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The Use of(Catha edulis) in Yemen Social and Medical
Observations
Wijdan Luqman, B.Sc., M.B.Ch.B. (Edin); and T. S. Danowski, M.D., F.A.C.P.
(1975). Annals of Internal Medicine 85:246-249.
Catha edulis, or khat, a plant indigenous to Yemen, Ethiopia, and East Africa,
has sympathomimetic and euphoriant effects. Its role in the economic,
social, and political lives of people in North and South Yemen and certain
clinical and psychiatric aspects are discussed.
In North and South Yemen, khat is more than aplant. It is the
basis of a life style and plays a dominant role in celebrations, marriages, and
political meetings. Indeed,from khat results in social isolation.
Use of khat has increased concurrent with -the advent of modern medicine,
customs, and education. One of us (W.L.) has observed the khat
phenomenon both as a native and as a physician.
Khat grows best at 3000 to 6000 feet above sea level and reaches a height
of 20 feet. It is seedless, and this may explain its limitation to the Yemens
and nearby Ethiopia and East Africa. Though it is considered to be a thirsty
plant, during droughts it grows when other crops fail. Its leaves and twigs
can be harvested throughout the year.
The demand for and the price of the khat plant vary with the soil and climate
in which it is grown. In South Yemen, the price of the two common varieties,
the Dhali and the Yaffee-named after the areas in which they grow-is low,
reflecting their lower appeal. In North Yemen, with its larger agricultural
areas and numerous varieties of khat, the Taizi, Shami, Sawti, Khat al Wadi,
Sharwa-with qualities dependent on the highlands where they are raised-the
greater rainfall is said to have different effects. Thus, the Yaffee variety of
South Yemen is believed to produce more insomnia and occasional
hal ucinations. Those grown in North Yemen may elicit more or less
depression, and aphrodisia. These, however, are regional or
personal preferences and are difficult to evaluate.
Irrespective of which variety is used, khat is an expensive habit. In 1955 the
money spent on khat in the 75 square miles of the original Aden Colony
(now the capital of South Yemen) exceeded 40 million shillings (five million
dol ars). Most of this represented expenditures for khat imported from
Ethiopia daily by air.
Khat Gatherings
Yemenite homes are constructed to provide a warm reception room for khat
chewing. In keeping with the total segregation of the sexes at social
functions, women are excluded. However, women do hold their own khat
sessions, but they are much less frequent. At either event, the guests are
distributed in accord with their familial, social, or political importance and
prestige. Drafts interfere with comfort at a khat gathering, and hence the
choice places are those farthest removed from the doors and windows.
The chewers lean against three or four special y made large and hard
pillows. Each side of the room accommodates six to 10 persons, and
occasional y up to 20. One or two communalpipes or "hubble-
bubbles" stand in the center. Each consists of a tobacco bowl, a 3- or 4-foot
high metal pipe, a water filter, and a 20-foot long flexible tube. The tobacco
is ignited with a layer of charcoal, and the flexible tube is passed from guest
to guest. Each must limit himself to a few puffs because excesses produce
dizziness, tremulousness, palpitations, and severe nausea.
During such khat sessions, drinks are available, that is, cola, weak black tea,
or just cold water.
IN THE CITIES AND TOWNS
Urban khat sessions usually begin soon after lunch. The chewers prefer fresh
leaves, and they are therefore purchased just before or after lunch. Purchase
of the leaf matches the acumen of the habitual chewer against the sel er's
attempts to peddle yesterday's leaf. The expert khat buyer first shakes and
smel s the sui)t)ly because fresh leaves do not fall off and have a
characteristic odor. Arguments about price may involve shouting and
pushing, but violence is rare. Once the khat has been acquired, the
customer leaves with a smile of satisfaction and anticipation.
The chewing session starts with slightly euphoric behavior and a friendly
sense of humor. The leaves are plucked off the twigs, chewed, and stored
against one or the other cheek. The mixture of saliva and extract from the
leaves is swallowed. As new leaves are taken, the cheek bulges out. The
euphoric effects appear shortly after the chewing begins, suggesting
absorption through the oral mucosa. The session and the friendly
atmosphere last about 2 h. These are followed by a mood of zeal that lasts
another 2 h, and during this interval current subjects and problems are
discussed. This in turn is supplanted by a serious mood and may be
accompanied by irritability.
IN THE RURAL AREAS
In the country the chewing of khat starts earlier, that is, soon after
breakfast, and continues throughout the day. Even the children chew khat.
The stimulant effect lightens the daily tasks. In such regions, food,
education, medicine, and recreation are lacking. The anorexiant effect of
khat decreases the need for the midday meal or even the evening meal and
assumes a major role in day-to-day living.
Behavioral Changes
Khat-engendered abnormal behavior develops in only a minority of the users
but is socially acceptable. It is at least in part dose-related and may include:
[1] withdrawal in "psychotic seclusion" and solitary wandering in the bush or
by the sea; [21 garrulous speech using impressive words that do not fit the
context, distinguishable from schizophrenia only in that it is transient and
the speaker can e made aware of its incongruity; and [3] aggressive verbal
outbursts.
Religion and Khat
The Moslem faith of the Yemenites forbids intoxicants other than those
prescribed for medical reasons. However, the Koran mentions onlyperhaps because use of khat did not become widespread until after
occupation by the Ottoman Turks in -the sixteenth century*.
Other countries in the Middle East impose heavy penalties equivalent to
those fororon anyone who carries or uses khat. This is not
so in Yemen, where even religious leaders may practice the habit. This may
be because, in contrast to opium and cannabis, khat produces milder
antisocial behavior and is more akin to amp tamine- or caff eine-type
substances.
Khat as a Political Issue
In 1957 a legal ban on khat, instigated by the Adeni Political Party and a few
educated politicians, was imposed in Aden in South Yemen (then the British
Aden Colony). Vil ages bordering Aden then received thousands of visiting
khat chewers daily and prospered. Meanwhile, demonstrators in favor of
khat filled the streets of Aden. These demonstrations and processions were
nonviolent but abusive -and reflected the agitated depression that follows
the withdrawal of khat. The Adeni Party collapsed over the khat issue, and
the ban was lifted in 1958. However, khat continued as a major factor in the
political campaigns of Aden. Such comments as "he is anti-khat" or "pro-
khat" were frequent, especially before the elections.
By September 1972 political tension had developed between North and
South Yemen. The North Yemen Government then proposed a ban on khat
with the hope of alleviating some of the tension in North Yemen. The radio
and government media put on a massive anti-khat campaign. Nevertheless,
war broke out in September 1972 but lasted only 1 week. Shortly thereafter,
the anti-khat campaign died.
Clinical Implications
Fluckiger and Geroc first found anin khat in 1887 and called it katin.
Subsequent research identified five fractions, namely cathine, cathinine,
cathidine, edulin, and ephedrine. Of these, cathine proved to be ( + )
norpseudoephedrine, and it may be the most important ingredient ( I ).
Subsequent studies of fresh leaves have isolated another alkaloid similar to
(+ ) norpseudoephedrine but with different chemical stability. This might be
a precursor of cathine. This may explain the chewers' preference for the
fresh leaf (1). It is not clear, however, if all of the active ingredients in khat
have been identified or if the pharmacology of those recognized to date has
definitive application to man. Khat also contains tannin (7% to 14% by weight in dried leaves), vitamin C (150 mg/100 g of fresh leaves), and minute amounts of thiamine, niacin, riboflavin, and carotene, as wel as iron and amino acids.
Halbach (1), in his review of the pharmacology and clinical actions of khat,
concluded that its effects reflected largely its sympathomimetic ingredients.
He postulated that the spectrum of its actions lay between the
amphetamines and This premise was based on the predominant
component identified to date, that is, (+ ) norpseudoephedrine rather than
knowledge of al of its ingredients and their pharmacologic manifestations.
Also, the data cited covered a span of 2 decades and antedated the more
recent identification of alpha- and beta-adrenergic receptors, blockers, and
modifiers. In the absence of more definitive information, one can only cite
clinical observations*t and continue with hypotheses concerning clinical
disorders in the users of khat.
THE SETTING FOR A PSYCHOTROPIC AGENT
In the rural areas of North Yemen, perinatal, infant, and childhood death
rates still equal or exceed 50%. Also, the life expectancy of adults is
curtailed to an unknown degree. Chronic illnesses, infections, and
malnutrition remain the rule rather than the exception. The revolution in
1962 was fol owed by 8 years of civil war, which may have at times further
increased human suffering. These many burdens, the death of relatives,
drought, and famine have provided an understandable setting for a
euphoriant such as khat.
MENTAL AND EMOTIONAL EFFECTS
Schizophrenic behavior has been observed by one of us during and after use
of khat. This disappears within several days. It may be more frequent in
those with latent psychoses. Similar reactions and schizophrenia and
paranoia follow chronic ingestion of amphetamines (1, 2).
The occurrence of possible long-term schizophrenic reactions to khat is
difficult to assess. Health facilities are lacking, persons with psychosis are
usually locked in their homes by their families, and medical opinion is only
rarely sought.

Known schizophrenic patients are frequent chewers of khat. It would appear
that they have more difficulty in control ing or stopping the use of khat.
However, those who do quit seem to make better social adjustments and are
more amenable to treatment and rehabilitation. In others, the use of khat
probably aggravates the intensity of the schizophrenic problem.
Khat may interact withused in therapy of other diseases and produce
emotional and mental disorders; for example, when combined with
niridazole-aused in treating schistosomiasis-severe anxiety reactions,
insomnia, and even psychoses can develop. Such reactions are less frequent
with niridazole alone.
Khat interferes with sleep. Most khat chewers can estimate the quantity they
need to produce the desired effects without insomnia. The beginners always
chew lesser quantities. Tolerance then develops, and most chronic chewers
cease to experience the initial insomniac effect.
Some use khat, but only infrequently, for its insomniaproducing effect. This
avoids the tolerance and enables them to work an additional hour or two at
night.
Students are frequent users of khat. With improvement in education, the
new generation of students favors the ban on khat even though they
continue to chew the leaves before examinations. During the last campaign
against khat, some writers used it to help them prepare anti-khat articles.
The side effects of khat, especial y the insomnia, have led to a search for
counteracting agents. Perhaps this is why the consumption of tranquilizers
and alcohol has increased. So far, the end-result seems to be a decrease in
side effects and not to find new effects.
WITHDRAWAL FROM KHAT
There are no physical symptoms on withdrawal of the type experienced with
alcohol,or the barbiturates. Abandoning the habit, however, is
followed by depression. This is demonstrated by lack of interest, loss of
energy, and increased desire to sleep. The severity of depression varies and
may lead to agitation and sometimes sleep disturbances. General y, the
overall effect on health is beneficial, and the former users tend to sleep
better and longer. They are less prone to constipation, and they smoke less.
If they drank alcohol, they now drink less, and their appetite increases.
DENTAL AND ORAL HEALTH
Dental cavities are rare among users of khat in Yemen, but this may be
attributable to the low consumption of sweets, fluoride in the water, and the
use of a primitive toothbrush carried on the person, rather than to khat.
Stomatitis is common among those who begin to use khat and persists with
chronic use, producing local irritation and secondary infection. In both
instances, the concomitant smoking of tobacco may contribute to the
stomatitis. Furthermore, such stomatitis in the rural areas may be the result
of vitamin deficiency.
GASTROINTESTINAL AND URINARY TRACTS
Gastritis is common among users of khat (1). It responds readily to
antacids. In the few instances in which X-ray films were available and
revealed ulceration, gastric ulcers exceeded those in the duodenum in
frequency. An antispasmodic action of khat on the fundus and pylorus could
account for the higher incidence of gastritis and gastric ulcers, but this
requires documentation.
Some patients with X-ray-proven ulcers reported that khat decreased ulcer
pain. Also, the frequent intake of fluids probably provided some relief.
Irrespective of active ingredients in the leaves, the chewing of khat and the
resultant secretion of saliva may decrease the acidity of the gastric contents.
Constipation is frequent in both North and South Yemen. It is often
accompanied by hemorrhoids. It may be that khat is partially responsible for
the constipation, perhaps because its tannin content has an astringent effect
on the bowel (I ). Irrespective of the cause, it is of interest that during the b
' an on khat imposed in 1957 in Aden, the sale of laxatives decreased by
90% (1). The constipation of users of khat appears to be relatively resistant
to ordinary laxatives administered in usual dosage. On the other hand,
paralytic ileus has also been attributed to the ingestion of khat.
One of us has observed urinary retention that developed during use of khat
by a dentist in his twenties. Hence, it is possible that khat produces
hypotonia of the smooth muscle of the urinary bladder.
Cirrhosis of the liver is frequent in the natives of the two Yemens, but it is
not clear that khat plays a role in its high frequency. It has been suggested
that the tannin present in khat has a hepatotoxic effect (1). However, in
Yemen other factors could account for the cirrhosis, including malnutrition,
schistosomasiasis, infectious hepatitis, and enteric diseases.
CARDIOVASCULAR SYSTEM
During a khat session, the extremities of the user feel cold and he complains
of drafts, and this may be followed II)y palpitations andhat
also can raise the blood pressure (1). Such increases are generally not
marked, and severeis not observed. These could represent
vasoconstrictor and cardiac effects due to sympathomimetic compounds in
khat, but the participants also ingest caffeine and smoke tobacco.
are not to be used with khat for the usual
reasons, that is, hypertensive effects. Coronary artery disease seems to be
less common in Yemen, but definitive statistics are lacking.
RESPIRATORY SYSTEM
Some users of khat report relief from asthmamatics who use khat also state
that theophyl ine taken in therapy of an attack produces tremors and
palpitations, effects known to occur with ephedrine. it may be that (+)
norpseudoephedrine in khat is responsible for the synergism.
ENDOCRINE ASPECTS
A staring look, or pseudoexophthaimus, is characteristic of users of khat,
especially after a substantial quantity of of khat has been chewed. In
addition to the stare, the conjuncative become congested and the pupils
dilate (1). The chemosis is aggravated by the hot, humid, and smoke-filled
atmosphere of the khat chamber.
The overall effect of khat on diabetic patients is deleterious. The anorectic
effect of khat leads to omission of the evening meal. also, the user is less
likely to fol ow dietary advice, and the consumption of sweetened beverages
with khat aggravates the hyperglycemia.
Nursing mothers in North Yemen frequently complain of poor lactation. This
could be related to the use of khat. Levodopa, the precursor ofand norepinephrine, is an inhibitor of prolactin secretion (3). This raises the
possibility that (+)norpseudoephedrine acts on the same receptor sites.
This, with the rarity of bottle-feeding and the anorectic effect of khat on the
mother, interferes with the nutrition of infants.
Khat chewers claim varying effects on their sex life, but most report delay in
the ejaculation phase. This is used to treat premature ejaculation. Some say
that khat is an aphrodisiac. The overall potency, however, is lowered. Many
khat chewers report a spontaneous secretion of spermatic fluid. This process
is referred to locally as "sollass."
Khat may enhance sexual activity in the depressed person. On the other
hand, khat may exacerbate or accentuate anxiety states. Many variables
affect sexual behavior, and this probably accounts for at least part of the
varying and conflicting effects of khat. Finally, it may or may not be true
that the different varieties of khat affect sexual behavior differently.
ACKNOWLEDGMENTS: Received 1 December 1975; revision accepted 19
March 1976.
References
1. HALBACH H: Medical aspects of the chewing of khat leaves. Bull WHO
47:12-19, 1972
2. BEESON PB, McDERMOTT W (editors): Cecil-Loeb Textbook of Medicine,
13th ed. Philadelphia, W. B. Saunders Co., 1971, pp. 107-149
3. DICKEY R, STONE S: Drugs that affect the breast and lactation. Clin
Obstet Gynecol 18:95-111, 1975 Read more:

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