The khat dilemma

In this guest blog, Professor Kamaldeep Bhui discusses the health issues surrounding the plant khat, and the need for more research into its effects on physical and mental health. 

A Home Office report on khat and the social and health harms associated with its use was recently published with the view that there was insufficient evidence that it caused health problems.

The report considered a great deal of evidence from scientists, communities, and legal and clinical experts, including ourselves [Cultural Consultation Service], taking international as well as local evidence into account. Although legal in the UK, khat has been banned in the US and 16 EU countries.  

On Wednesday, April 17, at a Global Public Mental Health & Cultural Psychiatry Masterclass, in association with mental health charity Careif, we will be presenting research evidence and practice innovations that will include a debate on khat and its place in current health and social care policy and practice.

The tension between global public health systems and localism is evident and there is some concern among cultural psychiatrists about the universal application of these systems without a proper understanding of cultural contexts and histories. Khat is one such example. It requires an in-depth discussion and new research evidence to investigate its harms and cultural role. 

Khat is largely used by Somalis, Yemenis, Kenyans and Ethiopians; it is sold in markets as a leaf that is chewed or brewed. The fresh leaves are reputed to have amphetamine-like properties as it releases cathinone and cathine, both stimulants that are produced by the breakdown of amphetamine when metabolised in the body.

Despite the moral panic that ensues when comparisons with amphetamine are made, the active ingredients are released very slowly and at a fraction of the dosage that would produce amphetamine-like effects, so the comparison is not a good one. 

Amid the evidence considered by the Home Office, there have been assertions that khat consumption is linked to crime, domestic violence, homicide, road traffic accidents, suicide and even terrorism, war and poverty. The Home Office report rejected these assertions.

The nature of the link with poor health, causal or associational, is the subject of much controversy with little epidemiological or quantitative population-based research supporting these claims.  

In the evidence we submitted to the Home Office was the fact that the treatment of psychosis in patients with pre-existing psychosis can be complicated by heavy khat use. Yet the population data doesn’t show a direct association of psychotic symptoms with khat consumption.

The medical evidence suggests it can be harmful in people predisposed to mental illness and can exacerbate psychosis, and possibly suicidal ideation. Other evidence indicates hepatic damage and cardiovascular collapse.  

Meanwhile, members of the communities in which khat is consumed, along with some clinicians, such as cardiologists, hepatologists, psychiatrists and substance misuse experts, complain of the damaging effect on families, young people and community prosperity.

The dilemma is that khat consumption continues to be a culturally important ritual which many wish to protect. Also the attacks on khat consumption are seen to be based on a fear of stigma, of attracting a poor image, as well as indicating a fear of foreignness.  

Amid the Home Office report’s recommendations is a clear signal to local authorities, public health and wellbeing bodies, the Department of Health and criminal justice agencies that they have a duty to start monitoring khat’s impact.

Whether this will happen remains to be seen. Currently there are no designated khat services or clinics anywhere in the country. There are no health screening, monitoring or needs assessment strategies in place. Health promotion and awareness raising are non-existent. So how is it possible to gauge khat’s current impact on Black and minority ethnic communities’ wellbeing and that of the children who can buy it in their local shop as if it is confectionery?  

Despite access to a plethora of evidence from different sources, the report admits that much more comprehensive research needs to be done. Yet research commissioners seem equally uncommitted to it.

For example, our recent grant application to the National Institute for Health Research to investigate its harmful effects, and to compare it to other substances, with particular reference to psychological, cardiovascular and oral disease, was greeted with a stark response: that it wasn’t a priority, wasn’t affecting many people and the case for a major investigation was not evident to them. This begs the question, how well informed are commissioners? 

The implication that serious conditions or risks to health and wellbeing can be overlooked when it affects minority communities is worrying. At a time of great change in the NHS, such an approach neglects the key public health drive to recognise the links between physical and mental illness, and that health risk behaviours are often shared.

We need commitment to a research agenda, evidence-based policy and health promotion, and a public health policy that does not neglect minorities, or the socially excluded, whose health will otherwise worsen.

Professor Kamaldeep Bhui is director of the Cultural Consultation Service (www.culturalconsultation.org.uk) at the Wolfson Institute of Preventive Medicine, Queen Mary University of London.

To see the event programme click here