The medical and social problems of khat in Djibouti
Pages: 34 to 36
Creation Date: 1957/01/01
The Bulletin reproduces herewith the main features of information on the question of khat transmitted by the French authorities to the Commission on Narcotic Drugs. In order to throw more light on the problem, it seemed desirable to describe the situation which prevails at Djibouti. An increase in the general disease rate in that city has led the health authorities to conduct a survey which has revealed that the consumption of khat could become a significant social danger. Doctors Guedel, Lafaurie and Marguet, who were in charge of this survey, give the following description of the physiological effects of the consumption of this drug in their report.
The following effects were observed in a khat user, the observations being related to his behaviour when in the company of his friends, and using as appropriate the words of the addict or of his family:
Mental effects: "We may take such typical cases as a labourer who works all day in the sun in a workyard or a messenger who has shuffled around from one office to another carrying documents. These men, upon leaving their place of work, suddenly become animated and with a set look join the procession of khat addicts and hurry to the shopkeeper on Avenue 13.
" Several men form a group 'chew'; as they do so, a feeling of mental alertness comes over them, they become talkative and understand things which they did not understand before. They become imaginative, discuss matters and respond quickly; other things are forgotten; then their eyes are wide open and their sight slightly blurred, as if they had a veil before their eyes.
" The whole process is in the mind; there is a pleasant sensation of things going round quickly in the head, which is so full of thoughts that it feels as if it may almost burst. The blood that mounts to the head brings thoughts with it, and the khat user can go on thinking all night without feeling sleepy; sleep seems totally unnecessary, and there is no desire to go to sleep. There is a feeling of strength, heavy weights can be easily lifted; movements are effortless and the whole body experiences a sensation of well-being.
" The khat user has no appetite; even if he wants to eat, he is unable to do so; he can swallow nothing but broth, milk and water. Moreover, he becomes thirsty as he chews; his throat is parched, he talks and perspires, which make him all the more thirsty.
" Enjoyment is even greater if cigarettes are smoked; even non-smokers smoke when chewing.
" Tobaco smoke enhances the effects of khat, and the chewer chain smokes, using up a whole pack before leaving."
Cardio-vascular effects: "The blood circulates faster, especially in the head and eyes; it can be felt circulating in the veins and the heart pumps abundantly."
Effects on the sexual functions: " When a man Chews khat, he becomes sexually excited and seeks the company of women. But khat has an inhibiting effect on the male, its use generally causing temporary impotence or otherwise impeding the full accomplishment of the sexual act."
Digestive effects: " After chewing khat, the abdomen is hard and slightly swollen.
" Habitual khat chewers suffer from constipation for several days at a time or even a week. As they do not eat, they grow thin, have stomach ache, and sometimes have to be taken to hospital at night because the pain is too great."
The tonic phase of khat is followed by the usual depressive phase, which is common in the case of all nerve stimulants.
Those who chew khat only after the morning's labours work harder in the afternoon and are stronger, quicker and more energetic.
At night they sleep well and regain their strength during the depressive phase.
On the other hand, those who chew at night stay up late; they generally take more than the others and that prevents them from sleeping all night. The depressive phase begins in the morning when it is time for them to go to work. They do so reluctantly, cannot bear to talk; sometimes they seem to have grown alarmingly thin, and on occasion they have to be sent to the doctor, who diagnoses the complaint by the brownish-green furry aspect of the tongue.
It is quite certain that a fairly large number of people have acquired the habit of taking khat for enjoyment.
" If the plane from Ethiopa is late some day, you can be sure that there are one, two and perhaps three thousand inhabitants of Djibouti who will be looking up at the sky. Some of them do not return home for dinner. Sadly they wait for their khat."
However, that temporary condition is dependent on the addict's power to obtain the drug at a moment's notice; neither the symptoms nor the duration of the condition are comparable with those experienced by drug addicts while deprived of their drug. The desire for khat is not as strong as that for alcohol or tobacco.
The condition is characterized by sadness, bad temper, lethargy, general debility accompanied by physical and mental slackness, and a disinclination to effort, which may last for several hours or days without resulting in any organic disturbance or any serious mental disorder.
The fact that there is no addiction to khat has been confirmed by observations in hospital wards. Most of the hundreds of sick persons who were studied during the survey and treated at the Djibouti hospital for various complaints were khat users who were physically run down and had suddenly been deprived of the drug. After several days in the hospital they began to put on weight in a striking manner and did not seem at all affected by the withdrawal of the drug. They gained weight on a diet of nothing but rice and meat, and their skin became smooth.
Patients questioned by us did not complain of being deprived of the drug; they were glad to be out of the way of temptation and to be able to sleep, eat and put on weight.
Deprivation of khat, therefore, is not associated with any morbid condition. No drug withdrawal psychosis is created. There is no real craving.
On the other hand, there is a neurosis among khat users associated with the knowledge that they have it in their power to indulge in the drug, which seems to be a sort of ecstasy preceding actual consumption.
As is well known, khat is a highly perishable substance which is preferably consumed during the first few days after harvesting. It was formerly imported to Djibouti by rail, but since the end of the war it has been almost exclusively imported by air. The drug comes almost exclusively from Ethiopia. A plane brings an average of almost 600 kg of khat every day to Djibouti and also supplies to Aden, from where it is distributed throughout the neighbouring countries. Most of the khat transported by this route is consumed by the population of Djibouti. Very small quantities are delivered to a few villages near the city which can be quickly reached by road. It is primarily the extension of air transport service to Djibouti which has enabled the majority of the 18,000 inhabitants of the city to become khat users.
After 1952, imports reached a level of approximately 21,900 kg per month (i.e., 720 kg per day). The government authorities estimate that an additional amount of 5% of that figure was smuggled into the country, thus bringing the total to approximately 23,000 kg per month, which corresponds to 80,500 bunches (each bunch weighing 280 g). The peak year was 1953, a year of prosperity in which a record total was paid out in wages. The present slight decline actually conceals a steady increase in khat consumption among the population. There is less money available to buy khat, but a larger number of people are consuming it.
A study of khat movements from producer to consumer reveals that it undergoes sudden price rises at certain stages. A bunch weighing 280 g is bought for 20 French Somali francs from the Ethiopian producer, and eventually costs the consumer almost 200 francs. Prices vary from one day to the next, viz.: 180 to 200 francs at the beginning of the month; 160 francs at the end of the month; 200 francs on Sundays; 300 francs on Moslem holidays; and 600 to 800 francs in certain circumstances (such as a strike of importers).
The average price can be considered to be 180 francs per bunch, which we shall take as a basis in estimating the amount of wages spent on khat.
Every month, inhabitants of Djibouti buy more than 80,000 bunches at 180 francs each, which means that a city of 18,000 persons (including women and children) spend nearly 14.4 million francs on the drug; this is a staggering sum, especially when converted into its tangible equivalent in food rations, which is what really counts. The whole khat problem can be resolved into a problem of nutrition. The per capita food budget is naturally hard to estimate. It varies greatly between individuals, depending on their race, social position, dependents and habits. For the population as a whole, it can be determined only approximately on the basis of the average monthly wage.
On the basis of this calculation, it is astonishing to note that the 14.4 million francs which are spent on khat in Djibouti every month represent the equivalent of approximately 8,000 food rations which are sacrificed every day for the purpose of buying the drugs.
The medical consequences of this situation give rise to concern. The incidence of disease is so high that 400 hospital beds are permanently occupied by inhabitants of the city. Out of 130 beds in the medical services which are occupied by men, 110 are occupied by persons suffering from tuberculosis. The number of tubercular patients is considerably higher among the men than among the women. Among the women, the incidence of tuberculosis and pernicious anaemia is about the same. The clinical picture among the children fluctuates, the most common cause of hospital admissions being the early phase of cachexy, or general debility. Khat is clearly the cause of this state of affairs, mainly because it stays the pangs of hunger, as happens in the case of alcoholics, who similarly do not suffer from hunger and fall an easy prey to tuberculosis.
Khat users eventually become physically run down because they eat only occasionally, go without sleep and use up their nervous energy. One day, the entire family will be taken to hospital, the father going to the tubercular ward and the mother and child to an adjoining ward for patients suffering from anaemia and debility caused by malnutrition. When he arrives at the hospital, the khat user has a pink tongue, covered with the brownish fur deposited by the drug; he may not be well nourished, but at least he has an average count of red corpuscles, whereas his wife suffers from anaemia and avitaminosis.
The amount spent on khat by wage-earners represents a big proportion of the family budget. According to individual cases, it can be estimated at 15% to 30% (25% is probably an average figure). This large percentage means, in the first place, that the wage-earner and his family do not receive adequate nourishment. It also has repercussions on the wage problem. Every fluctuation in the retail price of khat automatically leads to wage changes, which are made under some other pretext.
A consequence which is perhaps les sapparent is the degeneration of family life. The husband spends long hours in a cafe or house chewing khat with his friends; his wife is left to shift for herself and bring up her children as best she can. In addition, when the husband comes home late at night the effects of khat have done their work and his virility is generally impaired. In the long run, this type of impotence may lead to a chronic condition requiring medical treatment. As a result, there are frequent and repeated divorces, and marriages hang by a thread. Paternal authority, in such cases, is greatly undermined.
Adolescent boys take to the khat habit at a very early age, and recently a certain number of women have also become addicts.
On the social level, certain major trends are apparent: Work output is undeniably reduced and this results in a vicious circle; low output means low wages. Similarly, it is surprising to see the lack of initiative and interest which many of these people display in self-improvement. This is all the more surprising because these people are quite intelligent and are far from being intellectually ungifted. It is not unlikely that this situation can be traced to the fact that they devote their leisure time to the consumption of khat, with the resulting impairment of their will-power.
Together with low work output and disinclination to self-improvement, there is also, among the male part of the population, a state actually bordering on mass neurosis. The individual is obsessed by a frantic desire for khat which seems to inhibit aspirations toward higher aims; it makes the man a slave to his vice.
In view of the situation which has been brought about by khat at Djibouti, as objectively described above, the French Government had to consider whether it should continue to regard khat as simply a habit-forming substance. To answer that question, it referred to the definitions approved by the Expert Committee on Addiction-Producing Drugs in its seventh report.*
It was found that khat does not fall clearly within the terms of either of the two definitions of drug addiction and drug habituation. In fact, in the light of the description of the situation prevailing in Djibouti, it can be said that khat falls within the definition of' habituation given in the first three paragraphs:
There is a desire (but not a compulsion) to continue taking the drug for the sense of improved well-being which it engenders.
There is little or no tendency to increase the dose.
There is some degree of psychic dependence on the effect of the drug, but absence of physical dependence and hence of an abstinence syndrome.
WHO Technical Report Series, 1957, No.116.
On the other hand, although there may be some doubt with regard to the theoretical definition of the effects of khat, it is obviously necessary to take energetic steps combat this social evil without delay.
In view of the urgency of the question, the French Government decided, even before the meeting of the Commission on Narcotic Drugs, to prohibit the use of this plant.
The following decree was passed on 2 April 1957 and published in the Journal officiel of 5 Apri1 1957:
Art. 1. The Public Health Code (Part II) has been supplemented by a new article R.5166-I, which reads as follows:
"Khat is classified as a narcotic drug.
"The importation, exportation, production, possession, trade in and use of, khat and preparations containing khat or prepared with a khat base are prohibited.
"For the purposes of this code, ‘khat’ means the leaves of the shrub Catha edulis ( Celastrus edulis) of the celastrus family."
Art. 2. Article R.5229 of the Public Health Code (Part II) is supplemented as follows:
" Any quantity of khat or its preparations which are seized in connexion with the violation of the terms of Article R.5166-I shall be destroyed after two samples have been taken which shall be forwarded respectively to the competent judicial authority and to the Central Office for the Repression of the Illegal Traffic in Narcotic Drugs."
Art.3. The provisions of this decree shall be applicable in Algeria, in the Overseas Territories and in Cameroons.