REDUCING ALCOHOL RELATED HARMS IN REDUCING ALCOHOL RELATED HARMS IN SETTINGS OF NONSETTINGS OF NON--COMMERCIAL ALCOHOL COMMERCIAL ALCOHOL PRODUCTION: A CASE STUDY OF KAKUMA PRODUCTION: A CASE STUDY OF KAKUMA

REFUGEE CAMP AND SURROUNDING REFUGEE CAMP AND SURROUNDING COMMUNITY, KENYACOMMUNITY, KENYA

Paper presented by Paper presented by

PROFESSOR MORUF ADELEKAN PROFESSOR MORUF ADELEKAN CONSULTANT PSYCHIATRISTCONSULTANT PSYCHIATRIST

c/o ROYAL BLACKBURN HOSPITALc/o ROYAL BLACKBURN HOSPITALBLACKBURN, BB2 3HHBLACKBURN, BB2 3HH

UNITED KINGDOMUNITED KINGDOM

At theAt the1818thth International Conference on the International Conference on the

Reduction of Drug Related Harm, Warsaw, Reduction of Drug Related Harm, Warsaw, Poland, 13Poland, 13--17 May 200717 May 2007

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

INTERNATIONAL CENTER FOR ALCOHOL INTERNATIONAL CENTER FOR ALCOHOL POLICIES (ICAP) FOR SPONSORING MY POLICIES (ICAP) FOR SPONSORING MY PARTICIPATIONPARTICIPATION

UNHCR/WHO GENEVA, FOR PERMISSION UNHCR/WHO GENEVA, FOR PERMISSION TO USE KAKUMA STUDY FINDINGS FOR TO USE KAKUMA STUDY FINDINGS FOR THIS PRESENTATIONTHIS PRESENTATION

PROFESSOR GERRY STIMSON FOR INITIAL PROFESSOR GERRY STIMSON FOR INITIAL INVITATIONINVITATION

OUTLINE OF PRESENTATIONOUTLINE OF PRESENTATION

DEFINITIONSDEFINITIONS

KAKUMA CASE STUDYKAKUMA CASE STUDY

WHICH KNOWN WHICH KNOWN INTERVENTIONS ARE INTERVENTIONS ARE APPLICABLE IN KAKUMA?APPLICABLE IN KAKUMA?

CONCLUSION ON CONCLUSION ON IMPLICATION FOR POLICY IMPLICATION FOR POLICY AND INTERVENTIONS IN AND INTERVENTIONS IN SIMILAR SETTINGSSIMILAR SETTINGS

ALCOHOL AS A GLOBAL BURDEN ALCOHOL AS A GLOBAL BURDEN OF HEALTH (WHO)OF HEALTH (WHO)

Responsible for an estimated 774,000 Responsible for an estimated 774,000 deaths per year deaths per year

Constitutes an estimated 3.5% of the Constitutes an estimated 3.5% of the total burden of disease using the total burden of disease using the disability adjusted life years lost disability adjusted life years lost (DALYS) method (DALYS) method

Developed countries face larger Developed countries face larger problems due to alcohol at present, problems due to alcohol at present, although rate of rise is highest for although rate of rise is highest for developing countriesdeveloping countries

Developing countries have fewer Developing countries have fewer resources to take care of the additional resources to take care of the additional burden, hence face a massive burden, hence face a massive challenge in the coming yearschallenge in the coming years

NONNON--COMMERCIAL ALCOHOL (NCA)COMMERCIAL ALCOHOL (NCA)

Also sometimes called Also sometimes called ““MoonshineMoonshine””, , ““IllicitIllicit””, , ““IllegalIllegal”” or or ““UnrecordedUnrecorded””alcoholalcohol

Traditionally produced in homes and Traditionally produced in homes and villagesvillages

Fermentation +/Fermentation +/-- distillation of seeds, distillation of seeds, grains, fruits, vegetables of palm tree grains, fruits, vegetables of palm tree juicejuice

Varying alcohol content, higher in Varying alcohol content, higher in distilled productsdistilled products

Generally cheaper and more Generally cheaper and more affordable, hence popular among lowaffordable, hence popular among low--income groupsincome groups

May account for as much as 50% of May account for as much as 50% of total alcohol consumption worldwidetotal alcohol consumption worldwide

NON COMMERCIAL ALCOHOL (contd.)NON COMMERCIAL ALCOHOL (contd.)

Production and consumption reported from Production and consumption reported from several countries across the globeseveral countries across the globe

Illegal in many countries, not so in othersIllegal in many countries, not so in others

Not always injurious to health in many Not always injurious to health in many countries where quality of preparation is countries where quality of preparation is assured.assured.

May be contaminated by toxins from May be contaminated by toxins from production materials (lead, production materials (lead, gylcolgylcol) or ) or additives for potency (e.g. methanol, additives for potency (e.g. methanol, formalin, battery acid, chicken parts) formalin, battery acid, chicken parts)

Several newspaper headlines available on Several newspaper headlines available on clusters of major complications: blindness, clusters of major complications: blindness, diarrhoea, death resulting from unhygienic diarrhoea, death resulting from unhygienic or contaminated NCAor contaminated NCA

NCA has strong historical, cultural and NCA has strong historical, cultural and sociosocio--economic links to the lives of the economic links to the lives of the people in many countries people in many countries –– hence difficult hence difficult to controlto control

KAKUMA: THE CASE KAKUMA: THE CASE STUDYSTUDY

MAP OF AFRICA SHOWING MAP OF AFRICA SHOWING KENYAKENYA

MAP OF KENYA SHOWING MAP OF KENYA SHOWING KAKUMAKAKUMA

The The KakumaKakuma ProjectProject

A joint UNHCR/WHO Geneva Project A joint UNHCR/WHO Geneva Project undertaken in September 2006undertaken in September 2006Part of a Global Assessment of Part of a Global Assessment of Substance Use in ConflictSubstance Use in Conflict--Affected Affected and Displaced Communitiesand Displaced CommunitiesSimilar assessments took place also Similar assessments took place also in Liberia and Thailandin Liberia and ThailandKRC established in 1992 after the KRC established in 1992 after the arrival of 12,000 arrival of 12,000 ““Lost boys/girls of Lost boys/girls of SudanSudan”” and later the Ethiopiansand later the EthiopiansTotal population as of 10 Sept. Total population as of 10 Sept. ’’06 06 was 94,707was 94,707

ECONOMIC CONTEXTECONOMIC CONTEXT

For significant majority: For significant majority: unemployment, idleness and unemployment, idleness and dependencydependencyRefugees cannot officially take up Refugees cannot officially take up paid jobspaid jobsSources of livelihoodSources of livelihood–– BrewingBrewing–– Fund remittance from abroadFund remittance from abroad–– DowriesDowries–– AIG projects (Laundry Soap, AIG projects (Laundry Soap,

Vulnerable Women), Vulnerable Women), –– petty businesses incl. trading, shopspetty businesses incl. trading, shops–– bicycle transportation and repairs, bicycle transportation and repairs,

cyber cafes, hidden prostitutioncyber cafes, hidden prostitution

KAKUMA STUDY:AIMS KAKUMA STUDY:AIMS

To describe the current situation To describe the current situation with respect to substance use and with respect to substance use and related adverse consequences in the related adverse consequences in the KakumaKakuma Refugee Camp (KRC) and Refugee Camp (KRC) and surrounding community (SC), with surrounding community (SC), with particular reference to HIV particular reference to HIV vulnerabilityvulnerability

To identify a range of interventions To identify a range of interventions that can be feasibly implemented to that can be feasibly implemented to minimise the adverse consequences minimise the adverse consequences related to substance use in KRC and related to substance use in KRC and SCSC

KAKUMA: METHODSKAKUMA: METHODS

Rapid Situation Assessment Rapid Situation Assessment (RSA) method comprising:(RSA) method comprising:

–– Secondary data: e.g. reports, Secondary data: e.g. reports, agency documents, publications agency documents, publications etc.etc.

–– Primary data collectionPrimary data collectionDirect observation and mapping of Direct observation and mapping of sites relevant to substance use (6 sites relevant to substance use (6 visits made)visits made)SemiSemi--structured interviews with 19 structured interviews with 19 Key Informants Key Informants Focus group discussions with 17 Focus group discussions with 17 ethnic and other relevant groupsethnic and other relevant groups

Kakuma Refugee Camp by nationalities

80%

13%

5% 2%

SudaneseSomalisEthiopiansOthers

Kakuma Refugee Camp by age distribution

12%

35%

25%

26%

2%

0-4 yrs

5-17 yrs

18-25 yrs

26-55 yrs

>55 yrs

Kakuma Refugee Camp by gender distribution

59%

41%

MalesFemales

FINDINGS ON ALCOHOLFINDINGS ON ALCOHOL

Fermentation of maize/sorghum = Fermentation of maize/sorghum = busaabusaa; ; yeast+wateryeast+water==kaadakaada; Distillation of fermented ; Distillation of fermented millet, maize, sorghum, yeast = millet, maize, sorghum, yeast = changchang’’aaaaKenyan laws: Brewing Kenyan laws: Brewing changchang’’aaaa is illegal, while a is illegal, while a licence is needed to brew/sell licence is needed to brew/sell busaa/kaadabusaa/kaadaProduction and consumption widespread in KRC Production and consumption widespread in KRC and the LCand the LCProduction mainly by women, but consumption Production mainly by women, but consumption by both genders usually > 18 yearsby both genders usually > 18 yearsFactors adduced for massive production include Factors adduced for massive production include economic, cultural, lack of alternative job, ready economic, cultural, lack of alternative job, ready market, ready availability of ingredients from market, ready availability of ingredients from food rations and easy technologyfood rations and easy technologyConsumption is associated with multiple Consumption is associated with multiple physical, social and psychological complicationsphysical, social and psychological complicationsConsumption also goes hand in hand with Sex Consumption also goes hand in hand with Sex Work with little or no attention to safe sexual Work with little or no attention to safe sexual practices practices Level of awareness about adverse consequences Level of awareness about adverse consequences lowlowPolice interdiction is the only currently available Police interdiction is the only currently available intervention and it is ineffectiveintervention and it is ineffectiveThere is low capacity to address the problem in There is low capacity to address the problem in the service agenciesthe service agencies

1

11

1

1

1

1

2

2

2

2

2

3

3

4

4

5

5

6

6

7

7

Sudanese

Somalis

Ethiopians

Burundi

Congolese

Rwandese

Ugandans

Multinationals

1

1

1

1

11

1

1

1

1

2

2

2

22

3

3

4

4

5

5

6

6

7

7

Sudanese

Somalis

Ethiopians

Burundi

Congolese

Rwandese

Ugandans

Multinationals

Drug Hot-spots

2

1

1

11

11

1

1

2

2

2

2

2

3

3

4

4

5

5

6

6

7

7

Sudanese

Somalis

Ethiopians

Burundi

Congolese

Rwandese

Ugandans

Multinationals

Drug Hot-spots

Chang’aa

Miraa

CHANGCHANG’’AA :ADVERSE EFFECTSAA :ADVERSE EFFECTS

PHYSICALPHYSICAL–– Makes baby drowsy through breastfeedingMakes baby drowsy through breastfeeding–– Weakens immune system and general body Weakens immune system and general body

strength strength –– TB, diarrhoea, tremorsTB, diarrhoea, tremors–– loss of weightloss of weight–– Abdominal ulcersAbdominal ulcers–– Liver cirrhosisLiver cirrhosis–– Sudden deathSudden death

SOCIALSOCIAL–– Reckless sexual activity, CSW and inability to Reckless sexual activity, CSW and inability to

engage in safe sex, hence increased chances of HIV engage in safe sex, hence increased chances of HIV infection infection

–– Violence, fights, traumasViolence, fights, traumas–– Sexual offences: rape, defilement etcSexual offences: rape, defilement etc–– Domestic violenceDomestic violence–– Divorce and separations commonDivorce and separations common–– Diversion of family resourcesDiversion of family resources–– Food insecurityFood insecurity–– Poor family planningPoor family planning

PSYCHIATRIC/PSYCHOLOGICALPSYCHIATRIC/PSYCHOLOGICAL–– BizzareBizzare and abnormal behaviourand abnormal behaviour–– Seeing strange things and responding to voices Seeing strange things and responding to voices –– Sleeping rough on the streetsSleeping rough on the streets–– Depression and SuicideDepression and Suicide

BusaaBusaa fermentationfermentation

ChangChang’’aaaa Production in KRCProduction in KRC

Busaa/ChangBusaa/Chang’’aaaa in in ““Hong KongHong Kong””

BusaaBusaa Hut in Hut in KambiKambi InamaInama (LC)(LC)

OTHER SUBSTANCES USEDOTHER SUBSTANCES USED

MiraaMiraa or or KhatKhat chewing found mostly in the chewing found mostly in the Somali communities, also Ethiopian Somali communities, also Ethiopian

Use of sleeping tablets common among Use of sleeping tablets common among MiraaMiraa users to help them sleep. users to help them sleep.

Bhang or Cannabis done discretely by Bhang or Cannabis done discretely by young people in view of heavy penaltyyoung people in view of heavy penalty

No evidence of use of heroin or cocaine use No evidence of use of heroin or cocaine use or injecting of sameor injecting of same

Some Current Drug Users report they sniff Some Current Drug Users report they sniff organic solvents and use ephedrineorganic solvents and use ephedrine

WHICH KNOWN INTERVENTIONS ARE APPLICABLE WHICH KNOWN INTERVENTIONS ARE APPLICABLE IN KAKUMA?IN KAKUMA?

POLICE INTERDICTION AND DESTRUCTION POLICE INTERDICTION AND DESTRUCTION OF EQUIPMENT/APPARATUS AND ALCOHOL OF EQUIPMENT/APPARATUS AND ALCOHOL ××

PRICE INCREASE PRICE INCREASE ××

RESTRICTIVE METHODSRESTRICTIVE METHODS–– Age Age ××–– Outlets/Public settings ? Outlets/Public settings ? ××–– ServersServers’’ trainingtraining√√

DETERRENTS: DRINK DRIVING LAWS, DETERRENTS: DRINK DRIVING LAWS, PUBLIC DRUNKENNESS LAWS PUBLIC DRUNKENNESS LAWS ××

ACCESS TO AFFORDABLE BRIEF ACCESS TO AFFORDABLE BRIEF TREATMENT AND REHABILITATION TREATMENT AND REHABILITATION √√

WORK PLACE MEASURES WORK PLACE MEASURES ××

RESTRICTION ON ADVERTISEMENTS RESTRICTION ON ADVERTISEMENTS ××

INTERVENTIONS (contd.)INTERVENTIONS (contd.)COMMUNITY DEVELOPMENT IN GENERAL COMMUNITY DEVELOPMENT IN GENERAL TO ENCOURAGE ALTERNATIVE ACTIVITIES TO ENCOURAGE ALTERNATIVE ACTIVITIES √√ALTERNATIVE INCOME GENERATING ALTERNATIVE INCOME GENERATING ACTIVITIES ACTIVITIES √√

TARGETED EDUCATION AND PERSUASION TARGETED EDUCATION AND PERSUASION AIMED AT HIGH RISK GROUPSAIMED AT HIGH RISK GROUPS

Brewers, Sex Workers, Other adult Brewers, Sex Workers, Other adult and young consumers, Motorcyclists and young consumers, Motorcyclists √√

PUBLIC EDUCATION PROGRAMMES AIMED PUBLIC EDUCATION PROGRAMMES AIMED AT THE COMMUNITY AT LARGE AT THE COMMUNITY AT LARGE √√

Mass media and Social Marketing Mass media and Social Marketing CampaignsCampaigns

MAINSTREAMING into other MAINSTREAMING into other programmesprogrammes √√

TRAINING (NGO staff, youth groups, TRAINING (NGO staff, youth groups, community and religious leaders) community and religious leaders) √√

CONCLUSIONSCONCLUSIONS

In view of the hidden nature of the In view of the hidden nature of the production and consumption of NCA production and consumption of NCA and the strong link to socioand the strong link to socio--cultural cultural and economic factors, conventional and economic factors, conventional control measures (higher taxes, control measures (higher taxes, restriction on availability etc) may restriction on availability etc) may not always be practicable.not always be practicable.

Depending on the contextual factors Depending on the contextual factors (historical, cultural, socio(historical, cultural, socio--economic, economic, legal) that are involved in the legal) that are involved in the production and consumption of NCA production and consumption of NCA in different parts of the world, in different parts of the world, innovative harm reduction measures innovative harm reduction measures could still be implemented to reduce could still be implemented to reduce associated adverse consequences.associated adverse consequences.