeding, makes aspirin an attractive treatment option for the extended prevention of recurrent VTE once oral anticoagulation has been stopped.
"Patients with a first episode of VTE usually receive initial therapy with heparin, which is given for five to seven days, and then they are switched over to oral anticoagulants," lead investigator Dr Cecilia Becattini (University of Perugia, Italy) told heartwire . "Oral anticoagulant therapy [with vitamin-K antagonists] is not very practical, as it requires laboratory monitoring and medical visits for adjustments. More important, there is the potential for harmful bleeding complications with warfarin, which can occur in about 3% of patients."
The past couple of years have seen the emergence of more anticoagulants for VTE, including the US Food and Drug Administration approval of rivaroxaban (Xarelto, Bayer/Johnson & Johnson) for prevention of deep venous thrombosis (DVT) in the setting of knee- or hip-replacement surgery. Apixaban (Eliquis, Bristol-Myers Squibb/Pfizer) has been approved in Europe for the prevention of VTE events in adult patients who have undergone elective hip- or knee-replacement surgery, while edoxaban (Lixiana, Daiichi Sankyo), another direct factor Xa inhibitor, is approved in Japan. Data from the RECOVER trial also showed that the new anticoagulant dabigatran (Pradaxa, Boehringer Ingelheim) was effective when used in the VTE setting, and it is currently approved for use in Europe.
"There are a lot of new agents out there that don't require laboratory monitoring, and some of these new oral anticoagulants have already been approved for use in patients with venous thromboembolism," said Becattini. "But again, they are anticoagulants, and while they are effective, the risk of bleeding complications is not zero."
In this study, known as WARFASA, which was presented at the American Society of Hematology 2011 Annual Meeting, the researchers tested whether the use of aspirin therapy was more effective than placebo in reducing the risk of recurrent VTE in patients treated with warfarin for six to 18 months following the first idiopathic VTE. After the initial treatment with warfarin, the drug was stopped, and 205 patients were randomized to 100 mg aspirin once daily and 197 patients to placebo.
During the two-year study period, recurrent symptomatic VTE occurred in 28 patients in the aspirin arm and 43 patients in the placebo group (6.6% per patient-year vs 11.2% per patient-year, respectively). In multivariate analysis, aspirin reduced the risk of recurrent VTE 42% (hazard ratio 0.58; 95% CI 0.36–0.93) compared with placebo. The risk of major bleeding and clinically relevant nonmajor bleeding was identical in the aspirin- and placebo-treated patients, with one major bleed and three clinically relevant bleeds reported in both groups. There was no significant difference in mortality.
Not as Efficacious, But Not as Risky
To heartwire , Becattini said that the bleeding risk with aspirin is 10-fold lower than that of other oral anticoagulants, and this study shows that putting a patient on aspirin extended therapy lowers the risk of recurrence without any significant increase in bleeding. It is a practical, low-cost option for clinicians and patients, even though it is not as efficacious for the reduction of recurrent VTE as other agents.
"You have to consider that in clinical trials, dabigatran and rivaroxaban showed an 80% to 90% reduction in the risk of venous thromboembolism, which is about double what we found with aspirin," she said. "These are the newer agents, but we don't yet know everything about their potential side effects. As well, there is the issue of cost."
After a three- or six-month treatment course with oral anticoagulants, Becattini said her center typically evaluates the risk for recurrent VTE by assessing conditions that were present at the time of the first event, such as trauma or surgery. Recurrent VTE can occur in as many as one in five patients in the two-year period following the withdrawal of oral anticoagulants.
"In cases that were associated with transient risk factors, we know the risk of a second venous thromboembolism is very low," she said. "So after three or six months, oral anticoagulants are usually discontinued. After the first episode, we'll stop the drugs and advise the patient about symptoms, telling them to come back to the hospital at the first sign something might be wrong.
Question
An 86-year old patient in a senior living center has lost 34 pounds in the past 6 months. She claims her appetite is good, and no medical problems are apparent. How should I approach the evaluation of weight loss in this elderly patient?
 | Response from Barbara Resnick, PhD
Professor, University of Maryland; Nurse Practitioner, a Continuing Care Retirement Community, Baltimore, Maryland |
Unexplained weight loss or losing weight without trying is often, but not always, associated with an underlying medical disorder. Loss of a few pounds is rarely a cause for concern in an older individual. A provider should be concerned, however, about unexplained weight loss over a 6-month period of 10 pounds (4.5 kg), weight loss of more than 5% of the patient's body weight, or weight loss that is persistent despite interventions.
The first thing to check when evaluating weight loss is whether the patient is eating a sufficient number of calories to maintain body weight. A dietician can be of value if help is needed in making such a determination. If intake is inadequate, it is helpful to look for psychosocial factors or normal changes of aging that might be contributing to reduced dietary intake. Changes in smell and taste, nausea, constipation, poor oral health, functional changes that make shopping and cooking challenging, eating alone, and being unable to afford food are all factors associated with reduced intake. If the underlying problem is found to be poor intake, interventions should focus on increasing oral intake and calories. High calorie snacks and small frequent meals are reasonable options. Nutritional supplements (eg, Ensure®), if accessible and affordable, are another option. Dietary restrictions (eg, low sodium diets) should be eliminated.
When dietary intake seems to be adequate, the weight loss is more likely to be a consequence of disease. Numerous medical problems can cause or contribute to unexplained weight loss (Table).
Table. Diseases Associated With Weight Loss
| Addison disease |
| Cancer |
| Celiac disease |
| Chronic obstructive pulmonary disease |
| Crohn disease |
| Dementia |
| Depression |
| Diabetes |
| Heart failure |
| HIV/AIDS |
| Hypercalcemia |
| Thyroid disease |
| Parkinson disease |
| Peptic ulcer |
| Tuberculosis |
| Ulcerative colitis |
| Irritable bowel disease |
| Clostridium difficile |
Causes include undiagnosed celiac disease, thyroid disorders, malignancies, dementia, depression, and diabetes. A comprehensive history and physical will guide the search for an underlying cause of the weight loss. History taking should particularly explore possible signs and symptoms that may indicate an underlying clinical problem such as cough, nausea, constipation, or pain. The physical exam should look for lymphadenopathy, breast changes, or thyroid changes. Laboratory tests should be ordered to evaluate for infection, anemia, electrolyte imbalances, and renal disease.
Treatment involves addressing the underlying cause for the unintentional weight loss (improving management of blood glucose in diabetes, treating depression, etc) and work to increase oral intake. If no improvement in weight occurs, then the patient should be re-evaluated with respect to the level of energy that is being expended (eg, is in the patient acutely ill or wandering excessively?) If no additional cause can be identified, consideration of pharmacologic management with appropriate medications to increase weight can be considered.
Question
How should vitamin D supplementation be managed in these specific populations?
 | Response from Darrell Hulisz, PharmD
Associate Professor, Case Western Reserve University School of Medicine; Clinical Specialist in Family Medicine, University Hospitals, Case Medical Center, Cleveland, Ohio |
A previous Ask the Experts column written by Dr. Darrell Hulisz, "Which Is Better: Vitamin D2 or D3?", generated many readers' questions. Dr. Hulisz answers these questions below in a follow-up column.
Vitamin D is essential for adequate intestinal absorption of calcium. Chronic vitamin D deficiency can decrease serum calcium and can trigger a compensatory release of parathyroid hormone (PTH).[1,2] This may produce secondary hyperparathyroidism, resulting in the mobilization of calcium from bone and a reduction in bone mineral density (BMD).[2,3] Chronic vitamin D deficiency can lead to muscle weakness and increase the risk for osteoporotic fractures, falls, rickets, and osteomalacia.[2,4,5] In light of the recent attention given to vitamin D deficiency, several questions arise regarding supplementation in special populations.
What form of vitamin D is recommended in chronic kidney disease?
Vitamin D is produced endogenously in the skin and converted to active metabolites in the liver and kidney. Upon exposure to ultraviolet irradiation, provitamin D3 (7-dehydrocholesterol) in the skin is converted to previtamin D3, which is then isomerized to vitamin D3 (cholecalciferol). Vitamin D3, whether cutaneously formed or obtained in the diet as cholecalciferol, is subsequently hydroxylated in the liver to 25-hydroxyvitamin D (25-OH VD). This is the major circulating form of vitamin D that is assayed to detect deficiency.[1]
A subsequent hydroxylation of 25-OH VD occurs in the kidney to form 1,25-dihydroxyvitamin D, the major biologically active form of vitamin D, also known as calcitriol.[1,2] Thus, in the setting of severe chronic kidney disease (CKD), formulations of calcitriol may be preferred over vitamin D2 and D3 to treat deficiency because the terminal hydroxylation occurs in the kidney.
In the setting of CKD it is important to estimate glomerular filtration rate (GFR) and to determine serum 25-OH VD, calcium, phosphorous, and intact PTH levels when choosing the most optimal regimen. Supplementation of vitamin D plays a major role in the prevention of secondary hyperparathyroidism in patients with CKD.[6-8] According to clinical practice guidelines from the National Kidney Foundation, the preferred form of supplementation is guided by serum 25-OH VD levels, stage of kidney failure, and presence or absence of secondary hyperparathyroidism.[9] Before and during supplementation, both serum calcium and phosphorous levels should be drawn every 3 months. If levels of these minerals rise, vitamin D supplementation may need to be withheld or the dosage modified.[9]
In the presence of secondary hyperparathyroidism, which usually begins in stage 3 or 4 of CKD (GFR 30-59 mL/min and 15-29 mL/min, respectively), the preferred agent for supplementation is an activated vitamin D sterol (eg, calcitriol or paricalcitol). Supplementation should begin when serum levels of 25-OH VD fall below 30 ng/mL. The vitamin D sterol dose depends on the serum levels of 25-OH VD, PTH, calcium, and phosphorus. Likewise, in stage 5 of CKD (GFR < 15 mL/min and patients treated with hemodialysis or peritoneal dialysis), an activated vitamin D sterol is also preferred in lieu of vitamin D2 or D3.[9]
However, in the absence of secondary hyperparathyroidism, as is often the case in patients with GFR > 60 mL/min or only mild renal impairment, either oral vitamin D2 or D3 can be used. Studies indicate that vitamin D2 (ergocalciferol) is much less potent and has a shorter duration of action than D3 (cholecalciferol) and that vitamin D3 more effectively raises 25-OH VD levels.[10-13] Thus, cholecalciferol is preferred in patients with normal or mild renal impairment (GFR > 60 mL/min) with a normal intact PTH level.
What dose of cholecalciferol is suggested for preventing deficiency?
Several guidelines have been issued by national organizations that recommend varying amounts of vitamin D intake. A recent consensus report has been issued by the Institute of Medicine.[13] This guideline states that for most patients the recommended daily allowance of vitamin D should be 600-800 IU. However, increased amounts are necessary for treating known deficiency, such as 25-OH VD levels below 20 ng/mL. Supplemental vitamin D may become necessary in conditions in which risk factors for deficiency exist, such as living in extreme northern latitudes or lack of solar exposure, malabsorptive states, corticosteroid use, chronic dietary deficiency, and pregnancy. However, in these situations the dose of vitamin D is best guided by 25-OH VD levels.
What is the upper limit of vitamin D intake?
As a dietary supplement, patients should not exceed a daily amount of 4000 IU of vitamin D,[13] though higher doses may be needed temporarily to treat documented deficiency. Most cases of vitamin D toxicity have been associated with 25-hydroxyvitamin D levels greater than 88 ng/mL, a level that would necessitate a daily intake of 40,000 IU or more of vitamin D.[14] No significant changes from baseline in serum calcium levels or urinary calcium excretion were noted in patients given 4000 IU/day of vitamin D3 for up to 5 months.[15] In addition, cholecalciferol 100,000 IU administered to patients every 4 months for 5 years was found to be safe.[16]
Which vitamin D preparations are available in an oral liquid?
Vitamin D3 (cholecalciferol) is available as a concentration solution, ranging from 400 IU to 4000 IU per drop. Vitamin D2 (ergocalciferol) is also available in various liquid formulations, but it is commercially available in limited supply due to the superiority of cholecalciferol. Calcitriol, the activated vitamin D sterol, is available in a 1-µg/mL solution for oral administration.
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Dr. Wm. Millward
April 1993
Unclassified
Abstract: The first of this two-part series examines the roots and goals of the Islamic revival that has been taking place in the Middle East and North Africa, and the differences between mainstream and militant Islamism. April 1993. Author: Dr. Wm. Millward.
Editors Note: This issue of Commentary, and the next, comprise a two-part series on Islamic Fundamentalism by Dr. Wm. Millward, a Strategic Analyst in the Analysis and Production Branch of CSIS. Dr. Millward is a frequent contributor to these pages, having written on Egypt and Iran, the Middle East Peace Process and the Gulf War.
In Part I of this series, Dr. Millward examines the genesis and objectives of the Islamic revival, and traces its two basic patterns-mainstream and militant Islamism-in the major countries of the Middle East and North Africa. Deliberately excluded from this discussion, and left to Part II, is the question of support for Islamism in what the author terms "A Growing Iranian Islamist Network". In the next issue of Commentary, Part II focuses on the nature of the threat.
Disclaimer: Publication of an article in the Commentary series does not imply CSIS authentication of the information nor CSIS endorsement of the author's views.
Introduction
Periodic resurgence is an integral part of several major religious traditions around the world. The spiritual and cultural renewal of many parts of the Islamic world in the second half of the 20th century is neither unique nor aberrant; it has not happened in a vacuum or under static conditions. It coincided with the demise of the colonial era, the retreat from empire, the liberation and independence of a host of former colonial states, the emergence of a world system centred on the United Nations, and more recently, the end of the cold war and the disappearance of the bipolar world of East and West.
In this broad context it is hardly surprising that many Muslims in the Middle East and elsewhere have felt the need to renew their commitment to the faith of their ancestors, and use it as a badge of identity in forging their own unique place in the modern world. In the process, the belief system called Islam has shown itself once again to be both a durable source of religious inspiration and spiritual guidance, as well as an ideological frame of reference capable of motivating its adherents towards self-assertion in political and social affairs.
A Question of Terminology
By an informal consensus, religious activism in the Muslim lands of the Middle East and North Africa has been labelled Islamic Fundamentalism, although most Muslims regard the term as a misnomer. Islam they say, unlike some other traditions, has always been characterized by its observance of fundamental principles. According to one Western academic, "The basic problem with the concept of fundamentalism is that it is an ethnocentric, militantly secularist categorization based on specious cross-cultural analogies." [Gregory Rose, Religious Resurgence and Politics in the Contemporary World, ed. Emile Sahliyeh, Albany: SUNY Press 1990. p. 219].
Responding to these objections, many writers have preferred to use the term "the Islamic movement" or simply "Islamism" and "Islamist" when referring to the revivalist and activist tendency among modern Muslims. Other commonly used terms are "intégrisme" and "radical political Islam". Whatever this phenomenon may be called, it is important to distinguish its several varieties and their chief characteristics as these are manifested in the major countries and principal centres of Muslim activism in the Middle East today. The Islamic movement is not a homogenous, unified and monolithic social phenomenon wherever it appears.
It can also seem inaccurate to speak of Islamic revival as if Islam had lost a good deal of its popularity and was, if not moribund, at least much weakened. On the contrary, it has continued through the ages to be popular, vibrantly alive, and expanding in numbers of adherents and territories represented. The Muslim community has continued to draw on Islam's deep reserves of spiritual nourishment to expand the frontiers of its presence through migration and missionary activity in Africa, Asia, Europe and the Americas. By most estimates, one billion people today consider themselves Muslim. Until recently it was the politicalface of Islam that was largely missing from the stage of public affairs. To speak of Islamic revival in recent years is to emphasize the growing desire of more Muslims to assert themselves on the plane of social and political action.
The Genesis of Islamic Revival
Broadly speaking, the Islamist trend among Muslims refers to those groups and movements in several countries which are seeking to establish, overtly or covertly, an Islamic government or state. The rationale for such an objective is that an Islamic government could be expected to enforce some if not most of the laws and rules of Islam (the Shari'a), including those relating to dress code, relations between the sexes, prohibition of alcohol and gambling, punishments for specified crimes, and restrictions on banking and interest. This would allow those who were citizens of such a state to live their lives more fully in accordance with the requirements of faith. It would facilitate the earning of spiritual credit and smooth the path to salvation. It would also give the Muslims concerned a larger say in determining their own affairs and make it easier to protect their interests in relations with outsiders.
Muslims calling for the revival of their religion and community have stressed the need for individual spiritual renewal by rededication to the moral and ethical prescriptions of their faith, and the need to revitalize the community at large, the collectivity of the Muslims in its physical and political context. Some prominent Islamist thinkers and activists during the last century have emphasized the internal and spiritual axis of renewal, while others have urged specific steps or courses of action to improve the social and political condition of Muslims at large.
In the heyday of modern imperialism, one of the most outspoken activists was Jamal al-Din al- Afghani (Asadabadi), a thinker and orator who preached a gospel of pan-Islam and anti-imperialism-primarily in the Sunni Muslim territories of India, Egypt and Turkey-as the most efficient means of renewing the condition of Middle East Muslims in his time (d.1897). Other successful exponents of the Islamist movement and message have urged reform in both the internal and external dimensions of the lives of Muslims. It is not widely known beyond the frontiers of Iran that one of the most popular tracts by the Ayatollah Ruhollah Khomaini was a booklet dealing with individual moral and spiritual renewal, with the imposing title The Greater Crusade: The Struggle with the Carnal Self.
If adherents to Islam are urged to focus their attention on their relationship to Allah as well as their relationships to one another and outsiders, Islamists argue that the Muslims generally have neglected the second half of their responsibility as believers, particularly in the sphere of politics and relations with non-Muslims. The prototype of Islamic government was the system put in place in 7th century Arabia by the prophet Muhammad before he died in 632 A.D., and perhaps some of its successor structures, usually referred to as the Caliphate.
Since the abolition of the Ottoman Caliphate in 1924-the last of these indigenous multinational Islamic governments-most Middle Eastern Muslims have been governed either by traditional tribal, feudal and monarchical rulers, or by modernized and at least partly secularized élites. The latter and most of the former, so the Islamists say, are more responsive to the interests of outside powers and forces, mostly non-Muslim, and not sufficiently attentive to the real needs of their subjects as Muslims. They must therefore be replaced by individuals who are more cognizant of the Islamic method in government and more likely to enable the majority population to live their lives in stricter conformity with the rules of Islam.
Objectives of Islamism
Most Islamist groups in the Middle East share the common objective of creating a truly Islamic society in which they can live under a régime governed by the rules of their faith as codified in Islamic law. For the extremists, the first condition for the achievement of this objective is the forcible overthrow of the current ruling élites in the Middle East, including such diverse régimes as the monarchies of Morocco and Saudi Arabia, the Emirates of Kuwait and the United Arab Emirates, and the secular governments of Algeria, Egypt and Tunisia. For Islamists in Israel and the Occupied Territories, it is the destruction of the state of Israel. The imported ideologies of communism, socialism, liberalism and nationalism are regarded, not completely without justification, as failures where they have been tried, and undesirable where they have not because they are either non-Islamic in their policies, or appear otherwise incompatible with Islamic norms.
The longer-term objective of the Islamist movement is the formation of a bloc of states whose governments apply Islamic law and practices. It hopes that such a bloc would be able, by itself or in alliance with other Third World nations, to change the rules of the international system, especially in relation to trade, and thus alter the current balance of economic and political power world-wide. In this sense, some consider their worldview threatening to the West. The Islamists believe that Islam can create, or help to create, a just political order at the international as well as at the state level. As for most Third World régimes, for them the current rules and regulations were laid down by the great powers to protect their own interests and to perpetuate their political and economic dominance.
Two Basic Patterns: Mainstream and Militant
Those Muslims who strive to establish an Islamic government or state can be divided in two groups according to the methods they employ to achieve their aims. The mainstream Islamist trend seeks to accomplish its aims by working within the existing rules and regulations of its members' respective societies. They are generally not opposed to a degree of political pluralism, to working within the system, to democratic participation, and acknowledge the interests and rights of minorities. These Islamists are generally pragmatic, and do not rule out the existence of a market economy. Mainstream Islamists include the Muslim Brothers of Egypt and Jordan, and some sections of Front islamique du salut-the Islamic Salvation Front (FIS) in Algeria, before it was deprived of its electoral victory, declared illegal and driven underground.
The second category of those who espouse the concept of an Islamic state are the militant, radical and revolutionary Islamists who are prepared to use violence in their efforts to unseat existing governments. This trend is best illustrated in Egypt by some elements of the Islamic Organizations (Jama'at Islamiyya) and by Islamic Jihad (Jihad Islami). The threat of Islamic fundamentalism which is widely publicized in the West these days comes exclusively from this group of Islamists. They generally reject the idea of pluralism, political or otherwise, decry democracy as non-Islamic, and repress ethnic, linguistic and religious minorities. Terrorist tactics are normally considered a legitimate tool in the arsenal available to such groups.
Social Support for Islamism
As general economic and social conditions remain static or decline in many parts of the Islamic Middle East, and governments remain incapable of dealing with these problems, the popularity of the Islamist outlook rises. Social and economic distress today-poverty and unemployment among the youth-feed the growing sense of disenchantment with the social and political status quo. The general economic malaise is exacerbated by the growing disparity between rich and poor. Régimes which count on imported social and economic programs-some dictated by the International Monetary Fund-to solve domestic problems are regarded as failures and un-Islamic.
In Algeria there is a substantial base of broad support for the Islamist current. Roughly 25 percent of the electorate, some three million people, voted for the Front islamique du salut (FIS) candidates in the federal election in the fall of 1991. Estimates of the number of committed, hard-core activists identified with FIS have varied from a handful to several hundred. Since the organization was declared illegal and severely repressed, the number of those who are now prepared to use violence to achieve their goals has substantially increased. The Algerian military is considered a bastion of opposition to the Islamists; while this assumption may be quite safe with regard to the higher ranks, many observers worry about the junior officers and lower ranks, which are thought to contain Islamist sympathizers whose loyalty to the current régime may be soft. Severe state repression is believed to have increased sympathy for the Islamists, even in intellectual circles.
In Lebanon, Hizballah is a religious, military and, since its participation in elections in the summer of 1992, a political force. Its primary constituency is the Shi'a population of the northern Biqa' valley, along with several villages in the Jabal 'Amil region in south Lebanon. The Shi'ites in Lebanon number 1.2 million, the largest religious group-41 percent-in a population of less than three million. Hizballah does not represent all the Shi'i Muslims of Lebanon but competes with the much more moderate, and numerically stronger, AMAL organization which it tries to radicalize, albeit with only limited success. The two groups were involved in a bitter three-year struggle that terminated in a peace accord in 1990 sponsored by their patrons in Tehran and Damascus. Hizballah candidates elected to the Lebanese parliament are believed to have drawn support from some Christian voters as well.
As for the membership of Hamas and Palestine Islamic Jihad, they represent a cross-section of all classes in the Occupied Territories of the West Bank and Gaza Strip. The 417 men from these two groups deported in December 1992 by Israel into south Lebanon give some indication of the people who support the Islamic movement in the territories. They are described as "ardent Islamists". Among them were several imams or spiritual guides. The militants included young students, labourers, shopkeepers and small traders, mechanics and a few professionals, mostly physicians and engineers. Some observers estimate that support for these militant Islamic groups in the Occupied Territories is running as high as 40 percent of the adult population.
In Egypt, the government has gone on the offensive against the Islamic militants, whose activities have long since spread from Upper Egypt to the capital. The Minister of the Interior, Abdel Halim Musa, in a press release in early February, claimed that in the preceding year religious extremists had killed 34 members of the police and security forces, military and civilian. [al-Hayat, February 6, 1993. p.7] Estimates of the number of militants active in Egypt vary between 10,000 and 30,000. Whatever the real number, it is in fact quite small as a percentage of total population. The mainstream Islamists of the Muslim Brotherhood are far more numerous than their extremist counterparts with perhaps as many as two million members and hundreds of thousands-if not millions-of sympathizers. A high percentage of Brotherhood members belong to the professional classes.
There is little prospect that economic and political conditions are going to improve in Algeria or Egypt or the Occupied Territories. An Islamist-oriented régime may well come to power in Algeria in the medium term. Another possible scenario is that growing Islamic extremism coupled with an increasingly harsh government response will lead to social fragmentation and anarchy in Algeria. In Egypt, although the government is under increasing pressure from Islamic militants, and is responding in kind, it is unlikely that an Islamic government will come to power in the next three to five years. As the level of tension between the authorities and their Islamist opponents rises, the possibility that a new round of conflict could spark a crisis increases proportionately. In the interim Egyptian officials will expend greater effort to step up the dialog with the Islamists and try to ensure that domestic and foreign policies continue along the path of gradual Islamization. As in Algeria, so in Egypt, the military is concerned with preserving its relative position in the social hierarchy and would therefore not approve the establishment of an Islamist-based government at this stage.
Saudi Arabia: Fundamentalist-Yes; Islamist-Yes and No
In a special sense the Kingdom of Saudi Arabia is the quintessential fundamentalist Islamic state. In addition to its role as the custodian of Islam's two sacred sanctuaries at Mecca and Medina, the kingdom is said to represent the religious tradition in its most pristine or puritanical version, Wahhabism. This is not to be confused with "orthodoxy". Defenders of the current political system in the kingdom argue that it still reflects today the ideals of the first Islamic revolution begun two and a half centuries ago with the formation of an alliance between the fundamentalist preacher Muhammad b. Abd al-Wahhab and the tribal chieftain, Muhammad b. Sa'ud, and completed with the conquest of Hijaz and the holy cities by their descendants Abd al-Aziz b. Saud and his supporters in 1924.
Critics on the other hand ridicule such claims and point out that since the discovery of oil and the acquisition of vast wealth, the monarchy has ceased to defend the interests of the Muslims at large and become dependent on non-Muslim power for its survival. Proof of this is the role played by Saudi Arabia in the Gulf crisis. The mere presence on the sacred soil of Arabia of nearly half a million non-Muslim combatants, albeit far removed from the two holy sanctuaries, for the purpose of defending the kingdom from Saddam and ultimately driving him from Kuwait, was a highly symbolic illustration of this dependence.
An Islamic, if not an Islamist, opposition in Saudi Arabia operates on three fronts. One is the Sunni populist and radical fundamentalist sentiment which was expressed in the takeover of the Grand Mosque in Mecca in December of 1979. This trend appears to have been eliminated since the incident was put down. The second source of opposition comes from that sector of the population, roughly 7 percent and located almost entirely in the Eastern province, who are Shi'a by rite, and have been subject to incessant propaganda from their fellow sectarians in Iran ever since the Islamic revolution. They seek full rights for Shi'a citizens, not state power. A third focus of opposition comes from many professional religious scholars who oppose the existing political system in the kingdom chiefly because of its dependence on the West. The institution of the ulama and the power it exercises in Saudi Arabia is tightly controlled by the government. It is unlikely that the dissident ulama will become a source of threat to the Saudi regime in the foreseeable future, but their presence behind the scenes will be a reminder to the government that some institutionalized forum for the expression of dissent is an urgent desideratum.
Increasing Organization: A Fundamentalist International?
The concept of organization and structure has been implicit in the Islamic faith and community from its inception. As a universal creed designed to accommodate humanity at large, even the earliest Muslims had to give their attention to the needs of new converts and the requirements of an expanding community. With the annual gathering of the believers in performance of the ritual obligation of pilgrimage, there is a sense in which the idea of the congress or annual general meeting was built into the system. But the universal caliphate was never coterminous with all the territory occupied by Muslims after the death of the Prophet. Power and control was frequently disputed from the periphery to the centre, and once the last Islamic empire of the Ottomans began to decline and fragment, the concept of structure and organization in the Islamic community became a more local and particular concern.
From the point of view of the Islamists, the transnational structures and organizations of the Muslim world have been dominated too long by those states which are subservient to foreign interests. The network of organizations and bodies with representatives in other Muslim states in the region has been controlled from the outset by the wealthy states of the peninsula, particularly Saudi Arabia. Through such groups as WAMY (World Assembly of Muslim Youth) and WML (World Muslim League) the peninsula states distribute funds for Muslim causes elsewhere, promote regular conferences and study groups, and attempt to defend Muslim interests and set the agenda for the Muslim world in its domestic and international settings.
The Jidda-based OIC (Organization of the Islamic Conference) is the most important Islamic body for discussing matters of foreign relations between Muslim states and international problems affecting Muslim interests. The Satanic Verses/Salman Rushdie issue was debated in the OIC. The same body is currently the forum for discussion of the Islamic dimension to the conflicts in the former Yugoslavia, Somalia, the West Bank and Gaza, and others. The OIC has not yet, however, been able to galvanize its members into taking joint action on issues.
Nonetheless, the concept of a "fundamentalist international" has occasioned widespread attention and an appreciable degree of discomfort and fear in the West. In this post cold-war era, some would even see it as having replaced communism as a major threat to world peace and security. We will turn the discussion toward the nature of this perceived threat in the subsequent issue (#31) of Commentary.
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150 mm Hg; 108% increase); risk with high-normal systolic BP (130–139 mm Hg) was similar to that with low-normal BP. These analyses were adjusted for clinical and demographic factors.
