THE CONDITIONS in Somaliland’s mental health centres have been shockingly described in a new Human Rights watch report titled “Chained like Prisoners”.
It explains how, even though authorities have recognised mental health as a serious problem, there are only two qualified psychiatric doctors in Somaliland for an estimated population of 3.5 million. Public facilities - as well as three of the private centres - were unhygienic and dilapidated, that patients are not getting any counselling or psychotherapy and the centres are not catering for people to return to society. Many of them were just cruelly chained up all day, for months on end.
There are no official estimates on mental health conditions in Somaliland however, existing research points to alarmingly high levels and one of the causes for mental health illness given in the report is the widespread use of khat.
Khat is a naturally occurring stimulant that has been compared to coca leaves, coffee and amphetamine. It is consumed by plucking off the leaves of the khat tree and rolling them into little balls that are pushed into the side of the cheek where they form a large, soft mass of leaves. The practice is usually referred to as khat chewing, but the leaves are actually kept in the side of the cheek.
When the juice has been extracted, the remnants are either swallowed or spat out. Because of its sharp taste, khat users often use sweet drinks or chewing gum at the same time.
The practice, almost done exclusively by men, has been around for centuries in the Horn of Africa - in countries such as Yemen, Ethiopia, Somalia and Kenya - for the euphoric high users can get. It produces mild psycho-stimulant effects such as increased energy, enhanced mood, reduced appetite and reduced sleep - but it has been shown to lead to mental health issues. In fact, psychosis is one of the reasons why exports of khat to the UK, despite generating huge amounts of tax revenue and the devastation it would cause to khat farmers in East Africa, was banned and classed as a Class C drug in 2014.
A recent literature review of khat and mental-health issues identified 41 English-language research papers where the authors generally provided comprehensive case details and reported a causative relationship between khat use and psychosis or psychotic symptoms. Khat was shown to not only exacerbate existing mental health problems but is also believed to directly trigger psychosis if used in excess.
As it stands Somalia as a whole is said to have one of the highest rates of mental health illness in the world, with the World Health Organisation estimating that one in three Somali’s has been affected by some kind of mental illness - not surprising considering the decades of conflict and fighting the country has endured and the emerging post-traumatic stress conditions that would emerge as a result.
This is particularly dangerous considering that the early onset of psychotic symptoms is related to excessive khat chewing. On average, cases with psychotic symptoms had started to use khat earlier in life than matched controls and had been using khat 8.6 years before positive symptoms emerged. But also concerning is that several studies have demonstrated increased use among individuals who already have mental disorders. They explained that they kept khat-chewing as a way to “forget” and to console over the losses of the past and the problems of the present.
But research shows that psychosis happens with healthy users too - as a result of excessive use.
Because of the nature of khat-chewing as a recreational habit, done communally or at home, there aren’t really concrete official figures by country that can be referred to, but there are snapshots of data that paint a broad picture of just how widespread and excessive use can be.
It’s estimated that 90% of adult males in the autonomous region of Somaliland chew khat, that men and women in Ethiopia chew 28% and 11% respectively, while in Kenya it varied according to region - those that produced khat showed a prevalence rate of just over 50% or 10.7% in a region without khat production.
There is some evidence of uncontrolled and problematic khat use in the refugee camps in Northern Kenya. With young men most vulnerable to chronic use. As transport networks open up, inland countries such as Uganda have documented that the consumption of khat is increasing especially among youths. There, 32% have experienced chewing khat and 20% claim to still be using it.
So while khat use increases the risk of mental health problems - some more so than for others - it should be emphasised that, unless the user is predisposed to a mental health disorder and chews a lot of khat every day, the risk is low. So, it’s not the usage per se - but rather how often it’s chewed that matters in terms of potential mental health issues.
Worryingly, usage among these chewers is high with many chewing large amounts for lengthy periods of time.
For example, in Somaliland, a typical khat consumer, about 75% of users, will consume between 1 and 2 bundles per day (each bundle weighs about 150 to 300 grams). Forty three percent of whom would consume khat 7 days a week and about 65% of the consumers also spend 7 hours per day chewing.