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Historically, epidemiology as the study of the distribution and determinants of diseases among human populations had undergone important changes. Over the last century, the scope of epidemiological research has been fruitfully extended from its initial focus on acute infectious conditions to non-communicable and chronic disorders, such as cancer, cardio-vascular diseases, nutritional deficiencies, mental disorders and drug dependence (1). With the developments in the field of epidemiology, due attention has been given to the basic differences between acute and chronic disorders. Acute epidemic diseases occur suddenly, sporadically or periodically and are caused by distinct pathogenic agents, whereas chronic disorders occur rather slowly, are more regularly seen within the population and are often attributable to a number of aetiological factors. These differences between acute and chronic conditions with respect to time, duration and the specificity or non-specificity of aetiological factors have brought about new developments in the concept approach and methodology of epidemiology. These are of great significance when considering the epidemiological aspects of the use of khat (Catha edulis Forskal).
In this respect, several questions arise. For instance, is the use of khat increasing or decreasing over time? Are the behavioural patterns of khat users changing? If so, what are the factors which have influenced these changes and in what direction? In answering these questions, as well as others, the aim of epidemiological studies of khat would be to develop relevant and practical measures for the effective control and, ultimately, the elimination of its use. However, it must be pointed out that the systematic collection and analysis of observations seeking to assess the prevalence and examine the origin, nature and consequences of khat chewing have been rather limited in scope and depth.
On the other hand, the United Nations Narcotics Laboratory, working in close collaboration with national bodies, was able to identify and qualify the various properties of khat (2) and eventually, in 1975, to isolate a new substance named cathinone whose configuration was established in 1978 as (-)-alpha-aminopropiophenone (3,4). The isolation of cathinone and the confirmation of its amphetamine-like effects is a crucial development in scientific knowledge on the chemistry of khat and its biological effects on the user. The epidemiological implications are also obvious. It is to be remembered that until very recently and even today in some countries where the use of khat is generally prevalent, the psychic effects of khat have not been seriously considered and are often viewed as being similar to those of excessive coffee drinking.
In this paper we will review some background information on the epidemiology of khat and present recent findings in the Republic of Djibouti as a case study.
Origin and history of khat use
Historical epidemiological data can provide a useful basis for the assessment of the current situation in the field of drug use. Despite the scantiness and limitation of the recorded history, the available information on the use of khat shows that it is deeply rooted in the social life of the people in a number of countries in East Africa and the South-Western part of the Arabian Peninsula. Though its origin is obscure, it is generally agreed that its use was first observed in Ethiopia and that from there, around the 15th century, the practice was transferred to the South-West of the Arabian Peninsula(5,6,7).
In the available literature, there are indications that khat, as early as the 14th century, was grown in plantations(7). However, it is not possible to assess the extent of its cultivation or the degree of its production. Consequently, there is no historical evidence of the prevalence of its use at that early time.
The terms used in historical literature such as "Tea of the Arabs" or "Abyssinian Tea" indicate that khat was used in the form of a decoction by boiling the dried leaves. Apparently, at that time, decoctions were a more popular mode of using khat than chewing, particularly in areas where it was not readily available in the form of fresh leaves and had to be transported via the caravan routes. There are obviously significant differences in potency between khat drunk as a decoction or chewed as fresh leaves. There is no way, however, to determine accurately why the use of khat as a decoction has died out and been replaced almost exclusively by the habit of chewing it. Among the major factors which might have contributed to this are the socio-economic changes and the introduction of modern means of transport (8,9).
The earliest report on khat presented to Western culture was made in the 18th century, when the botanist, Peter Forskal, identified th'e plant in Yemen and called it Catha edulis. (10) His findings were later edited by Niebuhr.(11) In his general observations, Niebuhr stated that he "never saw the Arabians use opium like the Turks and Persians. Instead of taking this gratification, they chew Kaad (khat). This is the buds of a certain tree, which are brought in small boxes from the hills of Yemen"(10). It seemed to him, that these buds were chewed, "merely from fashion". However, he made no reference to what was the driving force behind this fashion and how common it was among the people. Some of his interesting remarks on the buds of khat still hold true today, such as that "they have a disagreeable taste....
a parching effect upon the constitution and are unfavourable to sleep".
DATA FROM RECENT STUDIES.
During the last three decades, growing concern has been shown both nationally and internationally regarding the increasing problem of khat. This has focused attention on the need for collecting essential information to fill the gaps in our knowledge on the production, distribution,prevalence, socio-economic and health consequences of khat. The information now available, though still scanty, provides important background data on epidemiological parameters. A few relevant examples will be briefly outlined here.
1. The competition between coffee, sorghum and khat.
An important epidemiological parameter in any drug problem is its availability. Some of the countries in the Eastern Mediterranean Region, notably the two Yemens are producers of khat, others, mainly Djibouti and Somalia are importers. Information on production, importation, distribution and degree of availability are essential elements of the epidemiological date needed for the development of relevant preventive measures.
In 1956, a FAO Mission to Yemen reported on the Government's concern that the farmers were changing over from coffee to khat cultivation (12). What was causing this crucial shift could not be determined from the information available. Over the years, the competition for land between coffee and khat seems to have continued. The WHO sponsored mission, which visited Yemen in 1972 confirmed the growing shift from coffee to khat cultivation on account of the latter's greater profitability (13). A number of other factors have played a role in the competition between coffee and khat. These include: the outbreak of the revolution in 1962, which followed the civil war and continued until 1968, the severe drought of 1969 to 1971, the opening up of the country owing to political changes, the introduction of modern means of transport, the increased demand for khat in local communities as well as in some neighbouring countries (9). This shift to khat cultivation has continued in recent years. In the years 1972 to 1973, the khat cultivated lands increased by 17.4 and the following year by 11.8%. At the same time, there was an equal reduction in the land under sorghum cultivation indicating that khat is also replacing the production of such essential crops (14).
The overriding issue of this competition between coffee, sorghum and khat for farm land clearly indicates the major role played by khat in the socio-economic life of the Yemeni communities. This situation calls for careful planning of effective farming regulations and the control of khat use. Systematic epidemiological studies would help to elucidate the magnitude of these trends and to develop appropriate plans.
2. The prevalence of khat chewing.
In 1972, the WHO-sponsored Mission to Yemen estimated that "approximately 80% of adult men in the major cities and 90% of adult men in the villages of regions in which qat (khat) is produced are regular qat (khat) chewers. The prevalence of khat-chewing is lower among women and in rural areas where khat is not produced" (9).
In 1973, a study was conducted in Yemen Arab Republic among students in their third year of secondary education (15). On the basis of a structured questionnaire, 468 students were interviewed: 166 were from Sana'a, 190 from Taiz, 48 from Hodeida and 64 from Ibb. The students were between 17 and 21 years of age. In Sana'a, 8.3% of the students were using khat, 18.9% in Taiz, 10% in Hodeida and 13.3% in Ibb, giving an average rate of approximately 12%. 90% of these student's fathers were chewing khat and 60% of their mothers did so.
In Democratic Yemen, in 1976, a group of health workers estimated that 50% of the male adult population indulged in khat chewing (16).
In 1980, in Somalia, one of the authors observed an increasing tendency to chew khat (17). In 1981, it was generally estimated that about 75% of men and 7 to 10% of women chewed khat regularly and that khat abuse was increasing (18).
3. General pattern of khat chewing.
An important aspect of the epidemiology of khat is the pattern of its use. As in any drug study, some important factors must be considered, such as the social setting in which it is used, how the habit starts, the dosage and form in which it is taken and the cost. Based on previous studies (5, 13), the pattern of khat use can be briefly outlined as follows:
(a) The khat party, which usually takes place from 3 to 6 pm, is a dominant cultural practice. It is conducted in an elaborate and well-developed social setting. Under the stimulating effects of khat, the group dynamics and social interaction are enhanced. The mood is high and a general sense of well-being prevails. The pleasure induced by khat is an essential cause of the user's drug seeking behaviour and habitual indulgence. Khat is also used individually mostly by farmers in the field, labourers, etc. with the common belief that it improves their working capacity and counteracts fatigue.
(b) Khat has become an endemic phenomenon in several countries of the Eastern Mediterranean Region, namely Democratic Yemen, Djibouti, Somalia and Yemen Arab Republic. The habit is generally developed within the family between the age of 10 to 14 years. In urban centres, the influence of peer groups has been generally observed.
(c) Nowadays khat is almost exclusively chewed. The bolus formed is stored on one side of the mouth and the juicy extract is gradually swallowed. Though the amount used varies, khat seems to have a self-limiting effect and overdose is generally rare.
(d) Drinking cold drinks, such as coca-cola and smoking, normally accompany the practice of khat chewing. To overcome insomnia, which is a common consequence of the habit, there is a growing tendency to use alcohol, sedatives and tranquillizers (16).
(e) A certain percentage of khat users chew it daily and for long periods of their lives. These should be considered as khat addicts. In one in-patient study in the northern part of Yemen, the percentage of khat-dependent individuals in a sample of 27,410 was 60.26% among men and 24.91% among women (19).
Though it is generally believed that khat only causes psychic dependence, there are a number of physical withdrawal symptoms, such as undue fatigue, lassitude, shakiness and nightmares, which also point to an underlying physiological reaction (19). Compared to other, dependence producing drugs, the duration of the withdrawal reactions in khat chewing are relatively short and more amenable to treatment. In any case, whatever the precise nature of khat-dependence may be, its socio-economic implications and health complications are evidently serious.
4. Adverse effects of khat use.
Available information clearly indicates the harmful effects of khat on the user and his family. Among the low income groups, which forms the majority of the population in the affected countries, it has been estimated that 25 to 75% of the income is spent on khat. One third of the time that could be spent productively is lost for the khat user. This has directly adverse effects on family life and the society at large.
Though systematic epidemiological studies on the ill-effects of khat on health are still limited in their scope and depth, available information on general, clinical and descriptive observations points to a wide range of medical complications (20), mainly gastro-intestinal complaints due to the astringent effects of tannins and the possibility of a toxic hepatic reaction. There are also frequent complaints in the genito-urinary tract system, and their pharmacological basis has not been clearly elucidated (20 and 22).
A number of circulatory system disturbances, such as hypertension, cerebral haemorrhage, etc. have been attributed to the stimulant action of khat. However, more systematic epidemiological studies are needed to establish the determinant role of khat in the causation of these conditions.
Apart from the psychic dependence and general adverse psychological reactions such as morning irritability, reduced vitality and late arrival at work, there are also reports of true psychiatric disturbances, episodes of aggressive behaviour and psychotic excitation (21,23) .
THE REPUBLIC OF DJIBOUTI: A CASE STUDY.
In 1982, the authors visited the Republic of Djibouti from 29 October to 4 November to study the use of khat and recommend ways and means for dealing with its complex problems (24). During the visit, the WHO Mission was able to meet with a number of persons, including government officials, members of national associations, religious leaders and a good number of individuals, men and women, whose opinion on the problem of khat could be of interest. The visit was extended to two districts, outside Djibouti, namely Ali-Sabieh and Dikhil.
General background
The Republic of Djibouti has been an independent State since 1977. It has an area of 23,000 sq. kilometres. Situated in the Horn of Africa between Ethiopia and Somalia it faces to the east the Gulf of Aden and Democratic Yemen. The population is estimated at 350,000 plus approximately 50,000 refugees, mostly from Ethiopia. A little more than half of the population lives in the city of Djibouti and 45% of the population is below the age of 15.
The main health problems are associated with malnutrition and tuberculosis. Infectious and communicable diseases, including respiratory and diarrhoeal conditions are frequent. Djibouti is almost free of major tropical diseases, except for malaria.
The main income of the country is derived from services, especially from the port revenues. Khat plays a major role in the economy of the country.
Extent of khat chewing
Since the early fifties, khat consumption has become a mass problem in Djibouti. It is estimated that 90% of the men and 10% of the women indulge in khat chewing either daily or occasionally. One of the important new trends is that the younger generation appears in increasing numbers among the regular consumers. In the districts, the rate of consumption in men appears to be a little lower and female consumption is relatively rare.
Why has khat become a mass problem and a national issue?
There are many possible causes of the present situation. These include the many difficulties experienced by the people of Djibouti since the end of the Second World War, during the last decades of the colonial era; the struggle for independence; the modern drive for better standards of living; internal migration from rural to urban centres; the development of modern means of transport, especially air travel; and the rise of unemployment due to external events such as the closure of the Suez canal from 1967 to 1974.
With scant possibilities of work and few alternative leisure activities the people are exposed to the risks of an idle life; these risks are enhanced by the hardship of the climate and also by their poor standards of living.
Attitudes of consumers towards khat
Many of the individuals met by the authors were themselves regular or occasional chewers of khat leaves. They were frequently told that khat consumption was a source of pleasure, a recreational habit ingrained in social life and that it was used occasionally as a stimulant. The fact that Imams use khat to sustain themselves in long hours of prayer and meditation was quoted several times. Its effects were described as "making you more talkative, feeling well and becoming friendly with others". Very few admitted that for the great majority of people consuming khat daily, this habit had all the characteristics of drug dependence, with damaging effects on the individual and disastrous economic and social consequences, from the level of the family to that of the whole nation.
How is khat obtained in Djibouti?
Khat is not grown in the territory of the Republic, as it needs climatic conditions that exist only in neighbouring countries. Khat is then entirely imported from these countries, mainly from Ethiopia which produces plants of the best quality. Khat trade is regulated and controlled by the Government. A private corporation called SOGIK, whose bye-laws are officially recognized, organizes the importation and distribution of khat.
Previous attempts to reduce or even suppress this use have failed, and the Government has come to the conclusion that it should at least regulate trade and control the prices.
Every day, at about one o'clock in the afternoon, a plan arrives from Ethiopia loaded with eight metric tons of khat. This load is then carried by special lorries from the airport to the private compound of SOGIK to which distributors and dealers flock in great numbers. All these people are obviously in urgent need of getting their quotas. When the authors visited this site, it was obvious that the crowd was in a state of great excitement, reflecting the daily need and general demand of khat consumers.
Khat is distributed in sacks containing the equivalent of thirty bundles each. These sacks keep the leaves as fresh as possible. As soon as they are obtained from this central distribution area, they are hurriedly transported by car to selling points in the city of Djibouti and all parts of the country. During the authors' visit to the districts, it was observed that khat was delivered punctually to the local dealers for immediate sale to consumers in small bundles wrapped in plastic.
The individual experience of khat use
After a quick midday meal, the regular khat chewer buys his daily ration of leaves at the beginning of the afternoon. An average person's consumption ranges from one to four bundles a day. He will then join a group where he will spend hours with other consumers, chewing, drinking a large volume of water, tea or other beverages such as coca-cola, and smoking heavily in a confined space. Many homes have a special room for this purpose.
The intoxication develops in three phases well described by many authors. The first phase is a time of social interaction, pleasure, easy thinking, dreaming, fantasies and elation. After this stimulating period of time comes the declining phase where apathy, fatigue, depressive ideas, guilty feelings occur. During this second phase, the individual tries to prolong the stimulating effects by drinking alcohol and, more recently, by taking psychotropic drugs. Then comes the fight against insomnia which lasts until late in the night. Insomnia is one of the major ill-effects of khat. In recent years it has led more and more khat consumers to use sleeping pills, hypnotic drugs (barbiturates, methaqualone) and tranquillizers (benzodiazepines) with the attendant risk of new and more severe addictions added to dependence on khat. Finally, in the early hours of the next day, the khat consumer falls asleep. After such a night, he usually wakes up late and in poor physical condition, complaining of headache, fatigue and exhaustion. In order to improve his performance at work, he will frequently drink many cups of coffee or bottles of coca-cola during his few hours of work. At the end of the month when he has no money left to buy the drug, the khat user is exposed to withdrawal effects and prone to aggression and delinquency.
Two main patterns of consumption can be described: the occasional and the addictive type.
The occasional type is frequently found among high-income and educated people. Here khat is not used daily but either in leisure time, as a recreational habit, or on special occasions. It can also be used as a stimulant to increase one's ability to work or overcome some personal and transient difficulties. In these cases, the cost of khat does not deprive the family of its essential income and the individual is able to stop consuming without serious withdrawal effects. Nevertheless, even in these cases, khat use can seriously upset the family and social life of the consumer.
The addictive type is chiefly found among uneducated and poor people. In this case, use is associated with idleness and unemployment. Here, the daily consumption of khat is a substitute for activity and appears to be the only interest in life. Its cost has disastrous consequences on family life, depriving the wife and the children of basic necessities.
Medical consequences of khat use
It is not intended here to describe in detail the psychic, cardio-vascular, gastro-intestinal, urinary and genital complications of khat chewing. It is, however, necessary to underline the risks of acute and chronic complications.
Khat has a wide range of physical effects, mainly on the digestive, respiratory, cardio-vascular and genito-urinary systems.
The digestive system is the one most obviously affected. Complaints of constipation are common. In addition, stomatitis, dyspepsia and gastritis due to the astringent effects of tannins are often observed. Anorexia is a constant feature, responsible among other reasons for the reduction of food intake. The incidence of piles and hernia has been reported to be significantly high. Bowel obstruction may lead to abuse of laxatives.
As khat leaves must be kept fresh, the water used for this purpose can be responsible for infections. Epidemics of cholera have been reported in the past as being linked to khat use. Food poisoning caused by leaves sprayed with modern insecticides can also occur.
One of the effects of khat use on the cardio-vascular system is the congestion of the face commonly observed in consumers. Tachycardia and lability of blood pressure with a temporary rise are often seen. These effects can precipitate more severe cardio-vascular conditions, especially in the brain.
Anaemia, impotence, eye conditions associated with a lowering of ocular tension are among other classical medical consequences.
Some psychic effects have already been cited. They are associated with cerebral excitation resulting from the amphetamine-like action of the drug. Insomnia is a constant feature.
Acute episodes of excitation, agitated confusional states sometimes accompanied by criminal acts, may be observed. Schizophrenic reactions, when they occur, raise the difficult problem of their direct link with khat intoxication. As already indicated, khat chewers are at present increasingly exposed to the risk of becoming dependent on other drugs and alcohol.
Effects on family life
Essentially the habit of chewing khat can seriously affect all aspects of family life and be harmful to the working capacity of its users. As is usually the case with drug-dependent persons, consumers of khat are not as interested as they should be in the care and welfare of their families.
As already stated, the majority of khat chewers in the Republic of Djibouti are poor and frequently unemployed. In many cases their income is derived from the wife, who may be employed either in services or in doing some handicraft work. In these circumstances, the habit of buying an average of one to four bundles a day puts an unbearable strain on the family income, reducing it sometimes by more than 50%. Among the privileged, the economic consequences are less severe but marital relationships are also disturbed and the husband's ability to secure skilled work or hold a responsible position can be seriously impaired.
Khat consumption has very adverse consequences on married life. Husbands are absent from home until late at night. When they come back they can be either agitated, restless and aggressive or silent, remote and aloof. Khat use leads rapidly in many cases to a deterioration of sexual activity and a progressive state of estrangement between spouses. The number of broken marriages has rapidly increased in recent years and divorce rates have sometimes been estimated to be as high as 50.
Malnutrition, tuberculosis and inadequate rearing of the children are inevitable consequences of this situation. Children suffer also from feelings of inferiority at school, especially linked to the poor appearance of their clothes.
Women and khat use
Although anywhere in Djibouti men can be seen using khat openly, women, at least before they are married, only do so in secret. No women among those openly selling bundles in the street are seen chewing the leaves.
In recent years, an increasing number of privileged and educated women have developed the habit and a large proportion of the estimated 10$ of women regularly consuming khat belongs to this social group. In some instances, the habit is considered fashionable. Amongst the younger generation, girls joining mixed-sex khat parties are exposed to the risk of getting involved in deviant social and sexual behaviour. Married women regularly chewing khat will prefer to do so in groups of other women rather than look after their home and take care of their children.
Most of the men express their hostility against the use of khat by women unless they are old or heads of families. They condemn this use on moral grounds, insisting on the risk of misbehaviour, prostitution and vagrancy and on its negative consequences for child rearing.
An active "National Union of Djibouti Women" has been fighting since 1977 for women's rights. The three main objectives of their action are:
1) to improve the health education of women and children;
2) to overcome illiteracy, which is still the condition of the great majority of women in the country;
3) to develop handicraft and technical skills, as well as other capacities for self-support.
Although women are fully aware of the disastrous effects of khat use, especially on family life, the Union is not devoting much interest to the problem. Even the increasing number of female khat consumers does not seem to be one of its major concerns.
The younger generation
In the Republic of Djibouti, 24,000 children below the age of 16 go to school, 20,000 to elementary schools and 4,000 to secondary schools.
Some children in the population start chewing at the age of ten.
No education on the consequences of khat use is given to school children. Although there are no legal restrictions on its use, teachers are not allowed to chew khat during their working hours. In secondary schools, the use of khat occurs among older students seeking to stimulate themselves and prolong their study hours.
Adolescence is the time when most people start picking up the habit by imitating or identifying with adult behaviour within the family and social environment. Because of the lack of social restraint and religious interdiction, the young male starts chewing without any opposition from the adults. There is still a strong prejudice against girls doing so.
Since Independence, great attention has been given by the Ministry of Education, Youth and Sports to young people's use of leisure time. Sport and cultural activities, though currently limited, are systematically developed. A total of seven youth centres - four in Djibouti itself and three in the districts - have been created and are operating fairly efficiently. In these centres, the young can read, listen to music, see films and play different games.
After the age of twenty, men in Djibouti rarely practise any sport or show interest in sporting events. Sport is somehow looked upon as a recreation for children. This lack of interest should be overcome if sports are to be genuinely developed.
Economic aspects of khat use
The regular use of khat impairs the working capacity of a large number of men and drains off an important part of the national income. For these reasons the drug bears a major responsibility for the under development of the country.
The Republic of Djibouti depends almost entirely on imported food. Cereals, vegetables and fruit are not produced locally. Fish and meat productions are limited. There are only a small number of industries and the functioning of services suffers from absenteeism and inefficiency. Offices work officially from seven o'clock in the morning to one o'clock in the afternoon, but many khat consumers do very little work before nine and generally stop again by about twelve.
Khat plays a major role in the economy of the country. This role is well illustrated by the following table from the Ministry of Finance:
1) Djibouti franc
(2) Adjusted from figures obtained for the first ten months of 1982.
This table shows the magnitude of the problem. The average daily quantity officially imported in 1982 amounts to 8.1 metric tons. The average daily revenue from the tax on khat trade amounts to 5,439,692 Djibouti Francs (DF) or 30,560 US dollars (at the exchange rate of 178 D F for one US $).
Illegal importation increases the authorized daily total by 5 to 10%. This supplementary quantity is smuggled into the country. However, the legal authorities attempt to control carefully the daily quantity imported, to meet the eight-ton requirement.
A bundle of khat is sold in the Republic of Djibouti at a fixed price of 250 DF. Its weight is supposed to be 100 g but is frequently less. Of this total of 250 DF, the local dealer receives 30 DF; the amount paid to Ethiopia is estimated at 70 DF, the cost of air transport and distribution to the dealers at 23 DF; the tax paid to the Government is a little less than 67 DF. These various expenses amount to 190 DF. The remaining balance of 60 DF is left to the SOGIK Corporation as net profit on each bundle.
Thus, like many pleasure-inducing substances, khat is a very profitable business. According to 1982 figures, the daily profit of the Syndicate amounts to 4,860,000 DF or 27,303 US $ at the exchange rate of 178 DF for one US $.
It is estimated that an approximate total of 28,000 persons (8% of the population) derive their living from khat; 80$ of these are in Djibouti and 20% in the districts. About 240 heads of family are affiliated to the Syndicate.* An estimated 2,500 dealers and other employees are permanently working for them.
Previous measures against khat use
Attempts to reduce the importation of khat by punitive measures have failed. Temporary measures of prohibition were taken by France during the colonial era. In 1957, the French Government, considering khat as a dependence-inducing drug, passed a decree prohibiting its use in Djibouti, but this proved to be ineffective and was then abrogated.
Soon after Independence, in 1978, a new decree prohibited the importation of khat, but after a short time its use was authorized again. During the latter period of prohibition, the fight of public authorities against illicit trade was severe and yet proved ineffective. People were endangering their health by consuming dry or low quality leaves and were paying much higher prices.
Societal and political aspects of khat use
The increasing number of khat consumers, its regular air transportation from a neighbouring country and its trading as a business legally organized by a private corporation under the control of the Government, all seem to raise serious societal and political issues.
The habit of meeting in khat parties and its extensive use has developed khat chewing behaviour into an evolving ritual of social life. It is often said that many things which would be impossible without khat are made possible with it and this belief associates it with profitable business and good social relations.
Khat plays an important role in the political life of the country. It was and still is widely distributed at no cost to the electorate. Khat does not only have disastrous effects on the development of the country, it also makes this small and newly independent State completely dependent on its most powerful neighbour.
Since 1921, the United Nations have been concerned with the problem of khat. In 1957, WHO was officially asked by the Arab League to take the problem into serious consideration and study the properties of khat leaves. In 1975, the Arab League accused France of subjecting the population of Djibouti to intoxication. However, no concerted action against khat has been undertaken by the international community.
The Government of Djibouti is well aware of the devastating consequences of khat use for the future of the country and looks for all possible support to change the situation and achieve the effective control and ultimately the eradication of khat.
STRATEGY FOR FUTURE ACTION IN THE CASE OF DJIBOUTI
The problem of khat in the Republic of Djibouti is a serious national issue which calls for urgent action. Its complexity and severity stem from the nature of khat use and the close connection between its medical, socio-economic and political aspects. These facts have to be taken into consideration in the development of an effective strategy for future action.
The political will against the use of khat has been well expressed. A comprehensive and dynamic programme of action must be developed at both national and international levels. This programme should be based on the most valid and accurate information available and careful consideration should be given in its implementation to its relevance and practical applicability to the country.
Programme of action at national level
1. Objectives:
The main objectives of the nation-wide programme should be;
a) the protection of the younger generation against the risk of using khat;
b) the modification of the people's behaviour to contain and overcome the demand for khat.
2. Approach:
In view of the complexity and multi-faceted aspects of the khat problem, the success of a national programme requires a mass involvement of the people and a strong national commitment at the highest level. The approach should be multi-disciplinary and multi-sectoral and the various ministries, political organizations and related social institutions should be involved to ensure its proper development and effective implementation. Religious and teaching institutions can play an active role in persuading, convincing and changing the public attitude towards the use of khat.
3. Education of the younger generation
The protection of the younger generation against the risk of khat use could be achieved by an education programme and the development of sport and cultural activities which would encourage more active and healthy patterns of behaviour.
The education programme should be organized for young people from 10 years of age upwards. It should give all the necessary information on the ill-effects of khat on individual health and family life, as well as on the economic and social life of the community at large. This education should take place not only in schools but also in youth centres.
Teachers and educators should be well informed and specially prepared to ensure their effective role in the mass campaign against the use of khat.
The development of sport and cultural activities for both boys and girls would divert the interest of the young from khat use especially in leisure time. This entails the increase of youth centres and sports facilities to provide wider coverage.
4. Education for the adult population
Education against khat use should be provided for the adult population and campaigns of information should be organized through all possible media.
Cultural activities like drama, poetry and singing have already proved to be effective in women's groups. However, achievements in these fields are still very limited.
5. The role of the National Union of Djibouti Women
As already stated, the majority of women do not consume khat. However, with their children, especially if they are poor, they directly suffer from the consequences of khat use. With the help of the National Union, women could be a strong and reliable force against the use of khat.
Wives belonging to the low-income group will probably be more responsive to information regarding the damaging effects of khat on family life and the future of their children. Wives of the high-income group will probably be more responsive to information stressing the damaging effects of khat on their husband's capacity to hold responsible positions and on the future of the country.
6. The role of religious institutions
Religion is a strong deterrent against the use of drugs, including khat. Because of its adverse effects on behaviour and the damaging effects on family life, khat constitutes a harmful agent and its use should therefore be regarded as anti-religious.
The Qadi of the Republic concurred with this view and showed keen interest in participating in the mass campaign against khat. Special programmes should therefore be organized by the religious institutions at country level making specific use of the daily prayers in the mosque and the mass payers held on Fridays.
7. Socio-economic development
It must be realized that the use of khat in the Republic of Djibouti is closely linked to the underdevelopment of basic natural
resources such as water supply and agriculture. These are essential elements for socio-economic development and due attention must be given to them in the building up of an effective nation-wide campaign against the use of khat.
8. Formation of a National Board
The formation of a National Board to combat the use of khat is of cardinal importance. The Board should include members from all the official bodies concerned as well as representatives of the social and voluntary organizations. The main functions of the Board will be:
a) to coordinate national planning, organization and implementation of the programme;
b) to undertake its regular monitoring and periodic evaluation;
c) to facilitate the implementation of the national policy and legal measures;
d) to enhance potential national resources to combat the use of khat;
e) to enlist international support to deal with the problem of khat.
PROGRAMME OF ACTION AT INTERNATIONAL LEVEL
1. Foreign trade control
The availability of a drug is a crucial factor in the promotion of its use. A drug-dependent individual can hardly be freed of his habit if the substance is still readily available. In the case of khat, the substance comes from another country,thus, only decisive action at international level can succeed in modifying the situation and restricting availability. This calls for close collaboration between countries and the search for ways of persuading countries which export khat to discontinue the practice.
2. Dissemination of scientific information on khat
One of the first steps to be taken is the wide dissemination of scientific information and experience in dealing with the problem of khat. For this purpose, scientific meetings should be held. The results of these meetings should provide a sound basis for action by the international community.
The latter should be informed by all possible means about the disastrous consequences of khat use in order to obtain the strongest support and enlist the closest possible collaboration of other countries.
3. Technical support by UN agencies
The development of a comprehensive programme to combat the use of khat, as previously outlined, requires that international organizations such as UNESCO, FAO, UNICEF and WHO should offer their technical support at both national and international levels.
Despite the severity of the problems of khat use in the Republic of Djibouti, certain facts are particularly encouraging: a strong political will, the small size of the country and the existing national potential for developing a viable programme to deal effectively with the use of this substance.
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