CHEWING IT OVER KHAT USE INLAMBETH’S SOMALI

m r

COMMUNITY

QAYILNO AAN U

London Borough of Lambeth - and Alcohol Team

The Report of LBL NeedsAssessment for Lambeth’s SomaliCommunity in Relation to Khat Use andOther Issues

A partnership project between LBL DAT,Fanon Care, London SomaliDevelopment Partnership (LSDP) andEast African Health Concern

Abdigani Yussuf

Paul Asquith

Acknowledgements

The authors would like to thank Regat Zeray,

contributions made towards this research by

the following people: Megan Jones, Adina

Bozga, Vince Wakfer, Tseday Yilala (LBL DAT);

Dr. Abdul Qadir Afrah, Musa Hassan,

Abdurrahman Ibrahim, Dahir Mohammed

(LSDP); Abdi Mao, Ali Hossein (EAHC); Anita

Hayles, Lidia Artigas (EDDAT); Nicholas

Campbell-Watts, Regat Zeray (Fanon) Janice

Gittens (Lambeth Harbour), Claudio Costanza

(Lambeth Pyschology); Neil Thurlow (LBL CST),

Leah Levane (Streatham Town Centre Team);

Kate Cowburn (Mainliners); Yusuf Farah (LBL

EMAT); Mark Asquith (Wolfson College, Oxford);

Natasha Afflick (London Borogh of Lambeth);

Sue MacDonald (SMD Design) and all others

who have contributed their time and advice.

1.1 Executive summary 2

1.2 Key recommendations 4

2 Introduction 5

2.1 Background to the project 5

2.2 Developing appropriate responses to khat use 5

2.3 The Somali community in the UK – a historical perspective 6

2.4 Lambeth’s Somali community 7

2.5 Catha edulis – The ‘leaf of Allah’? 9

2.6 Effects on khat users 10

3 Methodology 11

3.1 Literature review 11

3.2 Research ethics and donfidentiality 12

3.3 Quantitative needs assessment 12

3.4 Prevalence estimation (indirect methods) 12

3.5 Multiplier methods 13

3.6 Capture-recapturemethodology (CRM) 13

3.7 Qualitative needs assessment 13

3.8 YP volunteering strand 14

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Sofia Ali

Amina Abdulkadir, Rahima Ali and Farah Naleye for their enormous support and assistance.

Authors would also like to acknowledge the

Drug (LBL DAT)

2007

4 Results 15

4.1 Quantitative Data – results from questionnaires 15

4.2 Prevalence estimation 15

4.3 Implications of prevalence estimation for total populations size 15

4.4 Demographics 17

4.5 Patterns of khat use 19

4.6 Health and other impacts of khat use 20

4.7 Attitudes to khat use 21

4.8 Knowledge/attitudes to other drugs; polydrug use 21

4.9 Accessing treatment and other services 22

5 Results from qualitative sampling 23

5.1 Qualitative data 23

5.2 General Concerns 23

5.3 Attitudes to khat use 24

5.4 Khat and health 26

5.5 Khat and sexual health 27

5.6 Khat and mental health 27

5.7 Khat and polydrug use 28

5.8 Khat and religion 29

5.9 Trying to quit 29

5.10 Accessing treatment services 30

5.11 Accessing other services 30

5.12 Police and community safety concerns 31

5.13 Responding to khat (mis)use 33

6 Analysis and conclusion 34

6.1 Methodological constraints 34

6.2 Prevalence estimation 34

6.3 Demographics 35

6.4 Patterns of khat use 36

6.5 Polydrug use 37

6.6 Attitudes to khat use 37

6.7 Health implications 37

6.8 Mental health implications 38

6.9 Public health implications 39

6.10 Marfesh mapping and Lambeth’s khat markets 39

6.11 Community safety and policing 40

6.12 Accessing treatment and other services 41

6.13 Project recommendations 42

Endnotes 43

Appendix 1 – Sample questionnaire 45

Appendix 2 – Focus group themes 51

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BACKGROUND

• Over the last ten years, Streatham andStockwell have emerged as centres for theSomali community in Lambeth with shops, cafésand other services. The sale and use of khat bySomalis was implicated as a factor incommunity tensions in 2004. In 2006, LondonBorough of Lambeth Drug and Alcohol Team(DAT) commissioned the Lambeth Khat Project, apartnership project between the DAT,FanonCare, London Somali DevelopmentPartnership (LSDP), and East African HealthConcern (EAHC). The project consisted of twostrands – a service delivery strand offeringculturally appropriate advice, signposting andreferral to those affected by khat misuse, and aresearch strand which aimed to gauge theextent of problematic khat use in Lambeth. Tworesearch project workers were recruited and a

was also formed at the start of the involving stakeholders from the community,

voluntary and statutory sectors.

METHODOLOGY

• The research was conducted as a mixed-methodology study comprising quantitative andqualitative elements. Research tools(questionnaires, focus group and interviewquestions) were developed and tested beforedata was collected by the research workers andvolunteers. In November 2006 a Somali youthvolunteering stream was added in order tocollect more information on the needs of youngSomalis, and 8 volunteers were given basictraining in data collection and analysis. Acomprehensive literature review focusing onlocal and national sources was also carried out.

• A total of 354 respondents completed or werehelped to complete questionnaires, one of thelargest data sets of any khat study conducted inthe UK. Focus groups were conducted withyoung men, young women, older men, olderwomen, religious leaders, and marfesh (khat-house) habitués. Stakeholder interviewswere also carried out with khat-users, as well ascommunity workers and leaders. Respondentswere selected using quasi-random andopportunistic sampling methods to try and avoidsample bias; stakeholder interviewees wereselected on a purposive basis.

• Data gathered from questionnaires wassubjected to statistical analysis and cross-referenced around important dynamics such asage, gender, employment, and education. Apared-down and simplified version of ‘capture-recapture’ methods was used to compareseveral data sets. Multiplier methods were alsoused to extrapolate likely population sizes andprevalence. Data from focus groups andinterviews were analysed thematically.

PATTERNS OF KHAT USE

• The research sample demonstrated very highlevels of regular khat use (77%) amongst Somalimen and women of all ages that are notdissimilar to those found in similar Londonboroughs such as Brent or Haringey. Thefindings suggest that the Somali community inLambeth is significantly larger than previouslythought. It is likely that the Somali population inthe borough is at least as high as 3000+, ofwhom at least 1000 are regular khat-users.

• Although problematic khat use has a significantnumber of negative impacts on the physical andmental health of users, it is a mistake toattribute the multiple deprivations and barriersto accessing services to khat use alone. In one

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1.1 EXECUTIVE SUMMARY

groupsteering project

sense, khat can be seen as a nexus for a broadrange of social exclusions that prevent bothindividuals and the community more broadly frommaking the most of their lives.

• From the data collected, it is clear Somaliwomen are using khat at similar levels to theirmen-folk. Women in particular are verysuspicious of accessing mainstream servicesaround khat use, in part because of the taboosurrounding female khat use, but moresubstantially due to a perception that manymainstream services are not as appropriate oraccessible as they might be.

HEALTH, WELL-BEING, AND TREATMENT

• Respondents reported a wide range of healthimpacts from khat use, including sleep disorders,paranoia, constipation, and loss of appetite.Although levels of direct reporting of sexual andmental health issues was low, a number ofphysical health effects reported can also beconsidered as symptoms of mental ill-health. Thisis likely to be, in part at least, a result of howmental ill-health is conceptualised in Somaliculture. Stigmas around mental ill-health alsomean that somatization of mental health issuescan be a problem for treatment providers.

• Most Somali clients in mental health services inLambeth use khat to one degree or another.There is evidence that dual diagnosis is arecurrent issue for these patients and also forthe many users who do not access mentalhealth support. Mental health services areusually only accessed at times of acute crisis,making treatment more difficult.

• Aside from the still embryonic service deliverystrand of the Lambeth Khat Project, there are notreatment services to assist problematic users

in addressing their Khat habit in the borough.Entrenched suspicion of services, the fear of thestigma associated with the term ‘drug’, and ageneral reluctance to accept that there is aproblem are all obstacles to accessing help.Some community members seem to activelydistrust Western medical/clinical approaches,especially in areas like mental ill-health.

THE KHAT MARKET

• There are at least 20 marfeshes 1 (or khat-houses) operating in the borough, with particularclusters around Streatham and Stockwell.Marfeshes are a dynamic business and one mayclose down only to reopen at a different venue.

• Khat use has a significant economic impact onusers and their families. Approximately 50% ofrespondents were unemployed, with a further23% as students. The average amount spent byeach user was the equivalent of £780 per year.One implication of this is that any harmreduction strategy must incorporate diversionaryactivities and job-finding support.

COMMUNITY SAFETY

• There is no established relationship between khatuse and crime in Lambeth. Such crime as canbe attributed to members of the Somalicommunity is predominantly being committedby young people. According to the police thecrime generated by the Somali community is notabove, and possibly below, average. However, ahigh proportion of respondents (41%) citedexperience (direct or indirect) of domesticviolence. Attitudes to and experiences ofpolicing in the borough were mixed.Islamophobia was a concern, while generic hatecrime (e.g. racism) was low.

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• The multiple difficulties and barriers faced bymany members of the Somali community deriveboth from their war-torn past, and currentissues both here and in the Horn of Africa. Theresolution of these problems, which involveshealing of trauma as well as reducing barriers toaccessing appropriate education and basicservices, is beyond the resources of any localauthority. It needs to be addressed on a London-wide, national and even international level.

• Continue resourcing the project at current levelsand seek funding to expand the number ofworkers to two full-time staff

• Work more closely with other statutory healthand mental health professionals, as well asthose community and voluntary sector groupsworking in this field, to strengthenreferral/signposting pathways, and develop aneffective model of care for khat use thatcombines harm minimisation advice andculturally appropriate psycho-socialinterventions.

• Extend the existing partnership arrangementwith the Fanon Resource Centre to include otherstimulant services in the borough wherepossible and appropriate.

• Greater provision of diversionary activitiestargeting at risk groups within the community,notably women, carers, the unemployed, andyoung people.

• Coordinate more effectively with other agenciesand departments within the Safer LambethPartnership (SLP) to address a broad range ofneeds within the Somali community andencourage the formation of a strategic-levelgroup at borough level of SLP and Somalicommunity members.

• Supported Housing providers need to ensurethat Somali tenants are adequately supported tomaintain their tenancies

• Access to skilled interpreters, especially intechnical fields such as health and law, needs tobe improved across a wide range of services,and made more localised. Many serviceproviders source interpreters through specialistagencies, which tends to bypass significantcapacity in the local community sector.

• Continue efforts to engage constructively withmarfesh owners, promote good businesspractice and greater awareness of health andsafety issues.

• Intensify efforts to engage young Somalis anddevelop initiatives to address potential khatand/or other drug use among this group, usinginnovative approaches– activities, events, etc.

• Support efforts to provide access to suitablecommunity venues

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1.2 KEY RECOMMENDATIONS

2.1BACKGROUND TO THEPROJECT

The Lambeth Khat Project arose out of ongoingwork by Lambeth Drug and Alcohol Team (DAT)and Community Safety Division (CSD) to address anumber of issues facing the Somali and othercommunities in Streatham. Over the last tenyears, Streatham and Stockwell have emerged aspopulation centres for the Somali community. Inparticular, tensions arose in 2003-4 in GleneaglesRoad (known locally as the ‘Dip’) around the useof street space by Somali men, and the perceptionthat some of these men were behaving in an anti-social manner.

The use of khat (khat)2 was implicated in thissituation, in particular unlicensed trading of khatfrom vans or other vehicles. In consequence, in2004 Lambeth DAT commissioned Drugscope toconduct a limited needs assessment of the Somalicommunity in Streatham. This identified khat(mis)use by the Somali community as a majorissue impacting the lives not only of individualusers, but also their families, and by extension thewider community.

At the same time, a number of interventions weremade to address the issues arising in Streatham.Trading Standards in conjunction with the policemounted raids on unlicensed trading of khat fromvehicles, Health and Safety officers gave advice toowners of marfeshes (khat-houses), and regularjoint patrols were set up between local policeofficers, street wardens, and Somali volunteers toease any tensions arising between Somali andother residents in the area.

In Autumn 2005, the newly appointed DATSubstance Misuse Engagement Officer was taskedwith continuing and expanding the DAT’sengagement of the Somali community around khatuse. This coincided with efforts of the police andCommunity Safety Team to maintain trust with the

community following the attempted terroristattacks in London on 21st July 2005. A number ofethnic Somalis were alleged to have been involvedin these attacks and there was a very real concernon the part of the Somali community that theywould be negatively affected by association.Indeed, there had been a number of articles in theLondon and national press over the precedingmonths, increasing after July, which negativelystereotyped Somalis.

In response, a coalition of local Somali communitygroups sought to build better relations with thelocal authorities. For example, an umbrella groupof local groups, London Somali DevelopmentPartnership, organised a community reassurancemeeting in Autumn 2005 that was attended bycommunity members and representatives of theStreatham Town Centre Office, Police, andCommunity Safety Team. Here, communitymembers were keen to disassociate the allegedperpetrators of the 21st July terrorist attacks fromthe Somali community, stressing the fact that thesuspects were in fact Ethiopian Somalis who hadbeen fostered in the UK with non-Somali families.

2.2DEVELOPINGAPPROPRIATE RESPONSESTO KHAT USE

One of the recommendations of the DrugscopeStreatham report was that a Somali outreachworker be employed to provide signposting andreferral advice to khat users. Moreover, a numberof drug and mental health treatment providers inthe borough had expressed an interest inattracting khat-using clients into their services.Previous attempts to do so seem to havefloundered for a number of reasons which will bemore comprehensively addressed in this study,foremost among which were the perception

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2 INTRODUCTION

among Somalis that ‘khat is not a drug’, and thelack of culturally appropriate provision.Following several months of negotiations overautumn and spring 2005-6, a pilot partnershipproject was established between Lambeth DAT,

Fanon Care, London Somali DevelopmentPartnership (LSDP) in Streatham, and East AfricanHealth Concern (EAHC) in Stockwell.The research project workers were based at the Fanon

in order to provide the structured

recognised provider, but would work on a satellite basis at LSDP and EAHC offices in

The project consisted of two strands–, a brief servicedelivery strand focusing on signposting,referral and broad-based health promotion advice and a needs assessment strand, todetermine levels and extent of need and thus themost effective model of service delivery. A dearthof hard data on the Somali community inLambeth, as well as other practicalconsiderations, meant that the latter strand tookprecedence between the summer of 2006 andJanuary 2007.

This report sets out the findings of the needsassessment strand of the Lambeth Khat Project,and makes recommendations for future work bothin terms of treatment services, and also forbroader service provision across all sectors of theLocal Strategic Partnership.

2.3THE SOMALI COMMUNITYIN THE UK – A HISTORICALPERSPECTIVE

In order to understand fully the issues facingLambeth’s Somali community, it is important firstto appreciate the situation of Somalis in the UK.Somalis make up one of the oldest immigrantcommunities in Britain, and arguably form thelargest Somali community in Europe. Somali men,recruited as seamen, began to settle in themaritime centres of England and Wales likeLondon, Cardiff and Liverpool in the latenineteenth century. They were recruited as cheaplabour, and undertook dirty and arduous – andunpopular – work as stokers firing ships’ boilers.These seamen spent long periods at sea and awayfrom home as they worked mostly in what wascalled the ‘tramp steamer trade’ on ships thatsailed from port to port following the availability ofcargo.

Most of these seamen came from what was thenthe British Protectorate of Somaliland. They also

in which they were paid less than the Britishnationals, could only work in the seafaring tradeand could expect to be forcibly removed from thecountry at the end of their contracts. They did nothave any entitlement to domicile rights in Britain,which would have – at least theoretically – giventhem the same rights as Britons.

Despite all these formidable barriers, some Somalismanaged to set up and operate boarding housesthat provided a shelter and refuge for theircountrymen during shore leave or ‘down time’

(Farah 2000). Others moved inland to work at

factories at industrial towns such as Birmingham,

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Centre (Fanon Care)

staff support of a

Streatham and Stockwell.

worked under the protectionist laws passed in 1894,

Sheffield, Derby and Manchester. Considerablenumber of Somali men joined the army and sawactive military service in the First and SecondWorld Wars and even much later in the southernAtlantic conflict of the Falklands. The immigrationout of Somalia took unprecedented proportions inthe late 80s and early 90s, when the politicalsituation exploded into full-scale war in the north and later in the south. This caused mass exodus

This conflict was to last the better part of 15years, until the uneasy peace imposed last year onareas under the respective control of the UN-backed Transitional Government (based in Baidoa)and the Islamic Courts Union (based inMogadishu). Most recently, Ethiopian forcessupporting the Transitional Government, withsome US support, have overthrown the IslamicCourts Union government. Ostensibly, Mogadishuis now under the control of the TransitionalGovernment but it is unclear how firm its grip willcontinue to be without a substantial multi-nationalpeace-keeping force to support it.

2.4LAMBETH’S SOMALICOMMUNITY

The first Somali refugee families settled in LondonBorough of Lambeth in the late 80’s and early90’s, though it was not until the late 90’s thatthere developed a nascent ‘community’ focusedaround Streatham and Stockwell. Indeed, incomparison with other London boroughs,

Lambeth’s Somali population is relatively small –in the order of 3,000-6,000, compared to 7,000-10,000 in Haringey for example. While there aresignificant population clusters in Streatham andStockwell, Somalis live in almost all areas of theborough.

Like all new communities settling in a foreigncountry through circumstances outside theircontrol, Somalis in Lambeth comprise of across section of a displaced population;predominantly families headed by single parentswidowed in the civil war, senior citizens,unaccompanied children and disabled people.Their previous occupations, educationalbackground and lifestyles range from those ofrural nomadic people to urban upper class fromboth private and public sectors. Levels of povertyand social exclusion of the community aresignificantly higher than those found amongstsome other BME groups in the area, for a numberof reasons including language barriers, legalrestrictions on employment, lack of appropriate (orconvertible) skills or training, cultural dislocation,family breakdown, social isolation, racism andislamophobia. Khat use – the object of this study –is commonly cited as another factor that hindersSomalis economically and socially.

Despite the difficult conditions they live in, Somalisin Lambeth (like their compatriots in the SomaliDiaspora in Europe and North America) manage tosupport their relatives back home financially. It isargued that this is necessary as there is noeffective central Government in Somalia and thatthis has resulted in mass unemployment, lack ofbasic services etc. Without the remittancesSomalis abroad send home every month, thehumanitarian crisis in Somali would be far worse.Similarly, there has been a huge attempt by theDiaspora to rebuild their homes damaged in thecivil war, or build new ones in all cities and major

7CHEWING IT OVER

, into neighbouring countries and as far as Europe,

north America and Australia. After the collapse of

warlords holding sways in different parts of the

Siad Barre's regime in Feb 1991, southern part ofthe country descended into clan conflict with

capital and other important cities.

towns in the country. Somali residents in Lambethhave had their share of that toil.

The Hagba or Xawaala (pronounced ‘hawaala’)is an indigenous systems of raising ready cash andmoney transfer mechanisms unique to thecircumstances of the Somali Diaspora, where allconventional methods of bank transactions andpostal services cannot be applied to a countrywith out such institutions. Similar systems operatein other diasporas (e.g. amongst Afghanis andPakistanis), but it is arguable that the importanceof Hagba and Xawaala has underpinned thegrowth of the telecommunications sector both inSomalia and also here in the UK.

Local business start-up for the community inLambeth has taken its first tentative steps in thelast five to ten years or so. At the time of thisresearch there are number of small shops, cafes,restaurants, internet-cum-telephone-cum-moneytransfer cafes (for communication and remittancepurposes to Somalia), and travel agencies inStreatham and Stockwell areas. This enterprisegrowth is encouraging, as the bulk of thesebusinesses took off the ground in the last 5 yearsor so. However, most of these embryonicbusinesses are at this stage largely targetingSomali clientele only, selling Somali cuisines,clothes, money transfer to Somalia etc. Thisreinforces the isolation experienced by thecommunity as well as causing tensions with othercommunities.

Being a predominantly Muslim community and aclosely-knit society inter-connected by extendedfamily relations and kinship, Somalis in Lambethtry hard to maintain their unique cultural identity.To ensure that the Islamic faith and ritualpractices, as well as the Somali languageknowledge, are passed to smaller children,several Malcaamas (Quran and Somali languagesupplementary schools) operate in Lambeth. Ontop of this extra-curricular activity, these weekend

classes also provide social forums for communitycohesion and socialising for children and forparents. In the absence of mainstream funding,parents pay for each child attending thesecommunity schools to pay for teachers’ salaries(although many teach on a voluntary basis), andother essential sundry expenses. To fully augmenttheir commitment to education for theirunderachieving children, some parents also payprivate tutors to provide once-a-week homesupport for their children’s curricular education,and pay up to £20 or £30 a week per child,depending on the number of children beingtutored for a family.

Newly arriving Somali asylum-seekers flow into the pool of other more established ones in Lambeth.These new arrivals nowadays take epic journeyscrossing the Mediterranean Sea in ‘death boats’(as reported by the international media in the lastyear or so), and enter southern Europeancountries like Italy, Malta and Greece. Some ofthese people reach UK, albeit with great difficulty,and seek asylum here. But as a result of racistincidents affecting refugees and asylum seekersthat were scattered through out the country as aresult of the Dispersal Policy practiced by theNational Asylum Support Service (NASS), manyasylum seekers, in fear for their safety, arediscouraged from accepting this dispersal, andremain in Somali populated cluster areas inLondon, mainly staying with friends and relatives.The implications for this can only be imagined notonly for its overcrowding effect on already largehouseholds, but also for its impact on the healthand economy of the host. Thus a situation oftrying to help a relative/friend in need, over time becomes a burden for many residents inLambeth. The Somali community in the UK israted as suffering from a number of tropicaldiseases and other illnesses includingTuberculosis, Malaria, and Stroke etc. (NHScensus 2000)

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2.5KhHAT –CATHA EDULIS – THE‘LEAF OF ALLAH?’3

Khat (Catha edulis, family Celastraceae, Ge’ez č̣ āt;Arabic: qat also known as gat, khat, chat, andmiraa), is a flowering plant native to tropical EastAfrica and the Arabian Peninsula. Believed to haveoriginated in Ethiopia, it is a shrub or small treegrowing to 5–8 m tall, with evergreen leaves 5–10 cm long and 1–4 cm broad. The flowers areproduced on short auxillary cymes 4–8 cm long,each flower small, with five white petals. The fruitis an oblong three-valved capsule containing 1–3 seeds.

Khat contains the alkaloid cathinone, anamphetamine-like stimulant which causesexcitement and euphoria. In 1980, the WorldHealth Organization classified khat as a drug ofabuse that can produce mild to moderatepsychological dependence, and the plant has beentargeted by anti-drug organisations like the DEA.4

The origins of khat are often argued. Many believethat they are Ethiopian in nature, from where itspread to the hillsides of East Africa and Yemen.Others believe that khat originated in Yemen beforespreading to Ethiopia and nearby countries.Richard Burton (1844) explains that khat wasintroduced to the Yemen from Ethiopia in the 15thcentury. There is also evidence to suggest thismay have occurred as early as the 13th century.Through botanical analysis, Revri (1983) supportsthe Yemeni origins of the plant.5 From Ethiopia andYemen the trees spread to Kenya, Somalia,Malawi, Uganda, Tanzania, Arabia, the Congo,what are now Zimbabwe and Zambia, and SouthAfrica.

Khat has been grown for use as a stimulant forcenturies in the Horn of Africa and the ArabianPeninsula, where chewing khat predates the use ofcoffee and is used in a similar social context. Itsfresh leaves and tops are chewed or, less

frequently, dried and consumed as tea, in order toachieve a state of euphoria and stimulation. Dueto the availability of rapid, inexpensive airtransportation, the drug has been reported acrossEurope, North America, and Oceania – essentiallywherever Somali and Yemeni diasporas are to befound. Khat use has traditionally been confined tothe regions where khat is grown, because only thefresh leaves have the desired stimulating effectsand the active ingredients only last for about 3days.. In recent years improved roads, off-roadmotor vehicles and air transport have increasedthe global distribution of this perishablecommodity.

Traditionally, khat has been used as a socialisingdrug, and this is still very much the case inYemen, Somalia, and Ethiopia where khat-chewingis a predominantly male habit. It is mainly arecreational drug in the countries which grow khat,though it may also be used by farmers andlabourers for reducing physical fatigue and bydrivers and students for improving attention.

Khat is used for its mild euphoric and stimulatingeffects. In Yemen it is so popular that 40% of thecountry’s water supply goes towards irrigating it,with the percentage increasing by about 10% to15% every year.6 [The water supply of Sana'a is sothreatened by the crop that government officialshave even proposed relocating large portions ofthe city's population to the coast of the Red Sea.

In Somalia, the Islamic Courts Union (or ICU),which took control of much of the country in2006, banned khat during Ramadan, sparkingstreet protests in Kismayo town. In November 2006,Kenya banned all flights to Somalia, citing securityconcerns, prompting protests by Kenyan khatgrowers. The Kenyan MP from Ntonyiri, MeruNorth District stated that local land had beenspecialised in khat cultivation, that 20 tons worthUS$ 800,000 were shipped to Somalia daily andthat a flight ban could devastate the local

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economy.7 With the surprise victory of theProvisional Government backed by Ethiopianforces in the end of December 2006, khat hasreturned to the streets of Mogadishu, thoughKenyan traders have noted demand has not yetreturned to pre-ban levels.

2.6EFFECTS OF KHAT ON USERS

Khat consumption induces mild euphoria andexcitement. Individuals become very talkativeunder the influence of the drug and may appear tobe unrealistic and emotionally unstable. Khat caninduce manic behaviours and hyperactivity. Khat isan effective anorectic and its use also results inconstipation. Dilated pupils (mydriasis), which areprominent during khat consumption, reflect thesympathomimetic effects of the drug, which arealso reflected in increased heart rate and bloodpressure. A state of drowsy hallucinations(hypnagogic hallucinations) may result comingdown from khat use as well. Withdrawal symptomsthat may follow prolonged khat use includelethargy, mild depression, nightmares, and slighttremor. Long-term use can precipitate thefollowing effects: negative impact on liverfunction, permanent tooth darkening (of agreenish tinge), susceptibility to ulcers, anddiminished sex drive. Khat is usually not anaddictive drug, although there are some peoplewho cannot stay without it for more than 4-5days. They feel tired and have difficultyconcentrating.8 However, a recent House ofCommons study study found khat to be lessdangerous than tobacco and alcohol.9

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The needs assessment was conceived of as a mixed methodology study which comprisedquantitative and qualitative elements. This wasimportant if the study was to capture both themodalities of khat use in Lambeth and the extent ofuse.10 A steering group was set up at the start ofthe project to provide strategic oversight aroundboth the service delivery and needs assessmentstrands of the project. This was composed of theresearch team, DAT and Community Safety staff,and representatives from FanonCare, LSDP andEAHC staff, the police, and other health providers.

The quantitative element was guided byepidemiological approaches including direct andindirect estimation of prevalence. A shortquestionnaire aimed at members of Lambeth’sSomali community was developed with theassistance of the steering group, which could becompleted by respondents on their own or withassistance from project workers and volunteers.The questionnaire collected basic demographicdata, information on respondents’ use of khat andother drugs, attitudes to drug use, andexperiences of khat use (direct and indirect).Questionnaire sampling was done a quasi-randomand opportunistic basis at a range of locations inthe borough including marfeshes, communityorganisations, mosques, and even people’shomes.

Qualitative data was collected through a numberof focus groups and one-to-one interviews withcommunity members, as well elite stakeholderinterviews with professionals involved in thehealth field locally. Attempts were also made tomap the number of marfeshes (khat houses)operating in Lambeth and engage with theowners.

3.1LITERATURE REVIEW

Khat use is not an under-researched area – in thewords of a former UNICEF country director forSomalia, “there has almost been too muchresearch done on khat.”11 The research teamconducted a comprehensive literature review,drawing on work done in the UK and worldwide, tolook at the implications of khat use for physical andmental health, access to services, and models oftreatment/intervention, as well as the broadersocio-cultural impacts.

There is disagreement in the literature around thehealth impacts of khat use, especially in terms ofmental health problems linked to khat use. Anumber of studies have shown evidence of khatuse being linked to a range of mental healthconditions ranging from paranoia to psychoticepisodes.12 This is a somewhat controversial (orcontroversialised) subject. Most of these studieswere conducted on very small sample of userswho were almost all already within treatmentservices. However, as Warfa (2006) points out,there is no evidence of any causal link betweenkhat-use and mental ill-health, and in this sensethe debate closely mirrors that surroundingcannabis, and especially ‘skunk’ use.

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3 METHODOLOGY

3.2RESEARCH ETHICS ANDCONFIDENTIALITY

Previous experience of the research team, andother studies done on khat use, showed thatensuring complete confidentiality was crucial ifrepresentative data were to be collected. Allrespondents were informed that any informationthey gave would be treated in the strictestconfidence, and would be used by the researchteam only for the purposes of this study.Respondents were asked to give their consent toparticipating in the research, either by means of atick-box on the questionnaire or verbally in thecase of focus groups and interviews. Moreover,data collected were stored in secure locationsduring the course of the project, and will bedestroyed at the end of the needs assessmentphase of the project.

3.3QUANTITATIVE NEEDSASSESSMENT

To assess the magnitude of health and otherproblems related to drug use, and to plan theservices needed to address these, an estimate ofthe total number of drug users in the population isrequired. The prevalence of drug use is normallyexpressed as the number of users per 1000 headof population, aged 15 – 44 years. However,researching khat use differs somewhat fromresearch into other drugs for a number of reasons.Firstly, there is no systematic collection of data onkhat use as there is for other drugs, and commonindicators such as the number of drug-relateddeaths do not apply. Similarly, treatment data fromservices submitted as part of NDTMS (NationalDrug Treatment Misuse Service), or data on crime(e.g. British Crime Survey) do not report khat use,directly or indirectly.

Secondly, there is a real lack of quantitative dataon Somali communities in the UK, and in Lambethspecifically. This situation is further complicatedby issues of under-reporting; many Somalis areeither unable or unwilling to participate in surveyssuch as the national census, and subsequentlythere is a significant ‘invisible’ population. Thirdly,there is a widespread distrust within somesections of the Somali community about being‘researched’ – where will such information go,who will have access to it, and what will it beused for, are not uncommon concerns.

Data sources consulted by the research teamincluded a national study of khat use in four Britishcities carried out by the Home Office and TurningPoint, two small-scale local needs assessmentsexamining drug use in African communitiescarried out by UCLAN/ACCHRO and East AfricanHealth Concern, as well as the aforementionedDrugscope report, and research carried out byUCLAN on khat use in Brent, Haringey, Greenwich,and Harrow.

3.4PREVALENCE ESTIMATION

Estimating the prevalence of any drug use usingpopulation surveys is problematic, due to its legalstatus, underground nature, and social taboosregarding most forms of drug use. This limits theuse of direct estimation methods such asextrapolation from national surveys, andconsequently indirect methods are more effective.

There are two main methods for estimating‘hidden’ populations. Multiplier methods take dataon numbers of users in contact with a given datasource (a ‘benchmark’) and using the proportionof users given in the data source it is possible toderive an estimate of the total population.Capture-recapture methods (CRM) involve using

CHEWING IT OVER12

two or more data sources to analyse the overlapbetween the data sets in order to estimate whatproportion of the population is observed, andthereby derive an estimate of the total populationfrom this.13 CRM has been widely used in the fields of drug misuse, in epidemiological estimates andin animal ecology studies.14 Both methods havetheir limitations in this context, not least thepaucity of data on Somali populations in the UKmentioned above.

3.5MULTIPLIER METHODS

An estimation of the total number of khat userswas obtained by applying an estimated multiplier(prevalence of khat use in Lambeth’s Somalicommunity) derived from the questionnaire datato the estimated Somali population in Lambeth. Anapproximate ‘benchmark’ was calculated as meanof the rates of prevalence of khat use from thesesources and applied to the estimated Somalipopulation in Lambeth. This benchmark wasfurther compared with prevalence estimatesderived from the national, regional, and local datasources given above.

3.6CAPTURE-RECAPTUREMETHODOLOGY (CRM)

Normally, overlapping lists of users collected fromdifferent sources would be used to undertakeCRM. In the absence of such lists, a pared-downor ‘internalised’ version of CRM was adapted forthe purposes of the study.15 Questionnaires weredistributed across a number of different sitesacross the borough, distributed bothgeographically and in terms of different venue;

each questionnaire was individually coded toreflect this. Respondents were not allowed tocomplete more than one questionnaire. Theresulting ‘sub-samples’ were then tested andadjusted for variance by combining two samplesand comparing prevalence rates; by estimatingdifferent combinations of two-by-two samples;and by log-linear regression analysis (i.e. findingthe simplest model with the best fit). Whileapplying CRM methods in this context was notunproblematic, this enabled researchers to testthe distribution of khat users to non-khat usersacross the different ‘sub-samples’ and ascertain amore accurate estimate of prevalence.

3.7QUALITATIVE NEEDSASSESSMENT

The research team identified key groups withinthe Somali community for qualitative assessmentby focus groups: young people, men, women,older men and women, and Somali religiousleaders. A short list of questions or prompts weredeveloped and piloted. Focus groups werecomposed of between 5 and 10 people and lastedno more than one hour. Additionally, a number ofsemi-structured one-to-one interviews wereconducted with khat users, community membersinvolved in the health or mental health fields,health professionals, and marfesh owners.

In both the focus groups and the interviews,respondents were asked permission for sessionsto be recorded to facilitate data collection; inalmost all cases, however, this permission wasrefused, for fear of confidentiality being breached.This forced researchers to rely on written notes,which obviously impacted the amount and qualityof data collected. Data from focus groups andinterviews was analysed thematically and bycontent analysis.

13CHEWING IT OVER

Finally, information was sought from other Londonboroughs doing work on khat use, and in particularareas where there are projects working to addressproblematic use of khat, to determine what modelsof care already existed around khat use, and whatlevels of service provision there are.

3.8YOUNG PEOPLE’SVOLUNTEERING STRAND

By November 2006 it was becoming evident thatthere were a number of barriers to researcherscollecting data on young people. In order toaddress this, and as part of the DAT’s commitmentto engaging young Somalis around substancemisuse, a volunteering scheme was established inpartnership with Somali Centre for Informationand Advocacy (SOCFIA). Eight young Somalis, aged15-18, were recruited to work as volunteerresearchers, and provided with basic training insubstance misuse issues and data collection bythe DAT Community Engagement Officer and KofiAsante from the Drug Education Department. Theywere then tasked with collecting data from theirpeers using questionnaires, interviews and focusgroups. Although due to practical considerationsno focus groups could be carried out, a significantnumber of questionnaires and interviews werecompleted.

CHEWING IT OVER14

4.1 QUANTITATIVE DATA –RESULTS FROMQUESTIONNAIRES

Results from questionnaires given in this sectionare given thematically, in line with the differentsections of the questionnaire. A total of 354questionnaires were collected, a considerableachievement given the difficulties of research inthis area. However, prevalence rates arediscussed first as these are in some ways themost problematic aspect of the data collected.

4.2PREVALENCE ESTIMATION

272 respondents cited regular use of khat on atleast a weekly basis, i.e. 77% of the total samplesize. Note that this does not include those whomay use khat on a less regular basis (e.g. monthly,or on special occasions) – something highlightedin some interviews. If we exclude khat-usingrespondents who are not Lambeth residents (23respondents), this figure drops to 76%. It shouldalso be noted that there was no appreciabledifference between the prevalence rates amongmen (76%) and women (75%), although menmade up roughly two thirds of the total sample.Although there is plenty of anecdotal evidence forthe use of khat by women, this is significant in asmuch as this is the first time such data has beencollected in a UK study.

Similarly, khat use was fairly consistent acrossdifferent age sets. The highest rates of khat usewere found among those aged 21-25 and 31-35(84% and 82% respectively); the lowest amongthose aged 26-30 and 46+ (64% and 55%). Khat use by the 16-20 age group was higher thananticipated at 83%.

4.3IMPLICATIONS OFPREVALENCE ESTIMATIONFOR TOTAL POPULATIONSIZE

According to the 2001 Census, there were 982individuals resident in Lambeth who were born inSomalia. However, this is certainly a significantunder-estimate, as the Census does not recordSomali ethnicity, in addition to the problems ofunder-reporting noted above.

Data on school registrations gathered by Demie’sresearch on educational under-achievementamong Somali and Portuguese pupils in Lambethshows that the number of Somali pupils hasgrown between 2001 and 2005 fromapproximately 500 to 900 pupils.16 Whilst thisexcludes Somali pupils who attend schoolsoutside Lambeth, this gives an indication of therate of growth in the size of the Somali communityin the borough, i.e. roughly 180%.

If we factor in a 10% rate of under-reporting – aconservative estimate derived from thepercentage of questionnaire respondents whowere not British citizens or who had not beengranted Exceptional or Indefinite Leave to Remain(ELR/ILR) by the Home Office – this indicates thatthe Somali population in Lambeth is at least 2000.If we assume that two-thirds of these are aged15-44, direct estimation of the prevalence of khatuse by multiplier methods suggests that there areapproximately 1140 regular khat users inLambeth’s Somali community.

Despite the attempts to obviate sample bias, it ispossible that the prevalence estimate of 76% isslightly inflated. Using a linear-log progressionmodel (best-fit) suggests a prevalence of 68%,which still suggests a using population of at least1000 individuals. However, when we compare the

15CHEWING IT OVER

4 RESULTS

prevalence estimates generated by this study withother UK studies, another picture emerges. Basedon six studies carried out nationally, regionally,

and locally, a mean prevalence rate wasestablished of 42% (Table 1).

Supposing that the Somali population aged 16+ is1500 individuals (a1), then this study (a2) sampled24% of this figure. If b=24%, and a3= the numberof Lambeth-resident khat users sampled (249), andc= the extrapolated number of Somalis aged 16+of which a3 is 42%, i.e. 1500x 0.42= 593, thenthe total number of Somalis aged 16+ is likely tobe c/b= 2471. If we assume that Somalis under16 make up a quarter of the total population, thissuggests that the total Somali population ofLambeth is approximately 3088 people.

Even if the prevalence rate is between 42 and68% (a significant disparity), it is reasonable to

assume that the khat using Somali population is atleast one thousand individuals, and the totalSomali population of the borough is at least 3000.It should also be stressed that the assumptionsunderpinning these calculations have been madeas conservative as possible, and it is probable thatthe actual number of Somalis living in Lambeth –and the number regularly using khat – is stillsignificantly higher than this.

CHEWING IT OVER16

Prevalence of khat

use in other UK

studies

HomeOffice/TP

UCLANHaringey

UCLANBrent

UCLANLambethA

UCLANLambethB

EAHCLambeth

60

44

77

18

30

27

42 630

(405 – 1115)

Questionnaire

sub-samples,

adjusted by linear-log

regression model

Stockwell

Streatham

Norwood

Brixton

Kennington

63

77

60

72

68

68 1020

(945 – 1115)

TABLE 1: INDIRECT PREVALENCE ESTIMATES FOR LAMBETH USING MULTIPLIERAND CAPTURE-RECAPTURE METHODS (CRM)

Indicator Data source Rate per Mean rate Overall100a per 100a estimate (range)

a Lambeth Somali population 16+ = 1500

4.4DEMOGRAPHICS

This section details the basic demographic datacollected from respondents. Unless statedotherwise, all percentages given are of the totalsample (i.e. n=354)

AGE (Figure 2) – The over representation of 16-20 year olds within the total sample can beattributed to the introduction of the young people’svolunteering scheme relatively late in the projectto ensure data on this group were collected

GENDER – 63% of those sampled were male,while women made up 37% of the total.There areconsiderable barriers to sampling women as partof any survey into taboo areas like drugs. This isthe largest number of women sampled in any UKstudy of Somali communities.

DISABILITY – Levels of disability aregenerally in line with, or slightly higher than,disability in the general population. 10% of thesample stated they were disabled. Disabilitiesspecified included blindness, deafness, lack of mobility, and diabetes. Data collected on Muslim communities in Lambeth (24% can beconsidered disabled) suggests sample bias maybe an issue here.

AREA OF RESIDENCE (Figure 3) –Although there are obviously population centresfor Lambeth’s Somali community in Stockwell andStreatham, Somalis live throughout the borough.

LANGUAGE AND LITERACY (Figure 4) –Somali and English were the main languagesspoken and written. Literacy levels of respondents(59% for English and 80% for Somali) were higherthan expected, in comparison with other Londonstudies. There was little disparity betweengenders around language and literacy. Otherlanguages mentioned included Kiswahili, French, Russian, Dutch, Finnish, and Swedish.

17CHEWING IT OVER

FIGURE 2: AGE OF RESPONDENTS

0

20

40

60

80

100

16-20 21-25 26-30 31-36 37-45 46+

No o

f Res

pond

ents

Age in Years

FIGURE 3: AREA OF RESIDENCE

Streatham 25%

Outside Lambeth 8%

Clapham & Stockwell 27%

Brixton 20%

Norwood10%

Kenington10%

FIGURE 4: LANGUAGE AND LITERACY

No o

f Res

pond

ents

0

50

100

150

200

250

300

350

English Somali Arabic Italian Other

Written

Spoken

LANGUAGE AND LITERACY BYGENDER (%)

English English Somali Somali spoken written spoken written

Males 79 85 97 87

Females 72 80 99 79

There was also a clear correlation between age andlevels of literacy, primarily in terms of English.Predictably, the younger a respondent was, the morelikely they were to speak and read English. Note thatthe questionnaire did not differentiate betweendifferent levels of spoken and written language

EDUCATION (Figure 5) – A high proportion of thesample were educated to degree level and above. Thisis consistent with other new communities from east Africa.

EMPLOYMENT STATUS (Figure 6.)-Unemployment levels were high (42%), but not as highas suggested by some other studies of Somalicommunities in London (e.g. 80% in Brent).17 Womenwere roughly twice as likely to be unemployed than infull-time employment.

HOUSING (Figure 7) – Most respondents wereeither council tenants or renting with private landlords.A surprisingly high proportion of the sample (20%) wasliving in short-term accommodation. Note that ‘livingwith friends/family’ is also likely to include a numberof ‘hidden homeless’.

MARITAL STATUS – The proportion of singlerespondents would have been significantly lower hadthere been fewer respondents aged 16-20.

Marital Status % of RespondentsSingle 33Married 40Widowed 5Separated 5Divorced 17

CHEWING IT OVER18

FIGURE 5: EDUCATION

Primary 5%

No formal education 19%

Secondary 30%Higher Ed 46%

FIGURE 6: EMPLOYMENT STATUS

F/T 16%

Other 1%

P/T 14%

Unemployed 42%

Student 23%

Self employed 4%

FIGURE 7: HOUSING

TempAccommodation5%

NFA 7%

Living with friends/family 28%

Tenant 45%

Own House 7%

Hostel 8%

LEGAL STATUS (Figure 8) – The majority ofrespondents had residency rights within the UK. Nearly40% had been granted leave to remain as refugees –slightly less than the proportion of British citizens.Some respondents citing ‘Other’ will have beengranted some sort of residency in other EU states;others will have no legal rights to reside in the UK. Asignificant proportion chose not to answer thisquestion.

4.5PATTERNS OF KHAT USE

PREFERRED PLACE OF KHAT USE (Figure9) – Most users chewed khat either with friends athome or in marfeshes. Women did not generally usemarfeshes, although there is apparently a women-onlymarfesh in Lambeth. A small number of users chewedkhat in their vehicles – suggesting they worked asdrivers of some variety.

AMOUNT CHEWED PER SESSION – Mostmale users (40%) chewed 4-5 bundles of khat in eachkhat ‘session’ (n=272); women generally chewed lessthan men. Roughly the same proportion of male tofemale users chewed more than 5 bundles per session(14% of the using sample as an aggregate). There wasa also a clear linkage between age and amountchewed per session. Those aged 30-45 used the moston a sessional basis, although the 16-20 age groupalso showed quite high levels (roughly 40% of thesechewed 4-5 bundles per session).

AVERAGE WEEKLY EXPENDITURE ON KHAT (Figures 10-11) – Male users spent moreon average than female users, as might be expectedfrom the amounts used show above. The highestlevels of expenditure were among the young andmiddle-aged. There was a clear correlation betweenexpenditure and employment status; those who spentthe most were the unemployed. As might have beenexpected, this group also spent the most sessionschewing khat each week.

19CHEWING IT OVER

FIGURE 8: LEGAL STATUS

Other 6%

Exceptional leave to remain 7%

Indefinite leaveto remain 23%

BritishCitizen 42%

No response 13%

FIGURE 9: PREFERRED PLACE OF KHAT USE

F

M

Tota

0

50

100

150

200

No o

f Res

pond

ents

With fri

ends

With fa

milyAlon

e

Marfes

hes

Work Car

FIGURE 10: AVERAGE WEEKLY EXPENDITURE

0

40

60

80

100

140

20

120

160

£3-10 £11-20 £21-30 >£30

F

M

Total

No o

f Res

pond

ents

AVERAGE LENGTH OF SESSIONS(Figure 12) – Session length varied according to age,gender, and employment. Female users spent lessthan half the amount of time on each session thanmales. The longest sessions were among the young,the unemployed, and those aged 30-45.

STARTING TO CHEW – Most users (justunder 45%) started using khat before the age of 20,and many were under 16. Users were most oftenintroduced to khat by friends; users were roughly aslikely to start of their own accord as to be introducedby family members

4.6HEALTH AND OTHERIMPACTS OF KHAT USE

Figure 13 – Users cited a wide range of effects onhealth from using khat. Most common were sleepdisorders and paranoia, followed by constipation,loss of appetite, and hallucinations. Note therelatively low levels of reporting for mental healthand sexual health issues. This is in line with stigmasattached to both types of issue. However, it shouldbe noted that sleep disorders, paranoia, andhallucinations can all be considered as symptoms ofmental ill-health.

PROBLEMATIC EXPERIENCES OFKHAT USE (Figure 14) – The total sample reported

a range of problematic experiences of khat use (theirown or that of others). Financial difficulties were themost common, as were negative impacts on health,employment, and education. Respondents citingexperience of domestic violence was higher perhapsthan expected; note also the disparity between maleand female respondents in this area. This is arguablyattributable to stigmas surrounding reportingdomestic violence by women.

CHEWING IT OVER20

0

10

20

30

40

50

60

70

80

£11-20

£3-10

£21-30

>£30

FT PT

Unemplo

yed

Stude

nt

Self-e

mploye

d

FIGURE 11: AVERAGE WEEKLYEXPENDITURE BY EMPLOYMENT

Sleep

diso

rders

0

20

60

80

100

140

40

120

No o

f Res

pond

ents

Oral pr

oblem

s

Cons

tipati

on

Loss

of ap

petite

Halluc

inatio

ns

Heart p

roblem

s

Paran

oia

MH prob

lems

Sexu

al he

alth issu

es

F

M

Total

FIGURE 13: EFFECTS ON HEALTH

0

20

40

60

80

100

120

No o

f Res

pond

ents

1-3 hrs 3-5 hrs 5-8 hrs 9 hrs

F

M

Total

No o

f Res

pond

ent s

FIGURE 12: AVERAGE LENGTH OF SESSION

KHAT USE AND SMOKING – More thanhalf of respondents said they regularly smokedcigarettes or other forms of tobacco (e.g.shisha) when they used khat. The proportion ofsmokers to non-smokers was roughlyequivalent between male and female users.

4.7ATTITUDES TO KHAT USE

Respondents reported almost uniformlynegative effects of their khat use acrossdifferent areas of their lives, with the exceptionof the contribution to social life which wasvalued positively. Women were twice as likelyto consider the impact of khat use on their sociallife as a positive thing than men.The majority ofrespondents considered khat use to be anindividual problem (40%) or a problem forfamily and friends (47%). Only 12% ofrespondents described it to be a ‘drugmenace’; surprisingly, fewer still consideredkhat to be a cultural practice only.

4.8KNOWLEDGE/ATTITUDESTO OTHER DRUGS;POLYDRUG USE

Broadly speaking, levels of knowledge aboutdifferent types of drug were relatively low.Cannabis and alcohol were the most well-known (49% and 45% respectively), followedby cocaine (44%). Women were 3 to 4 timesless likely than men to claim some knowledgeof different drugs.

Fig. 15 – As might have been expected, mostpolydrug use reported was the use of cannabisand/or alcohol with khat. The 16-20 age setwere the most susceptible to polydrug use.

21CHEWING IT OVER

FIGURE 14: PROBLEMS EXPERIENCED BY USERS

0

50

100

150

200

250

No o

f Res

pond

ents

Finan

cial d

ifficu

ltyHea

lth

Emplo

ymen

t

Educ

ation

Mental

healt

h

Sexu

al he

alth

Crime

Violen

ce in

the h

ome

Violen

ce ou

tside

the h

ome

No res

pons

e

FIGURE 15: POLYDRUG USE

No o

f Res

pond

ents

0

10

20

30

40

25

35

25

15

5

No

Alcoho

l

Cann

abis

Heroin All

Yes b

ut dru

gCri

me

21-25

16-20

26-30

not s

tated

31-36

37-4546+

F

M

Total

0

40

60

80

120

140

20

100

GP

Frien

ds/fa

mily

Mosque

Spec

ialist

khat

serv

ice

Would

not s

eek h

elpOthe

r

F

M

Total

4.9ACCESSING TREATMENTAND OTHER SERVICES

Fig. 16 – There was a clear preference amongusers for accessing help from a specialist khatservice. It is significant that male users were aslikely to access help from a mosque for their khatuse than from their GP. Women were even lesslikely to access mainstream services for help withtheir khat use. Note that khat users are unlikely toapproach religious leaders for help or advicearound khat use directly; they are more likely toseek help for related concerns

Giving Up Khat – over half of respondents hadthought about or tried quitting khat at least once.Slightly fewer had tried more than once than hadtried to give up on just one occasion. The highestproportion of users (28%) had never consideredgiving up.

ACCESSING HELP AND SUPPORT

Fig.18 – Of the total sample, GPs scored highly foraccessing help with khat use. However, womenwere far less likely to seek help from a GP orhospital, and most likely to seek help from aspecialist khat service. This suggests that stigmaand fears about confidentiality being breached areactive barriers to women accessing services forhelp with khat use, either their own or someoneelse’s.

CHEWING IT OVER22

FIGURE 16: PREFERRED SOURCEOF HELP

0

20

40

60

80

10090

70

50

30

10

No o

f Res

pond

ents

Frien

dFa

mily GP

Hospit

al

Mosqu

e

Commun

ity Org

Spec

ialist

at se

rvice

Other

F

M

Total

No o

f Res

pond

ents

FIGURE 18: PREFERRED ACCESSPOINT FOR HELP

Kh

5.1QUALITATIVE DATA

A total of 6 focus groups were carried out by studyproject workers and volunteers, covering differentsubsections of the community: male khat users,male non-khat users, female users and non-users;elders; religious leaders, each made up ofbetween 4 and 8 participants. In addition to this16 semi-structured stakeholder interviews werecarried out, including an ex-khat user, a Somalimedical doctor, a former marfesh owner, a publichealth professional, a community leader, a mentalhealth worker attached to a communityorganisation, a psychiatrist working in a mentalhealth hospital, a religious leader, two femaleusers, a female non-user, and 5 young people.

A significant barrier to collecting qualitative datawas a widespread reluctance on the part ofparticipants to have their views recorded, despitereassurances about confidentiality. This meantthat researchers had to take notes by hand,supplementing these with memory wherenecessary, and inevitably led to a degree ofinconsistency between interviews.

Participants were asked a standard set ofquestions that covered attitudes to khat use,general concerns within the community, andattitudes to services in Lambeth (see appendices1 and 2 for samples). Results from focus groupsand interviews are here presented thematically.

5.2GENERAL CONCERNS

“You become cut off from the rest of society.You will only be best friends with your friendsat the marfesh but there is no way you can bepart of wider society… Our circle of lifebecomes getting benefits and chewing” (MALE USER/FORMER MARFESH OWNER, 30S)

Khat use was by far the greatest concern across allthe different groups, users and non-users,professionals and non-professionals. This concernwas articulated in different ways by individuals,with some respondents highlighting its negativeimpact on employment and education, othersstressing the financial drain it imposed onindividuals and families, while others still worriedabout the effects of khat on health and mentalhealth.

“They learn English here, but not the sort ofEnglish that will help them find good jobs.”(MALE ELDER)

Young people were identified as the secondgreatest issue of concern among respondents.Older community members worried about youngpeople dropping out of school, and gettinginvolved in drug use and gangs. Particularemphasis was placed on their interaction with theeducation system. Many felt that more supportwas needed to help bridge the gap betweeneducational experiences outside the UK and theBritish system. Concern was also shown abouteducational standards. Of the young peoplethemselves, over half felt threatened living inLambeth, either from other young people or thepolice. Islamophobia was cited by several youngwomen as an issue in this regard.

“We have many graduates, but we are not[adequately] represented in the workforce”(MALE USER, 30S)

“Although we have a large community in Lambeth we do not still have anyrepresentation in most services or service providers” (FEMALE NON-USER, 20S)

23CHEWING IT OVER

5 RESULTS FROMQUALITATIVE SAMPLING

The existence of barriers for Somalis in Lambeth –real and perceived – to accessing training andemployment opportunities, and to accessingservices – was a major issue for respondents. Acommon observation among participants was thatthere were no Somalis working for the council, asopposed to other communities. One communityworker framed the problem thus: “we encouragepeople to apply for jobs that they do not get. Thisfeeds the perception that these jobs are ‘not forthem’ and so when there are jobs available theydo not apply.” Transferability of skills andqualifications was identified as an issue in thisregard, as was language skills. Combined with alack of ESOL provision, this underscored themultiple barriers Somalis in Lambeth face in termsof finding employment.

“Users spend too much time at the marfesh,and this puts severe pressure on families andmarriages…it can be like having anotherperson to look after” (FEMALE ELDER, 50S)

Women and families (and the impact of khat onthis) was a significant worry for manyrespondents, male and female. A commonperception was that the traditional family modelwas under severe pressure; cultural dislocationand isolation was leading to the breakdown offamilies. Use of khat by women was seen by manyas a response to this.

Additionally, the cost of khat use on families wasunderstood in economic and emotional terms –not only was there less money available to spendon family needs, but use of khat by both sexesplaced greater emotional pressures on carers anddependents. In the words of one respondent:

“One of my biggest concerns with khat at themoment is, the man loses his role as a father.He will be no good for himself either. Thus thefamily breaks down. The mother thenstruggles to bring up her children on top ofher other social problems. She may then turnto khat use. She will then be unable to copewith all her motherly duties. That is how khat isdestroying our family and social fabric.” (MALE NON-USER, 40S)

5.3ATTITUDES TO KHAT USE“My biggest concern is the Somali singlemothers coping with life on their own with thechildren and mostly cultural and languageproblems being the usual obstacles. It is easyfor them to take up the khat habit” (MALE NON-USER, 30S)

Respondents were divided over their attitudes tokhat use. Users generally felt that it was animportant cultural practice that helped reinforceSomali identity and which performed a functionnot unlike alcohol for other communities: khat wasseen as a source of relaxation and release fromstress, as well as providing an opportunity forsocialising and social bonding. By contrast, non-users felt that khat use was actively holding backthe Somali community in Lambeth as it was eitherresponsible for, or reinforced, the problems facingindividuals and families.

“I used to chew khat back home and it affectspeople in different ways. It is more of aproblem now than it was in Somalia. Herepeople almost forget their families once theybecome addicted to khat, so it affects familylife greatly. It puts off some people from goingto work or study. It also prevents others fromperforming their prayers because they arebusy in chewing khat.” (MALE USER, 30S)

CHEWING IT OVER24

There was consensus, however, around the factthat the problems attributed to khat were related tochanged patterns of use. A number of users andnon-users contrasted the way in which khat was‘traditionally’ used in the Horn of Africa withcurrent patterns of use in London.18 A lack ofemployment or other activities meant thatchewing sessions were longer, and more khat waschewed, which exacerbated the problemsassociated with khat use.

“I use it to socialise with my friends. Wecannot go to the pub or clubs. This helps usde-stress after the week.” (FEMALE USER, 20S)

The use of khat by women forms a good exampleof this process. Female khat use is heavilystigmatised in Somalia (although much khat is soldby women) and is quite rare. In the UK however,increasing numbers of Somali women are taking itup. Respondents explained this change in terms ofthe changing position women find themselves inhere in London. Many women came to the UKalone, or have ended up being single parents dueto marriage breakdowns.

Although arguably there are greater opportunitiesfor women in London, feelings of isolation,language barriers, and a shortage of appropriateactivities actually limit what Somali women feelthey can do. Khat use thus offers an opportunity forsocial bonding and group support that does notexist elsewhere. Because of the stigma associatedwith female khat use, women generally do not goto marfeshes; they chew with friends at home.Several female respondents spoke of hiding theirkhat use from the wider community. Moreover, asthey are often primary care-givers, khat use bywomen could potentially have a greater impact onfamily life than that of men. According to onefemale user, “one of my [female] friends is aheavy khat user; she is up till four or five in themorning every night, and when she can’t get up in

the mornings the children don’t get taken toschool.”

The picture regarding use of khat by young peoplewas somewhat contradictory. On the one hand,many of the young people interviewed said thatkhat was something that only the elder generationdid. On the other hand, participants across allgroups agreed that the age of starting is usuallybetween the ages of 16-18 but these days wasgetting lower, citing instances where children asyoung as eleven had been seen chewing. Thosewith family history of khat were seen as more likelyto chew khat. Some felt that nowadays khat hasbecome a fashion for many young people and thisgives them higher status within their peers. Othersknew of young people who dropped out of schoolwho started chewing khat or taking drugs liecannabis out of boredom and frustration. Whatwas clear was the young people were using khat,and that this was perceived as preferable to theirusing other drugs common amongst their non-Somali peers at school.

All users that took part in focus groups felt thatchewing khat was relaxing and a form of release. Itwas seen as an escape from life’s problems, aswell as helping users relate to their friends.Participants also saw its role as a social lubricantas important in brokering consensus, citing asaying used when people have a difficult issue toresolve, “let us chew for it”. Most felt that khat usediscouraged Somalis from drug and alcohol use,which would lead to increased levels of crime andviolence within the community. Some consideredthat it occupied unemployed people’s time in aharmless way, preventing their involvement incrime.

25CHEWING IT OVER

5.4KHAT AND HEALTH

A wide range of physical health effects were citedby focus group participants and interviewees,including lack of appetite, oral health, insomnia.Some felt that despite this many chose to believethat it helped many common illnesses. Forexample, one user described how he felt it helpedhis diabetes.

Insomnia was highlighted as the most commoneffect and one of the most difficult to contendwith. Some users would be up so late that theywould have to keep themselves awake to attendappointments (e.g. at a GP’s surgery or benefitsoffice) the next day, before collapsing asleepafterwards. One user, a van driver, spoke of usingkhat as a stimulant but that when ‘khat-time’ (ieearly evening) came, he would feel unable to workany longer. The culture of marfeshes – which areoften open twenty-four hours a day, was seen toreinforce patterns of insomnia, and it was notunknown – if unusual – for users to be awake fortwenty-four to forty-eight hour periods.

As an appetite depressant, khat was linked by afew respondents to poor nutrition and weakenedimmune systems. One user spoke of living on abowl of pasta and a pint of milk a day. Conversely,several users noted the way in which khat usecauses constipation, which could be so severe asto require medical treatment. In the word of onerespondent:

“I witnessed a friend whose belly has swollenas nothing was coming out for two weeksbecause of constipation caused by khat. It wasvery uncomfortable and distressing for him.We then had to take him to hospital. He had tobe given oral and rectal medicine whichcleared all his stomach after a few hours”(MALE USER, 30S)

Participants also drew attention to oral healthproblems such as cuts and abrasions to gums andcheeks; several suggested users would only visitthe doctor or dentist if the condition becamesevere. Tooth decay was further exacerbated bythe prolonged use of sugary drinks like sweet teaand fizzy soft drinks to compensate for thedryness and bitter taste of khat. It was suggestedthat this was likely to cause problems withdiabetes for older users.

Two Somali doctors who were interviewedassociated khat with hypertension and stress. Bothargued that the linkage was complex because khatuse was in many ways a response to, and acoping mechanism for, stress; yet at the sametime using a stimulant like khat increased stresslevels. One likened this to nicotine for smokers,who think it is reducing their stress levels when itis actually having the opposite effect.

Both users and health professionals referred tothe role of tobacco in khat use. Even those who didnot normally smoke would often smoke cigarettesas part of a chewing session, often in poorlyventilated areas. Of particular concern to healthprofessionals interviewed was the potential undersuch conditions for spreading tuberculosis.Although no users themselves admitted tosuffering (or having suffered) from tuberculosis, itwas pointed out by several that rates of the illnessare highest in the UK among newly arrived,predominantly African, groups.

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5.5KHAT AND SEXUAL HEALTH

Participants agreed that a common perceptionwithin the community was that it has a Viagra-likeeffect, but that this was a myth. Some reportedgreater sensitivity and feeling but agreed that thisdid not translate into an ability to ‘perform’sexually. One estimated that three-quarters ofusers he knew had low libidos. Anothercommented:

“In my view khat misuse damages the chewer’ssex life whether they are married or not. I usekhat myself and I know for a fact that is true of80% of men chewers. Some people say that itincreases the sexual drive but I think that isjust a false drive” (MALE USER, 40S)

Similar attitudes were also found among somewomen, who blamed this aspect of khat use as afactor in marriage breakdowns, although onefemale respondent said that she found using khatactually improved her sex life.

5.6KHAT AND MENTAL HEALTH

“Don’t cry for dead men, cry for the mentally ill”(SOMALI SAYING)

The links between khat use and mental health wasone of the most contentious areas for differentrespondents. Several noted how in Somali culture,mental health problems were seen as incurableexcept by the will of God. Some users hadexperienced no or little impact on their mentalhealth, and scoffed at the idea that khat could doso. As with sexual health, respondents werereluctant to speak of their own personal

experiences of mental ill-health, and when theydid so, it was usually in terms of feelings ofparanoia or panic rather than specific conditions.None of the female participants reported sufferingfrom mental ill-health. Nevertheless, many menand women referred to the effects of khat onmental health of those they knew. Some usersreported seeing khat causing disorientation andaggression:

even aggressive. I have witnessed peoplefighting after chewing khat for long periods.You see it makes you disoriented, someonemight go to a place they did not intend to gowithout any plan.” (MALE USER, 30S)

Others saw the effects of khat on mental health ascompounding the difficulties faced by the young,and even interacting with marfesh culture.According to one user,

“So many young people have developedpsychological problems as a result of khatover-use. It also must be emphasized thatthose who have developed mental illnessesthen tend to regularly visit the marfesh andchew the most. I think that is because it is aplace they will be more accepted than if theywent to the cafés.”

A community worker who provides support on avoluntary basis to Somali patients on inpatientwards in Lambeth reported that all the Somalipatients he had seen were heavy khat users. Mostwere under 30 years old, and some combined khatuse with cannabis, and were suffering from someform of psychotic breakdown. He took up thetheme of how differing concepts of mental healthprevented Somalis from seeking treatment:

27CHEWING IT OVER

“Khat over-use makes you disorientated and

“Somalis don’t trust Western medication,especially for mental health conditions. Mostcommonly I have to try and persuade clientsjust to take the medication prescribed forthem by their psychiatrist. There is also thestigma attached to mental health issues in ourculture. People would rather send afflictedfamily members to see a sheikh (religiousscholar) in East London and pay severalhundred pounds for an exorcism than see apsychiatrist…there is one sheikh in Hargeisa(Somaliland) who sees five hundred clients amonth, from the East and the West”

Another community leader closely involved withSomali mental health patients said that thesediffering concepts of mental ill-health, combinedwith the stigma, prevented clients from accessinghelp until their condition became critical: “by thetime they do end up in treatment, their conditionis much worse than if interventions could havebeen made earlier”. Moreover, when patients arereleased into the community, there is no supportaround helping them stay off khat. A Lambethpsychiatrist noted that:

the Somali community. I have witnessedclients who were reasonably alright who wegave leave to. After consuming a certainamount of khat, some come back in acompletely different state while others evendecide not to come back, until they are foundby the police in the streets. Their situation ismuch worse by then.”

This was echoed by a director of a communityorganisation, who stated:

“Another thing is there is no follow-up forpeople who are discharged from hospital, andso it becomes a vicious circle – patients aretreated, released, start using khat, which caninterfere with their medication, and then theircondition deteriorates rapidly. There needs tobe much stronger case-working around this”

A Somali doctor stressed the link betweenhypertension, post-traumatic stress disorder(PTSD), and khat use, saying:

“Many in the Somali community are sufferingfrom PTSD and hypertension and either do notknow or do not want to admit it. You could saythey are self-medicating by chewing khat in themarfeshes, except that khat does not alwayshave a positive effect on their condition. Andwhen they do receive treatment for mental ill-health, issues of dual diagnosis are often notaddressed”

One final important point about mental healthproblems going unseen by GPs and hospital staffwas made by another health professional from theSomali community, who noted:

“There are about 25 terms for mental healthissues in Somali – all of which stigmatisemental health issues. One effect of this is thatSomalis often tend to somatize mental-illhealth and may present for treatment of aphysical health problem which is just amanifestation of an underlying mental healthproblem”

5.7KHAT AND POLYDRUG USE

As with the questionnaires, there was a generalreluctance on the part of focus group participantsand interviewees to be open about their own useof other drugs, with or without khat. A fewmentioned using sleeping pills to help counteractthe insomnia provoked by khat use; this wasreported infrequently and couched in terms of“people do this but it does not help them”.

Amongst younger participants there wassomewhat more openness about drug use. Abouthalf of the young women sampled, and a quite afew of the young men, admitted to using alcohol,cannabis, and speed, sometimes with khat,

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“khat use is very common among clients from

although no-one would speak expansively abouttheir experiences in this regard. Alcohol andcannabis were the most common drugs usedother than khat.

Somali health professionals were concerned aboutpolydrug use by young Somalis in particular, andyoung people growing up in a sub-culture that isfamiliar with different drugs.

No respondents reported using class A drugs inthe focus groups or interviews.

5.8KHAT AND RELIGION

Religious leaders who took part in a focus groupspent much time debating what the was thestatus of khat within Islam – did it count as anintoxicant? Although a majority felt quite clearlythat it was against Islamic principles, it wasacknowledged that some religious scholars,notably in the Yemen and Ethiopia, had defendedthe use of khat by Muslims.19 Faith was seen as aprotective factor generally against drug andalcohol use amongst Somalis. This was felt to beall the more important when young people were atsuch risk of getting involved with drugs.

Many of those who disagreed with khat use did soon religious grounds, or articulated theirdisapproval in religious terms. However, opinionwas not unanimous on the issue, with somearguing that khat had formerly been used as part ofreligious rituals. On the whole though, khat, likeother drugs, was seen as haraam or ‘forbidden’under Islamic law, and some noted that khat usemeant people neglected their religious and otherduties. One religious leader related an anecdoteabout a man who asked him to remarry him withhis wife. When the Sheikh enquired as to why thiswas necessary, the man replied that he had beenstoned on khat the day before and had divorced his

wife without realising. While this should perhapsbe taken at no more than face value it illustratesperceptions of khat use – and khat users – amongthe devout.

5.9TRYING TO QUIT

Users agreed unanimously that it was difficult tostop using khat completely. Some felt that whatmade it difficult was that ex-users were cut offfrom their social circle. One participant spoke ofhaving quit for four months, but he started usingagain due to loneliness.

All felt that the lack of activities and communityvenues available to them in the borough was ahuge barrier preventing them from quitting. Thelack of employment opportunities was inparticular seen as a major reason for khat use– anda major barrier to stopping. Several felt thatagencies were not doing anything to help them –and young Somalis in particular – get into jobs ortrainee schemes.

Attention was also drawn to the way how marfeshcustomers – and indeed staff – are ‘locked in’ to acycle of using because of their immigration status.Those who are not entitled to benefits and whocannot work may end up being employed bymarfeshes illegally, while those receiving statesupport will often be able to receive credit fromdealers on the strength of their benefits.

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5.10ACCESSING TREATMENTSERVICES

“For other drugs there’s lots of supportavailable – agencies, helplines, doctors. Forkhat, there is nothing” (FEMALE USER, 20S)

Almost all respondents felt that they could notaccess support from existing services. Reasonsfor this varied. For many, language and culturalbarriers were one of the main barriers toaccessing treatment from mainstream providers:

“There is a poor information or translationavailable in the language that the majority ofthe community read (Somali), so that is a bigbarrier for us to start with” (MALE USER, 30S)

The notion that khat was not a drug, or at least notlike other drugs, reinforced the view thattreatment providers would not understand theirproblems or be able to help. This, combined withthe stigma attached to accessing drug treatmentagencies, was a major barrier to receiving helpand support. As one respondent put it:

There’s no way I’d go into __________ (drugtreatment service based in Lambeth). Firstly,they wouldn’t understand me, my problems,my culture. Secondly, they’d do what – stickme in with a load of crack users? Thirdly, ifanyone saw me going there, they’d think that Iused [other] drugs, not just khat.” (MALE USER, 20S)

These barriers to accessing treatment were higherfor women than for men. In part this wasattributable to language issues, but equallyimportant was the sense of stigma attached towomen using khat. Some questioned the effectdisclosing they had a problem with khat use would

have on their families – would their relatives betold? What would happen to their children?Indeed, when asked where they would go for helpspecifically with khat use, most respondents (maleand female) said they would turn to a friend, orsomeone they felt they could trust:

“I would turn to my close friend, or maybe aSomali I can trust who works in the healthservice” (FEMALE USER, 20S)

One issue that was raised by a Somali healthprofessional living in Lambeth was that of people,especially young people, being sent back toSomalia to tackle problems they have withsubstance misuse. Sometimes individuals wereeven duped into going back:

“One person I know was promised that he wasgoing for a holiday in Dubai. It wasn’t till he got onthe plane that he found out he was being taken toMogadishu…he was kept there for severalmonths until he had been ‘reconditioned’”

5.11ACCESSING OTHERSERVICES

It is worth perhaps stressing that these barrierswere not unique to treatment services. Evenwhere language was not an issue, there was awidespread perception that services would not beable to meet their specific needs:

“Generally speaking the services in Lambethare not appropriate for our community. Theyusually ignore that we are a new migrantcommunity, that we have multiple needs suchas a very high rate of homelessness, very highunemployment, as well as cultural barriers”(MALE USER, 40S)

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A number of respondents reported receiving pooror even rude service in other providers, such ashousing and education. One woman noted:

“It can be really hard getting basicinformation. I am often ignored at mychildren’s school because of my lack ofEnglish” (FEMALE NON-USER, 30S)

Another issue for women was accessing culturallyappropriate services:

“I have been here 13 years and I have neverseen any support for Somali women. We needmother-tongue classes and women-only gymsessions that Muslim ladies can go to, likeother communities have. I know I can demandto see a female doctor, but not all women inthe community know this” (FEMALE NON-USER, 40S)

The lack of services and diversionary activitiesaimed at Somali young people also was a concernfor respondents:

“Somali youth do not get enough support ineducation or employment – that is why youcan see them around Streatham high roadsmoking hashish or chewing khat” (MALE USER, 20S)

Criticism was not only reserved for statutoryproviders in Lambeth, but also for the communitysector, who it was felt were not as effective asthey could be in responding to the needs of thecommunity:

“We have so many organisations butunfortunately we still do not have any voice inthe borough.” (MALE USER, 30S)

“I would ask the council to force ourcommunity organisations to prove that theyare really doing their work” (MALE NON-USER, 30S)

5.12POLICE AND COMMUNITYSAFETY CONCERNS

Respondents across all groups had mixed viewsabout community safety and cohesion issues.Approximately half felt safe generally living inLambeth; this dropped among young men andwomen. The interaction between young Somalisand other groups, as well as between theauthorities, was a particular cause for concern:

“Our young men are usually bullied, insultedor harassed by other people. Some of theterms used include ‘‘you refugees”. This is acause of a lot of the violence with other youthgroups” (MALE USER, 30S)

A number of respondents raised the issue of largenumbers of young Somali inmates at FelthamYoung Offenders Institute. It was quite common tohear claims that fifty or even eighty percent of theinmates there were of Somali origin. In actual factSomalis make up 5.3% of the prison population atFeltham – the largest ethnic group there – but thisstill demonstrates that young Somalis aresignificantly over-represented in the criminaljustice system.20

Gangs and gang-related crime was an issue forsome, but there was little evidence of widespreadinvolvement by young Somalis in gangs. One ortwo young men spoke of belonging to SMS (aSouth London gang operating in Lambeth) but itwas not clear whether this was really the case orif they were merely claiming to do so.

31CHEWING IT OVER

Islamophobia was an issue for some respondents.Women in particular had experiences of beingtargeted because of their dress:

“People still look at us as Muslims withsuspicion” (FEMALE USER, 20S)

“I know some people who have beenphysically or verbally attacked, most of themwearing hijab (veil). I do not believe that mostof them would report it because of languagebarrier.” (RELIGIOUS LEADER)

Although no-one alluded to the tensions betweencommunities seen in Streatham a few years ago,inter-communal relations were an issue for some:

“Generally, I have not experienced racism inLambeth. On the rare occasions that I have, itis from West Indians. My friends have also hadsimilar experiences. Why is this?” (SOMALI DOCTOR)

Attitudes to the police also varied significantly.Some felt confident that the police would takematters raised by the community seriously:

“I have full confidence in the police, I wouldreport any crime that I witness and I wouldreport if I were a victim.” (MALE NON-USER, 30S)

Others however expressed scepticism and distrusttowards the police:

“I’ve never been stopped, but many others Iknow have been, especially young men”(FEMALE USER, 20S)

“A friend who was homeless went to thepolice station and was arrested instead ofhelping him find a hostel place” (MALE USER, 40S)

“If I was a victim of a crime I would still reportit but I am not sure if all crimes will be dealtwith in the same way. For example if I reportthat my car was stolen or damaged it will beinvestigated properly where as if I reported arace hate or Islamophobic crime with my poorEnglish then unfortunately, I do not think thereis any much chance that it will be takenseriously.” (MALE NON-USER, 30S)

Some saw community organisations as the key tobetter relations with the police:

“It would have been better if police workedwell with the community organisations tobuild trust with the community” (MALE NON-USER, 40S)

Finally, domestic violence (DV) was an issue raisedby many respondents, male and female, in relationto khat use. While few suggested that using khat leddirectly to incidents of domestic violence, severalargued the pressures on families could beexacerbated to boiling point by problematic khat use:

“Yes, khat users can be violent. I know, I wasmarried to one.” (FEMALE NON-USER, 50S)

“I’ve seen it [DV] a lot in families. Thehusband spends all the time away from thehouse, and spends too much money on khat.This impacts on the whole family. His wifecomplains, and he snaps because he’s feelingaggressive and lashes out at her” (MALE USER, 40S)

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5.13RESPONDING TO KHAT(MIS)USE

When asked what would improve the situationwith regard to khat, respondents drew attention todifferent types of response. From some non-users,there was bewilderment that khat was still legal inthe UK. As one religious leader put it:

“The British government banned khat inSomalia during the colonial occupation... So why can’t the British government ban ithere in Britain?”

Others acknowledged that this would not be anappropriate response, and would likely push someSomalis into more mainstream drug and alcoholuse.

In terms of accessing help for khat use, most feltthat that this would best be achieved throughhaving Somali health workers who spoke thelanguage, could be trusted, and would understandthe issues faced by users, enabling them to giveuseful advice.

Health promotions was another strategy whichrespondents felt should be pursued more actively:

“As we do not have the option of banning it,the second best option is to educate thecommunity about its dangers, printing inSomali newspapers, Somali radio broadcasts,posters warning people about the dangers of khat” (MALE EX-USER, 30S)

Diversionary activities, and support findingemployment and training, were also seen asimportant, particularly for the young. Many feltthat community groups had an important role toplay here, particularly in partnership with thestatutory sector:

“We need to have specialist communityorganisations that specifically support Somalipeople in different areas such as health,training, employment, education and so on”(MALE USER, 30S)

“There is no youth club for us as Somali youth.We need a youth centre that is run by youngSomalis for young Somalis” (YOUNG MALE NON-USER)

“There needs to be closer cooperationbetween [community groups] and Lambethcouncil, the job centres in Lambeth, trainingcentres, the drug services and the local healthservice. We should also check if those placescan cater for the needs of such people” (MALE EX-USER, 40S).

Women also cited the need for appropriateactivities:

“There is a real need for a special women’ssupport group for Somali women, somethingthat can help them get advice, fulfil theirpotential and keep occupied. We also needcrèche facilities and Muslim study groups forour children – we worry about letting them go out” (FEMALE USER, 20S)

Finally, several respondents suggested thatmarfeshes should be more tightly regulated,particularly around health and safety and tradingstandards issues, as well as selling khat to youngpeople. A few even argued khat should be taxed:

“We need to tax the marfeshes like they do forcigarettes and alcohol cigarette, so thatLambeth becomes an example for other areas.However, we should also offer them otherchances to escape from these problems”(MALE EX-USER, 30S)

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6.1 METHODOLOGICALCONSTRAINTS

The needs assessment was conceived of as amixed methodology study which comprisedquantitative and qualitative elements. This wasimportant if the study was to capture both themodalities of khat use in Lambeth and the extent ofuse. Researching drug use in ‘hard to reach’groups is inherently problematic and mixedmethodology studies offer greater potential forassessing a broad range of needs in suchgroups.21 A steering group was set up at the startof the project to provide strategic oversightaround both the service delivery and needsassessment strands of the project. This wascomposed of the research team, DAT andCommunity Safety staff, and representatives fromFanonCare, staff from LSDP, EAHC, and othercommunity representatives, the police, and otherhealth providers.

The quantitative element was guided byepidemiological approaches including direct andindirect estimation of prevalence. Obviously anysocial research methodology has its limitations; inpart this was why a mixed-methodology approachwas adopted for the study. Sample bias is aparticular issue in this regard and is arguablyinherent in any sampling method. However, theresearchers felt that given the available time andresources, and the difficulties attached toresearching hidden and marginalised groups ofthis sort, the risk of a significant sample biascould be kept to a minimum. Certainly, the use ofopportunistic and quasi-random questionnairesampling helped minimize this risk, particularlythe use of these over such a diverse range ofsites. Indeed, as the extent of khat use withinLambeth’s Somali community became apparent, itbecame increasingly important – and difficult –for researchers to sample non-users, if onlybecause these were in a minority.

6.2PREVALENCE ESTIMATION

Estimating prevalence rates of substance use inhidden populations is difficult, even with a legaldrug like khat. Even when compared to other setsof drug users, local data sources for the Somalicommunity are almost non-existent. Theoretically,it would be possible to gain better local data if itwere possible to gain access to NHS and otherservice data; however, the fact that Somaliethnicity is not recorded in most cases meansthere would be little advantage in doing so.Consequently, it is likely that the prevalenceestimates are low due to the difficulties inidentifying unknown populations, and the lack ofadequate surveillance data. Stronger and morerepresentative data recording systems need to beimplemented in order to gain a more accuratepicture of the current Somali population inLambeth.

For reasons already discussed, general populationsurveys are not good for estimating theprevalence of drug use, and using national datamay not necessarily be representative of theproblem in Lambeth. Limitations of the multipliermethod include assumptions that individuals arestill using; that all users are recorded; and that themultiplier is realistic. The difficulty in establishinga benchmark further complicates the picture. The mean prevalence rate used (derived from anumber of limited local and national studies) islikely to underestimate the prevalence rate.

Capture-recapture estimation methods rely onassumptions that may not be met, such as usershaving available identifiers and not moving in orout of the sample area.22 Pre-existing lists ofusers may not be typical of the study population,for example women and minority ethnic groupsare often under-represented. Mutualindependence is the probability that users appearin one or more lists and this can be positive

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6 ANALYSIS ANDCONCLUSION

(where it lowers the estimate) or negative (whereit raises the estimate).23

In the case of this study, the lack of existing andreliable lists actually worked to the researchers’advantage in this regard, by forcing them to relyon data they had collected from a large number ofsites across the borough. Although the coding ofquestionnaires presented no small problems initself (i.e. ensuring codes carried enoughinformation to distinguish individuals and preventover-counting), using a simplified version of CRMenabled the team to check the consistency andrepresentativeness of respondents’ answers.

6.3DEMOGRAPHICS

The demographics of Lambeth’s Somalicommunity are interesting in terms of disparitiesboth from what might be expected from existingdata and also in comparison to other minoritygroups in the borough.

Clearly, one of the most important findings of thisstudy is that the Somali population is two to threetimes larger than was previously thought. Thisshould not be surprising: the main data set forLambeth’s population is the 2001 Census and it isclear from school registrations since then that theSomali community has been growing quickly boththrough growth of the existing community throughchildbirth and through migration into the borough.In addition to this, and in common with otherrefugee and asylum-seeker populations in the UK,there is a strong reluctance on the part of manyindividuals to be ‘visible’ to the authorities. Forexample, some will even refuse to register with aGP and prefer to seek treatment in Accident &Emergency wards where they can receivetreatment anonymously.

As data from this study and Demie’s research intoeducational attainment show, the Somalicommunity is increasingly a young one. However,while addressing young Somalis needs will be anincreasing priority, especially in terms of thosevulnerable to drugs or crime, it is important not toforget older members of the community who areless integrated, less capable, and more vulnerable.This is true both in the short-term and especially inthe longer term, and will present services across awide range of sectors with significant challenges ifnot addressed in some way.

The other striking finding is the inequalities thatexist in the Somali community, both in relation toothers and between community members. Levelsof education are high on average, at least amongmen; amongst female Somalis there aresignificant levels of illiteracy. Yet in both caseslevels of unemployment are high. In the case ofwomen, this can in part be attributed to a lack ofeducation and/or training and also a culturalattitude amongst some families that women’s role is to look after children and the home. Also,many individuals are actually debarred fromworking due to their legal status. Languagebarriers were cited again and again byrespondents as a barrier, if not the biggest barrier,to greater involvement in the workplace and thebroader community.

Moreover, the lack of transferability ofqualifications and experience prevents manyhighly-skilled people from working to their fullpotential. Nevertheless, it is likely that institutionalracism and/or islamophobia is a further factorpreventing Somalis from finding employment.Whether or not this is the case in any givenexample is a moot point; but the perception that‘these jobs are not for us’ certainly acts as abarrier to Somalis seeking employment. Somalisare not represented in any significant numbers inthe council’s workforce, for example, despite adesire from some services to recruit Somali staff.

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Housing was another area where inequalities werefocused. Approximately a fifth of respondentswere either no fixed abode (NFA) or living withfriends. In some cases this is arguably attributableto the desire of some people to remain ‘off-radar’,but combined with a high level of familybreakdown it suggests that there is a high level ofinstability in terms of people’s housing situations.Not only does this situation have implications interms of overcrowding for some tenancies, it alsoindicates that support needs in the broader senseare not being met for a significant number ofSomalis.

The data also showed that there were Somalisliving in every part of Lambeth. Traditionally, thefocus for both the community and the council hasbeen on Streatham and Stockwell. However, asthe Somali population spreads into other areasthis will doubtless create new social, economic,and cultural challenges and opportunities.

6.4PATTERNS OF KHAT USE

Perhaps the most striking findings in terms of khatuse were both its prevalence generally and morespecifically among Somali women. As notedpreviously, use of khat by women is very unusual inSomalia itself. Other research in London hassuggested some female use of the drug butlargely on an anecdotal basis and certainly nohigher than 10 or 15%.24 Yet the data showed veryclearly that approximately the same proportion ofwomen as men chewed regularly, althoughwomen generally chewed less per session andhad fewer sessions per week.

Some used khat with their partners or families, butmost chewed with (female) friends at home.Certainly, anecdotal evidence suggests the tabooagainst female use of khat remains strong, which

in turn drives the cycle of women’s isolation –note how few women would access mainstreamtreatment services or a mosque for help with theirkhat use. Use of khat by women is also shaping thekhat trade itself. A number of marfeshes run adelivery service; one respondent noted that thedelivery person would be “treated like a prince”upon arrival at a women’s chewing session, withincense being lit for him.25 Recent informationsuggests there is now a women-only marfesh inStreatham.

Men were the heaviest users of khat in terms oflength and frequency of sessions, and in theamounts consumed. The heaviest users fell intotwo groups: a younger group, aged 17-25 or 30,who were more likely to be employed andtherefore have some disposable income; and aolder group, in their late thirties or above, whowere generally unemployed. The latter group werearguably the most ‘problematic’ in terms of theeffect of their use: some were chewing up to 9hours a day (or night) every day of the week.Roughly a third of the sample could be describedas heavy users (with caveats around setting anbenchmark for how different people are affecteddifferently by drugs), suggesting at least 1000heavy users in the borough as a whole. Aside fromthe health impact on users themselves, this willimpact negatively on family and other carers in amuch broader way. Although there is no cleardirect causal link between (heavy) khat use andunemployment, some form of interrelationshipclearly exists.

Amongst young people sampled there was a cleardiscrepancy between the focus groups andinterviews on the one hand, and on thequestionnaires on the other. In the case of theformer, respondents tended to claim not to use khatand indeed looked down on it as a negative thing,whether seen as simply ‘not cool’ or throughstronger negative personal experiences. However,the questionnaire data shows not only that levels

CHEWING IT OVER36

of khat use are in fact quite high (albeitsignificantly lower than other groups in thesample), but also that the age of first use isgenerally young, around 15 or 16 years old. An implication of this is that education andpreventative work with young Somalis around

use needs to be ongoing.

6.5POLYDRUG USE

Reported use of other drugs by Somalis of all ageswas very low. In part this is a corollary of lowlevels of awareness within the communityregarding street drugs available in London. Mostpeople knew something about alcohol andcannabis (these are drugs well-known historicallyin N.E. Africa) but little beyond this. For thisreason, such polydrug use as was reported wasalmost (but not quite!) exclusively among youngpeople, male and female. However, there is reasonto believe both from anecdotal evidence and fromcertain aspects of the data set (inconsistency ofquestionnaire answer, for example) that reportinglevels of poly-drug use was low. The taboo againstdrug use remains strong, even amongst peers,within the Somali community, in common withmany Muslim communities, an issue whichaffected the young volunteer researchers. Furtherresearch needs to be done on this area, not leastas other studies suggest social exclusion is likelyto influence young people in some newly arrivedgroups to try drugs.26

6.6ATTITUDES TO KHAT USE

As was expected attitudes to khat use were quitesharply divided, both between generations andbetween genders. Women were more likely to be

against khat use than men, and young people weremore likely to be anti-khat in their attitudes.However, this is far from clear-cut as the data onpatterns of use demonstrates. Many users andnon-users felt khat was not a ‘drug’ like otherstreet drugs or indeed medical drugs, but rather acultural habit (even if it was a ‘bad’ habit). Acrossboth focus groups and questionnaires,respondents addressed their attitudes to khat usein religious terms – i.e. in most cases that khat usewas intoxicating and therefore haraam, orforbidden in Islam. Yet some argued that khat wasnot intoxicating or not ‘unislamic’, especially inrelation to other drugs and alcohol.

Those who opposed khat use repeatedly expressedtheir astonishment that khat was legal in the UK.Many felt that if it were banned the situation forthe community would improve significantly.Equally, khat use was not seen as something thatone could or should seek help or treatment for. As such, it has not been ‘medicalised’ orpathologised as much as the use of some otherdrugs has been. In seeking to address the veryreal impacts of khat (mis-)use on users and thewider community, health and treatment services,as well as service planners and commissioners,should take care not to over-medicalise the issue,as this will further disengage users.

6.7HEALTH IMPLICATIONS

As noted above, reporting of negative healthimpacts associated with khat use was both low andhigh. Low in terms of numbers of people citingsevere or significant ill-health due to khat, but highin terms of the number of respondents citingsome effect on their physical or mental health.This can be explained to a certain extent incultural terms – Somalis will often not seektreatment for health problems unless they

37CHEWING IT OVER

khat

consider it serious. But it also points to a lack ofawareness of the effects of khat use, both amonghealth and other professionals, but also amongstusers themselves. A user may report feeling acertain health effect, e.g. insomnia orconstipation, without considering the effect theirkhat use is having on their health in a more holisticsense.

Focusing purely on physical health, khat use likelyhave an effect on their diet and digestive system,as well as their oral and dental health. In additionto this, the ‘how’ of khat use for the typical user–high levels of smoking, lots of sweet sugary drinks– would increase risk factors further. Theeconomics of khat use also carry a health impact.Some heavy users are likely to be among thepoorest community members; as with users ofother drugs, they may spend what little moneythey have on khat rather than food. This can lead toweakened immune systems or even, in extremecases, malnutrition.

Health providers need to be more aware of khatuse, both in terms of its pharmacological effects,and in terms of the impact socio-cultural andeconomic factors may have on the health of users.

6.8MENTAL HEALTHIMPLICATIONS

Explicit reporting of mental ill-health was very low,and in part this can be explained by the strongtaboos existing against mental ill-health in Somaliculture. However, a high proportion of usersreported what might be construed as indicators ofmental ill-health in some cases – insomnia,paranoia, feeling jittery etc. As noted above thethere is substantial debate about the the exactnature of the impact of khat use on ill-health, but itis clear that it does have an impact. The picture isclouded by other, broader factors, such as the

general situation of exclusion within thecommunity, high levels of undiagnosedhypertension and post-traumatic stress disorder(PTSD) related to events back home or even thedifficult migration journey to the UK.

It is significant, however, that almost all theSomali clients visited by the project workers inLambeth Mental Health services were khat usersand suffered to varying extents from ‘dualdiagnosis’. As with dual diagnosis amongst usersof other drugs, this poses particular challenges todrug treatment and mental health services. In thecontext of khat use, very few providers in Lambethhave even begun to address the implications fortreatment and care of Somali clients.

One significant issue in this regard is a lack ofsuitably skilled interpreters. Interpreting incomplex areas like health and law requiresspecialist training, not least because the technicalvocabulary is large and precise, while in Somali(as in other non-Western languages) there existsnot just a different vocabulary but a fundamentallydifferent conception of mental ill-health.

In common with other BME groups, Somalisaccess mental health services much later thantheir white peers, and have less successfuloutcomes.27 Moreover, the lack of awareness ofand common cultural perceptions around, mentalill-health means Somalis are far less likely toaccess help or even conceptualise their distressas ‘mental-ill health’. This is compounded by adistrust of western medicine which makes someclients reluctant to take medication prescribed for them.

A related issue here is the compatibility ofwestern models of mental health care with clientsfrom Somali or other non-western backgrounds.Aside from distrusting medications for mental ill-health, it is unlikely that other forms of treatment,like Cognitive Behavioural Therapy (CBT), will beeffective if not adapted to the Somali milieu.

CHEWING IT OVER38

Psychosocial interventions may well proveeffective but they need to move away from anindividualistic model to one that involves familyand even community.28 There is a strong case fordeveloping more African-centred (or in this case,Somali-centred) approaches to mental healthtreatment.

6.9PUBLIC HEALTHIMPLICATIONS

While the data shows a limited impact on publichealth, there are a number of areas of concern.Firstly, the poor health and safety standards inmost marfeshes, which are usually smoky andpoorly ventilated, will have a negative effect onthe health of habitués. Secondly, chewing khatsocially in close proximity to others may increasethe risk of spreading diseases like TB.

Rates of tuberculosis infection are the highestamongst Somalis of any group in the UK, andwithout being alarmist some care should be takento ensure that marfeshes do not become a vectorfor spreading the disease. This needs to beapproached sensitively, however: negative andoften incorrect media assertions increasesuspicion and stigma against and within thecommunity, and anecdotal evidence suggestsSomalis often seek treatment for TB at a very late(and therefore more critical) stage in their illness.Care needs to be taken not to further discouragecommunity members who need treatment or are seeking it.

6.10MAPPING LAMBETH'''' ' ' j j j j S KHAT MARKET AND MARFESHES

One of the aims of this project was to mapLambeth’s marfeshes and try to engage betterwith owners. Counts of marfeshes in the boroughhad to be continually updated as new informationcame in. On one level, this is indicative of what adynamic business the khat trade is, withbusinesses opening and moving premisesrelatively quickly. At present, it is believed thatthere are approximately twenty marfeshesoperating in the borough, including one servingwomen only. Most are in Streatham andStockwell, but there are marfeshes in all of thefive ‘town centres’ of Brixton, Clapham andStockwell, Streatham, Norwood, and Kennington.

It is difficult to gauge the size of the khat market inLambeth. Based on data collected, the averageexpenditure on khat was £780 per person per year,or £212,160 per year for the sample as a whole.Bearing in mind the fact that respondents willgenerally under-report their levels of consumption(as with any drug), it is likely that the annual tradein khat in Lambeth is worth approximately £1m.However, it should be noted that London is aninternational entrepot for khat transit/smuggling.The price of khat in the US is in the region of 10 to15 times higher than the in the UK. A fewindividuals the researchers spoke to claimed toknow people in Lambeth involved in this illicittrade, and so it is likely that if this is taken intoaccount the total khat trade will be significantlyhigher.

Engaging with marfesh owners was complicatedby the community politics and events in the Hornof Africa. In the summer of 2006, the effectively-ruling ICU in Mogadishu banned the sale andconsumption of khat. This led to greater instabilityin the market; paradoxically one effect was aslight drop in the price of khat, and put greater

39CHEWING IT OVER

economic and social pressure on khat dealers.Researchers and partner community organisationstried to engage constructively with owners both interms of conducting research and also insupporting their businesses develop good practice(e.g. no selling to minors, closing at a set time)and health and safety. However, marfesh ownerswere actively quite hostile to any form ofcooperation. Indeed, researchers were told by onekhat dealer who supplied a number of marfeshes inLambeth that if any staff in those marfeshesspoke to researchers, they would stop supplyingthose establishments with khat. On anotheroccasion, a khat-dealer physically assaulted acommunity leader because he claimed that theindividual concerned was benefiting from theresearch.

Despite these difficulties, it is recommended thatattempts by the local authority to engage marfeshowners continue. However, such engagementwork needs to be undertaken with greatsensitivity.

6.11COMMUNITY SAFETY ANDPOLICING

Unlike in some other parts of London, Somalis inLambeth are no more likely to be involved incrime or disorderly behaviour than any othergroups. While a significant number of arrests bypolice in Streatham are of (predominantly young)Somalis, the police attribute this to thedemographic situation pertaining in that area.

Conversely, in contrast to other parts of London,policing of Somali areas has generally beencarried out in a sensitive manner. Police inStreatham have made efforts to engageconstructively with the Somali community, forexample supporting youth football teams with

pitch access as well as funding a mini-tournamentof Somali football teams. Significantly, the localSuperintendent has expressed his commitment toSomali issues and to be sensitive with regardingpolicing marfeshes and other khat-related issues.

During the course of the research there werecomplaints from some Streatham residents aboutgroups of Somali youth gathering in one streetlate at night to take drugs. However, furtherinvestigation showed that this group was notexclusively Somali, and the police arranged tomake extra patrols in that area. Another issueraised was of young men loitering outside bettingshops. Again, this was a phenomenon notrestricted to Somali youth. It should be noted inthis context that many community members,especially Somali young people, that there is alack of affordable venues in Streatham such asyouth clubs or community centres. Similarly,reports of Somali gangs forming in Lambethproved to be extremely exaggerated, if notactually baseless.

It is fair to say there has been no repeat of thesame tensions between Somalis and others thatwere seen in the area in 2004. The use ofwardens and Somali volunteers, often on jointpatrol with local Safer Neighbourhood PoliceTeams, has gone a long way to preventing therecurrence of such problems. However, with thedecision by the council to scrap the wardensscheme (despite the police drafting in a SomaliPCSO into the area) the situation will need to bemonitored.

On the other hand, many respondents felt at riskof crime or fear of crime in the borough. This wasespecially true of young people, but notexclusively a youth issue. Islamophobia was alsocited as an issue by some respondents. Reportingof crimes as another area for concern – a numberof respondents said they either had not, or wouldnot, report an incident even if it affected them

CHEWING IT OVER40

personally. One reason given for this was theperception that police would not take their matterseriously.

Overall, the police have built reasonably goodrelations with the Somali community in Lambethbut ongoing efforts at engagement need to beintensified.

6.12ACCESSING TREATMENTAND OTHER SERVICES

Qualitative and quantitative data showed veryclearly that there were enormous barriers torespondents accessing treatment and otherservices for help with khat use. Foremost amongthese were arguably a generic distrust ofmainstream services, coupled with the barriers; insimplistic terms, a feeling that services will notunderstand ‘their’ problem. It should be stressedthat this is born out of experience as much asperception. Mainstream drug treatment serviceswere in particular not felt to be appropriate forSomali clients, partly because khat was not seen asa drug, partly because of the stigma attached todrug use more generally. At the same time, somerespondents did state they would rather approacha service that had no roots with the Somalicommunity as they felt this would be moreconfidential.

Likewise in terms of accessing more generalhealth providers such as GPs and hospitals, therewere some significant disparities. Men seemedmore comfortable accessing help from their GPs,but nevertheless were as likely to approach theirlocal mosque for help. Women were far less likelyto approach any service at all. Focus group andother data suggested this was attributable to anumber of factors, including the taboo against khatuse by women, lack of confidence in their English

(and concerns about confidentiality using aninterpreter), as well as the suggestion that somewomen did not know they were entitled to see afemale doctor.

Varying literacy rates also highlight the care thatneeds to be taken with using written materials. Areferral letter might get thrown in the bin as junkmail by those who cannot read it; leaflets indoctor’s surgeries might go unread. Care shouldtherefore be taken not to simply produce lots ofliterature of local services in Somali (as hashappened in some parts of London). Moreeffective are likely to be ways of promotingservices that are more in tune with Somali needsand Somali culture. Specialist Somali healthintervention workers have proved effective in otherboroughs and certainly health promotion sessionsorganised by research project workers at Fanon withSomali ‘experts’ on nutrition, mental health etc,have proved very popular. Equally, visual mediasuch as DVD or video could also be used to goodeffect.

41CHEWING IT OVER

6.13PROJECTRECOMMENDATIONSTREATMENT

• Continue resourcing the project at current level with

• Work more closely with other statutory healthand mental health professionals, as well asthose community and voluntary sector groupsworking in this field, to strengthenreferral/signposting pathways, and develop aneffective model of care for khat use thatcombines harm minimisation advice andculturally appropriate psycho-socialinterventions.

• Extend the existing partnership arrangementwith the Fanon Resource Centre to include otherstimulant services in the borough wherepossible and appropriate.

• Greater provision of diversionary activitiestargeting at risk groups within the community,notably women, carers, the unemployed, andyoung people.

• Disseminate the findings of this report, as wellas a guide to working with Somali clientsproduced by East African Health Concern, to awide range of public health providers such asGPs and hospitals.

BROADER RECOMMENDATIONS

• Coordinate more effectively with other agenciesand departments within the Safer LambethPartnership (SLP) to address a broad range ofneeds within the Somali community andencourage the formation of a strategic-levelgroup at borough level of SLP and Somalicommunity members.

• Supported Housing and other providers to ensure that Somali tenants at risk are adequately assistedto maintain their tenancies

• Continue efforts to engage constructively withmarfesh owners, promote good businesspractice and greater awareness of health andsafety issues.

• Intensify efforts to engage young Somalis anddevelop initiatives to address potential khatand/or other drug use among this group, usinginnovative approaches– activities, events, etc.

• Support efforts to provide access to suitablecommunity venues

• Promote good relations with the police and thebroader community.

• Work more closely with other khat servicesacross London and relevant local authorities.Intensify efforts to establish a cross-borough khatworking group.

• Inform and educate local and other media of theissues surrounding khat (mis)use.

CHEWING IT OVER42

more focused service provision and seek funding to expand the number of workers to two full-time staff

1 Marfesh or marfesh is a khat-house, a place where khat is chewed. The plural in Somali is marfeshyo

2 There are a number of local variants of the plant’s name, such as chat, qat, jaad etc, plus names derived from place of origin

e.g. ‘Meera’ (an area in N. Kenya). However, the most common orthography used in the UK is ‘khat’. In this

3 This is the title of a book examining the history of khat use and production in Ethiopia.

4 http://www.dea.gov/slideshow/july2006.htm

5 Al-Hebshi & Skaug 2005:299

6 Alex Kirby, ‘Yemen’s Khat Habit Soaks Up Water’,http://news.bbc.co.uk/1/hi/programmes/from_our_own_correspondent/6530453.stm

7 http://news.bbc.co.uk/1/hi/world/africa/ 6142688.stm

8 http://www.drugs.com/npp/khat.html

9 “Drug classification: making a hash of it?” – HMSO Fifth Report of Session 2005–06

10 UCLAN/GLADA 2004 – Refs and Asylum-seekers

11 Dr. Shamis Hussein, personal communication

12 Luqman 1978; Griffiths et al. 1997; Warfa et al. 2001, 2006

13 Wright 1998

14 NTA 2002

15 The researchers are grateful for the guidance of Mark Asquith, of Wolfson College, University of Oxford, around adaptingCRM as far as possible in this way, and checking the statistical analysis of the data

16 Dr. Feyisa Demie, presentation to Somali Educational Conference, Dec. 2006

17 UCLAN Brent 2004

18 It is worth noting that khat use only became widespread in Somalia from the post-war period onwards, withimprovements in transport infrastructure in the region. In this sense, it is open to question just how ‘traditional’widespread khat use is.

19 A similar point is made by Richard Burton in his ‘First Footsteps in East Africa’, 3:31fn1

20 Personal communication from Leah Levane, Streatham Town Centre Manager

21 UCLAN/LDA – Refs and Asylum-seekers

22 Hook & Regal 2004:243ff

23 Ibid.

24 C.f. ARMA/UCLAN 2005; REEC/UCLAN 2006, amongst others.

25 Incense is used across a range of contexts in E. African culture, one of which is honouring guests.

26 UCAN/GLA 2004

27 Warfa et al 2006

28 Ibid.; see also Bhui, Bhugra, & Macdonald 2004

43CHEWING IT OVER

ENDNOTES

CHEWING IT OVER44

LAMBETH KHAT RESEAERCH PROJECT/ LAMBETH COUNCILKHAT QUESTIONNAIRE

This anonymous questionnaire is being used as part of a research project looking at how the issue of khatis affecting the Somali community in Lambeth.

The answers you give will be used to improve services available to the Somali community in Lambeth.

Any answers you give will be treated in the strictest confidence and will be used by Lambeth Council’sDrug and Alcohol Team solely for the purpose of this study. They will not be passed onto to other agencies.You do not have to answer any questions you do not wish to, although we urge you to be as frank aspossible.

Please tick the box below to confirm that you have given your consent to take part in this study.

Su aalahaan aan qofna ku magacowneyn (anonymous questionnaire), waa su’ aalo loogu tala galay infikard looga qaato cilmi baaris kooban oo ku saabsan isticmaalka qaadka ee soomaalida deganxaafada Lambeth. Jawaabaha aad ka bixiso waxay naga caawin doonaan sidii loogu diyaarin lahaacaawimaad soomaalida ku dhaqan xaafadan Lambeth.

Jawaabaha aad na siiso waxay noqonayaan kuwa loo isticmaalo cilmi baaristaan oo kaliya iyadoo aanqofna magaciisa la isticmaaleyn (anonymous). Looma gudbin doono urur kale.

qoran si loo xaqiijiyo ogolaansahaaga ka qeyb qaadashada cilmi baaristaan.

(tick here/ halkaan sax)

Thank you for your time/ Waad ku mahadsan tahay ka qeyb qaadashadaada.

PLEASE CIRCLE ANSWERS

PART A – PERSONAL INFORMATION

AGE RANGE

16-20 21-25 26-30 31-36 37-45 46 and over

GENDER

Male Female

45CHEWING IT OVER

APPENDIX 1 SAMPLE QUESTIONNAIRE

hadana khasab ma aha inaad ka jawaabto su'aal aadan ku faraxsaneyn. Fadlan sax santuuqa hoos kuInkastoo cilmi baaris ahaan ay wanaagsan tahay inaad sida ugu daacadsan uga jawaabto su'aalahaan

CHEWING IT OVER46

DO YOU HAVE A DISABILITY

Yes No

If yes please specify:

AREA OF RESIDENCE

Streatham Clapham & Stockwell Brixton Norwood Kennington Outside Lambeth

WHICH LANGUAGES DO YOU SPEAK AND/OR WRITE?

English Somali Arabic Italian Other

Spoken (please specify)

Written (please specify)

EDUCATION

Primary Secondary Higher Education No formal Education

EMPLOYMENT STATUS

Full-time Part-time Unemployed Student Self-employed

HOUSING SITUATION

Living in Hostel Own house Council Tenant Council Tenant

Temporary Accommodation Living with friends/ Relatives No Fixed Abode

MARITAL STATUS

Single Married Divorced Widowed Separated

IMMIGRATION STATUS

Exceptional Leave to Remain Indefinite leave to Remain British citizen

Other (please specify)

47CHEWING IT OVER

PART B – KHAT USE

(PLEASE ANSWER QUESTIONS IN THIS SECTION ONLY IF YOU USE KHAT)

WHERE DO YOU USUALLY USE KHAT?

Chew with friends at home Chew with family Chew alone Chew at Marfesh

Other (please specify)

AMOUNT CHEWED IN A SESSION

1-3 bundles 3-5 bundles 5 or more bundles

MONEY SPENT PER WEEK

£ 3-10 £11-20 £20-30 £30 or more

LENGTH OF SESSION

1-3 hours 3-5 hours 5-8 hours 9 hours or more

NUMBER OF SESSIONS IN A WEEK

1-2 days 2-3 days 3-5 days 5-7 days

REASONS FOR TAKING KHAT

To relieve stress To socialise As a cultural practice To become more energetic

Positive health effect

Other (please specify)

DO YOU FEEL KHAT USE CAUSES ANY OF THE FOLLOWING EFFECTS ON YOUR HEALTH?

Sleep disorders Oral problems Constipation Loss of appetite

Hallucinations Heart problems Paranoia Mental health problems

Sexual health issues

Other problems (please specify)

CHEWING IT OVER48

WHEN YOU CHEW KHAT, DO YOU SMOKE CIGARETTES?

Yes No Sometimes

DOES USING KHAT HAVE ANY OTHER EFFECTS ON THE FOLLOWING AREAS OFYOUR LIFE?

MARK WITH + FOR POSITIVE AND – FOR NEGATIVE EFFECTS

Family Social life Finances Employment Education

HOW OLD WERE YOU WHEN YOU FIRST STARTED USING KHAT?

Under 16 16-20 21-25 26-30 31-36 37-45 46+

WHO FIRST OFFERED YOU KHAT?

Friend Wife/ husband Other family member Bought it yourself

Other (please specify)

HAVE YOU EVER TRIED TO QUIT?

Never tried to quit Thought about quitting

Tried once Tried more than once Don’t need to quit

IF YOU WANTED HELP WITH YOUR KHAT USE, WHO WOULD YOU GO TO?

GP Friends/ Family Mosque Specialist khat service Would not seek help

Other (please specify)

DO YOU HAVE KNOWLEDGE OF THE FOLLOWING DRUGS?

Alcohol Cannabis Cocaine Amphetamine Ecstasy Heroin

Other (please specify)

HAVE YOU USED ANY OF THESE WITH OR WITHOUT KHAT?

Yes No If yes, which ones?

49CHEWING IT OVER

PART C – ATTITUDES TO KHAT

HAVE YOU EVER USED KHAT?

Yes No

IN YOUR OPINION, KHAT IS….

an individual problem friends’/family problem a community problem

not a problem, it is a cultural practice a drug menace

HAVE YOU EVER EXPERIENCED PROBLEMS WITH ANY OF THE FOLLOWING DUETO KHAT USE, EITHER BY YOURSELF OR BY OTHERS?

Financial difficulties Health Employment Education

Mental Health Sexual Health Crime Violence in the home

Violence outside the home

IF YOU OR SOMEONE YOU KNEW HAD A PROBLEM WITH KHAT USE, WHO ORWHERE WOULD YOU GO FOR HELP?

Friend Family GP Hospital Mosque Community organisation

Specialist Somali khat service

Other (please specify)

WHAT DO YOU THINK WOULD HELP REDUCE PROBLEMS CAUSED BY KHAT USE INTHE SOMALI COMMUNITY?

ARE YOU CONCERNED BY KHAT USE BY YOUNG PEOPLE IN THE SOMALICOMMUNITY IN LAMBETH?

Yes No

If yes, why?

CHEWING IT OVER50

ARE YOU CONCERNED THAT YOUNG PEOPLE IN THE SOMALI COMMUNITY AREUSING DRUGS OR ALCOHOL?

Yes No

If yes, why?

IF YOU WOULD LIKE MORE INFORMATION ON KHAT USE, OR ON OTHER DRUG ANDALCOHOL ISSUES FACING THE COMMUNITY, PLEASE CONTACT:

on

or

on

or write to them at:

Lambeth DAT/ Fanon Care 105-109 Railton RoadBrixtonLondon SE24 0LR

or email:

1YP FOCUS GROUP

• What do you think of Khat? Is it something youuse/would use, or just something for the oldergeneration?

• What are your experiences of khat use, either byyourselves or by other people? Have these beenpositive or negative? Do you feel there areeffects on health?

• What do you think are the main issues facingSomali youth in Lambeth today?

• How much of an issue is crime for you? Whendo you feel unsafe in Lambeth? Do you feel youare targeted by the police because you areSomali?

• Do you feel drugs are an issue for Somali youth?Have you, or someone you know, ever useddrugs?

• Who would you turn to if you had a problem witha) khat use b) drug or alcohol use? Who wouldyou like to be able to turn to?

• How do you feel about services generally(health, housing, jobcentre etc) in Lambeth?What do you think could be done to makeservices better for the Somali community?

• Do you have any other concerns?

2MEN’S FOCUS GROUP

• What do you think of khat? Is it something youuse/would use?

• What are your experiences of khat use, either byyourselves or by other people? Have these beenpositive or negative?

• What do you feel the impact of khat use on healthis? And what about work/ family and social life?

• How do you feel about the younger generationusing khat? And what about women using khat?What are your concerns about Somali youth?

• How much of an issue is crime for you? Do youfeel vulnerable in Lambeth? If so, how?

• Are you concerned about drug use in the Somalicommunity? Is this something you think affectsonly the younger generation? What can be doneto improve the situation?

• Who would you turn to if you, or someone youknew, had a problem with a) khat use b) drug oralcohol use? Who would you like to be able toturn to?

• How do you feel about services generally(health, housing, jobcentre etc) in Lambeth?What do you think could be done to makeservices better for the Somali community?

• Do you have any other concerns?

51CHEWING IT OVER

APPENDIX 2 FOCUS GROUP THEMES

3WOMEN’S FOCUS GROUP

• What do you think of khat use? Is it somethingyou would ever use yourself?

• What are your experiences of khat use, either byyourselves or by other people? Have these beenpositive or negative?

• What do you feel the impact of khat use on healthis? And what about work/ family and social life?Do you feel there is a link between khat use andproblems in marriage or family? What aboutdomestic violence?

• How do you feel about the younger generationusing khat? And what about women using khat?What are your concerns about Somali youth?

• How much of an issue is crime for you? Do youfeel vulnerable in Lambeth? If so, how?

• Are you concerned about drug use in the Somalicommunity? Is this something you think affectsonly the younger generation? What can be doneto improve the situation?

• Who would you turn to if you, or someone youknew, had a problem with a) khat use b) drug oralcohol use? Who would you like to be able toturn to?

• How do you feel about services generally(health, housing, jobcentre etc) in Lambeth? Doyou think services meet the needs of women inparticular? What do you think could be done tomake services better for the Somali community?

• Do you have any other concerns?

4ELDERS’ FOCUS GROUP

• What do you think of khat? Is it something youuse/would use?

• What are your experiences of khat use, either byyourselves or by other people? Have these beenpositive or negative?

• What do you feel the impact of khat use on healthis? And what about work/ family and social life?

• How do you feel about the younger generationusing khat? And what about women using khat?

• How much of an issue is crime for you? Do youfeel vulnerable in Lambeth? If so, how?

• What are your concerns about Somali youth?

• Are you concerned about drug use in the Somalicommunity? Is this something you think affectsonly the younger generation? What can be doneto improve the situation?

• Who would you turn to if you, or someone youknew, had a problem with a) khat use b) drug oralcohol use? Who would you like to be able toturn to for help?

• How do you feel about services generally(health, housing, jobcentre etc) in Lambeth? Arethe needs of the older generation being met?What do you think could be done to makeservices better for the Somali community, andfor the older generation in particular?

• Do you have any other concerns?

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