Categories
Kenya Medical

Khat

There was an external fixator holding his fractured tibia together. Pus was oozing from where the stabilising rods entered the skin. On standing, he was clearly in pain.

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“What happened?” I asked.

“I was hit by a car two months ago,” he replied. He went on to talk about not being able to work and the financial effects of his injury.

“Will you get compensation? Was the driver insured?” I asked.

He became evasive and didn’t answer my question. When I pressed him further, he said that the driver was a powerful man, who could make life difficult for him.

“Is he a witch doctor?” I asked.

“He is in the mirror business,” he replied.

This set me thinking. Mirror business? Something to do with magic based on your reflection in the mirror? Or something about selling mirrors, surely a niche market?

It was only a month later, when our vehicle was passed by a reckless speeding driver, that I had an epiphany. Our driver said, “That crazy boy is transporting miraa to Nairobi for the morning market.” Miraa (not mirror!) is the Swahili term for khat (or chat, qat, kat, qaad – choose your own spelling), the leaves of a shrub. Chewing the fresh leaves produces a stimulant effect somewhere between a strong cup of coffee and amphetamines. Latin America has coca leaves; India and South East Asia have betel nut; East Africa and Yemen have khat.

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Low bushes of khat seen from the road in Embu County

Khat has been used for thousands of years in the Horn of Africa. Men get together and chew the leaves (sometimes the soft branches, too), keeping a wad inside their cheeks. The leaves contain an alkaloid called cathinone which causes feelings of well-being, excitement and friendliness, stimulating conversation. These effects are quite rapid, kicking in after just 15 minutes.

Khat also suppresses the appetite and dries out the mouth, so users often drink coca cola to mitigate these effects. Other sympathomimetic effects are dilated pupils, increased pulse rate, high blood pressure and diminished sex drive. Like cannabis, a small proportion of people have a genetic predisposition to develop psychosis, which may be temporary or permanent.

The leaves are gathered in the early morning and laid out for sale on plastic sheets at the roadside. Buyers pack up the leaves carefully to avoid bruising and arrange for their rapid transport to Nairobi for the morning markets. At the end of the day, more leaves are collected and brought to market at Embu. There they are packed and loaded onto trucks for overnight transportation to Mombasa at the coast.

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I rarely go into the centre of town after dark, but driving back from a late clinic last week I saw a thriving night market, with clothes, electronics, shoes, food, hardware on sale. Enterprising stallholders had seized an opportunity to relieve the farmers of their earnings from the sale of khat.

Last month I was talking to a county health official who asked me what I knew about khat. I told him that I knew very little about it other than it had been classified as a drug of abuse in UK.[1]

He said that the Kenyan Government has a different view; it is an important cash crop. Indeed Meru and Embu Counties provide ideal climatic conditions for the cultivation of khat. He then asked me if I knew what pests attacked khat shrubs, and whether chemical spraying could deter or treat the infestation.

At first I thought he was asking for horticultural advice, but then I realised that people don’t wash the leaves before chewing them. Users could be at risk of organophosphate poisoning if the bushes had been sprayed. According to Wikipedia, organophosphates kill over 200,000 farmers in developing countries every year.[2] Perhaps we need to add treatment for inadvertent organophosphate toxicity (atropine and pralidoxime) to the cache of drugs we keep for use in emergency situations.


 

[1] Five years ago, after lots of discussion in Parliament, the then Home Secretary, Theresa May, decided to ban khat as a class C drug.

[2] Recently, a California court ordered the agrichemicals company, Bayer/Monsanto, to pay cancer-sufferer Dewayne Johnson damages of $289 million. “Roundup”, an organophosphate weedkiller, had been labelled as safe, despite the WHO warning it could cause cancer. The court ruled that the carcinogenic properties of Roundup had been suppressed by the company.

 

Categories
Kenya Medical

Psychiatric Unit

“He dropped out of school because he was receiving messages from God,” said Lucy, the veteran nurse in the Psychiatric Unit in Embu. “But his family thought this was very strange because he didn’t even go to church.”

Just off the main Nairobi – Meru Highway, close to the Isaak Walton Hotel, is the only psychiatric unit in Embu County. It is a square building with an internal courtyard, built in “Public Works Department 1960” style. To gain access, one has to pass through a locked gate by the nursing office. It has two wards, one with twelve male beds and another with six female beds. Adjacent to the female ward, there is an outpatient consulting room. The seclusion room has a steel door secured with a large padlock. There is a recreation room with a caged television and a broken pool table.

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According to a national newspaper, there are only six psychiatrists working in the public sector in Kenya. One of them works here in Embu. Each time I have visited the unit, I have only seen Nurse Lucy, as the psychiatrist spends a lot of time doing medico-legal assessments for the courts. There is only one other psychiatric nurse, who manages the inpatients. Student nurses do placements here, but few of them want to make mental health nursing their career.

On my first visit to the unit in May, all the student nurses were huddled in the nursing office by the gate. No nurses were in the open courtyard where some patients were walking around in the winter sunshine. I asked why the student nurses were not mingling with the patients. It was suggested to me that they found it too cold to leave the office.

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Lucy told me that drug-induced psychosis was common. “Embu is the catchment area for khat,” she said. (I am not sure she got the right word; “epicentre” would have been my choice.) The shrub khat contains two mild stimulants which are released when the fresh leaves are chewed. It is commonly grown in East Africa, where it is known as “miraa“. To get the best price for the leaves in the markets of Nairobi, drug traffickers drive like maniacs from Embu down the A2 highway in the early morning.

Although amphetamine psychosis is well-recognised, I had never heard of khat causing psychiatric disturbances such as hyperactivity, mania, hallucinations and, with prolonged misuse, psychotic depression. I learned that khat is used with other drugs, such as cannabis, to calm down as the feeling of elation recedes.

Lucy regularly visits schools to talk about mental health and the dangers of drugs and alcohol. She supplements this activity by health promotion using social media. Sadly, outreach clinics in the community have ceased. She has no vehicle and there no community mental health workers. Many people think that mental illness is caused by being bewitched. Rural communities tolerate people with severe mental illness until they start breaking things or attacking goats. Then they bring the person to Embu for a psychiatric consultation. During my previous visit, I saw a woman whose hands had been tied with rope sitting calmly in the outpatient waiting area.

Lucy also said that puerperal psychosis, schizophrenia and severe depression were common in patients attending the clinic. If she could not manage patients suffering from these conditions, she would refer them to Mathare Mental Hospital (formerly known at Nairobi Lunatic Asylum) in Nairobi.

It was obvious from visiting the unit that the patients were cared for with compassion. Lucy was a true champion for people with mental health problems. Unfortunately, she has plans to retire in 2022 and at present, there is no one being groomed to be her successor.