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Watch our new film, featuring Professor Kamaldeep Bhui, Lord Victor Adebowale and Micol Ascoli, among others, on the value of cultural consultation in mental health, the current political challenges and our commitment to research Khat and radicalisation.
The Advisory Committee on the Misuse of Drugs (ACMD) is to be congratulated on its evidence-based review of the harms associated with khat use. In January 2013, the ACMD updated its 2005 review to determine that khat should not be controlled under the Misuse of Drugs Act 1971.
Khat is known to release cathinone and cathine on chewing. There are no international comparable prevalence estimates for the use of khat and no reliable published evidence as to the rates of khat use in European countries.
Rates of khat use appear high among the general populous in Somalia, Yemen and Ethiopia. However the prevalence of khat use is far less among the Somali community living in the UK than in the population living in Somalia. Northern Ireland and Scotland do not report any figures on prevalence or treatment data of khat users engaging with the NHS.
Only six referrals have been recorded on the Welsh National Database for Substance Misuse since 2009. The NHS data for England for 2010/11 shows 112 clients started treatment for the first time, citing an involvement with khat at some point in their past. These findings suggest that there are no dedicated services to help manage the harms associated with khat use.
Although the ACMD report indicates no real evidence of the medical effects, we do know that there are numerous case reports showing a detrimental impact on mental health. Also some valuable larger studies indicate clear risks for cardiovascular, hepatic and oral diseases. What isn’t clear is whether these are due to the socially adverse environments, including cigarette smoking, in which khat consumption is common, or due to independent direct effects.
However, in countries where it is considered to be a high health risk it has been made illegal. These laws are not based on research evidence but suspicions of harm from a foreign product. Does this mean we should be complacent about khat, given it has been suggested to make psychosis worse, for example?
We should certainly provide better education and health promotion information to those encountering khat, particularly young people, through schools. Those selling khat should be openly encouraged not sell it to young people, or to those who are clearly already in poor health.
Providing health screening in geographical areas of khat consumption, and reviewing the role of social exclusion and adversity in creating cultures of consumption similar to those for cannabis or alcohol use, should be investigated with some urgency.
The Cultural Consultation Service (CCS) is working with the Cultural Psychiatry & Epidemiology research group at Queen Mary University of London, which has undertaken ethnographic, qualitative and epidemiological research on khat and mental health. This has been done with local communities using rigorous research methods. What isn’t so widely known is that this evidence informed the ACMD review.
There is still a clear need for research into this area. Yet research applications, even one to the prestigious National Institute for Health Research, were deemed to be a low public health priority. How can we build preventative strategies based on an evidence base, or consider the role of legislation, in the absence of evidence? How do we know what health education advice to provide if no one is willing to fund much needed research?
Perhaps, like many minority issues, khat research is not seen to be of relevance to the mainstream population. Meanwhile minority communities, who have a right to good health as citizens, seem to be overlooked and relegated.
The new public mental health policies promise better health for all, but will the socially excluded and poorest in society, and black and minority ethnic groups with their worrying health issues, receive the attention they deserve?
Service providers and professionals need evidence. Research commissioners must give this issue more priority and stop the unimaginative, albeit predictable, focus on research only for the more familiar majority population which assumes that inequalities are entirely social and confounding influences.
What needs to be considered is how inequalities may hold clues to the causes of illnesses and disease as well as social and biological harms. The ACMD undertook an exemplary evidence based review, but we are still left with sufficient concerns to warrant more research.
Kamaldeep Bhui is Professor of Cultural Psychiatry & Epidemiology, Queen Mary University of London, and Director of the Cultural Consultation Service.