Yemen

Life in Yemen

Dr.Thomas Antony

It was lunch time, the sun at its peak, and I was just about to enter our residential building. Just then I saw a shining Land Cruiser parked opposite to the gate, on an otherwise empty road, and a few westerners walking around, taking photos. I wondered if they were trying to locate the sea through some gap amid the buildings, when one gentleman wished me in Arabic. I returned the greeting and gestured to them how they could go to the beach. "Oh, you speak English!” He seemed surprised as he walked towards me. The others were three middle aged plump ladies in T-shirts and pants chatting with a local person.

He said he was Irish, now retired from a bank. The ladies with him were British. They all have come to Yemen on a short visit. This was a trip prompted by nostalgia, as all of them had spent their childhood here, in the late fifties or early sixties. They were the children of those who built the refinery in Aden or the first employees there.

By the beach he could find the old house where his tender memories lived. Occupied by natives, there was a tall compound wall around it now. It had been just a fence earlier. He was upset he was not allowed even a walk around the house by its present resident. That freedom cannot be allowed now; it is considered an intrusion into their privacy. Life has changed much and the old sparkle is gone.

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The British came here in 1839, made Aden their military base and built the refinery. They had to leave in 1967 when Peoples Democratic Republic of Yemen (South Yemen) was formed. This place built connections with other socialist countries. Some migrated to UK, some have dual citizenship.

North and South Yemen were separate countries, but they united in 1990. The communist government gave way to presidential rule. And a civil war in 1994 sent many foreigners back to their homeland.

The colours of western civilization left by the British occupation and the socialist regime in South Yemen were drowned by the inflow of orthodox culture from the North, after unity. All women began wearing black cloak that covered them head to foot. It is called 'abaya'. Some add a veil over the face. More and more young men accepted orthodox lifestyle, growing beards and covering the head, while most of their parents still sport clean shaven faces, with a hair combed neat.

One sees people from many countries in this place. Some have come for work, while others have integrated well into the society. Many Yemenis have studied abroad and could pick their life partners from there. Yemenis have taken wives from Russia, Ukraine, Czech, Romania and such places. They have a people from different ethnic communities here.

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History of this place dates back 3000 years. I read an article where it says this place is mentioned in the Book of Ezekiel. This is part of the Arabian peninsula which was known as Arabia Felix or 'Happy Arabia'. It was here Queen Sheba reigned. (Seba Kingdom; no idea if the Sebeans were the descendents of Seba, son of Cush (Genesis 10:7) It was from here she went to meet King Solomon, of Israel.

Because of its strategic position Aden has gone through a turbulent past. History also records migration of Yemenis to other countries. Mecca, Syria, Iraq, The Emirates, Spain, Romania, America, Libya, India are some of them. Once we met a malayalee wife of a Yemeni. And I know a malayalee who has married a Yemeni woman.

In spite of its rich culture and traditions, Yemen remains a poor cousin of the Arab world. The very rich here have mansions and most modern cars. And there are the very poor who find life a struggle. A strong middle class, so important for the economic development of any country (so I am told) is missing. For advanced medical treatment one has to go abroad, very often India or Jordan. There are government free hospitals, but medical treatment on the private side, whatever available, is costly.

However, the average Yemeni manages to remain happy. It is very rare to see them quarrel or fight. It is difficult to find rudeness or arrogance in them. If you hear shouts or loud conversation, be assured it is a crowd dispersing after a football match. Don’t let a row of cars with head-lights on and blaring horns panic you; it is a wedding motorcade. Armed with a politeness to disarm you, their pleasant high-spirited nature is transparent. There is an air of tranquility around. Before you know it, you begin to feel at ease with them. And then you realize they are the embodiment of patience. Once, waiting at Aden airport for the Mumbai flight, I was upset by its undue delay by over three hours. More so because of the ‘oh-what's-the-hurry’ attitude around. A hospital employee, who too was booked in the same flight, reassured me happily, "Smile, doctor! You are in Yemen."

Qat in Yemen...

Qat and Yemen

One of the various surprises that greeted me in Yemen was the hugely swollen cheek of men; and I had sincerely hoped to enrich my surgical experience on parotid. But as days went by, I understood that the swelling was not a pathological one. The cheek was filled with chewed leaves of “qat.” I saw them in many places, at work or leisure. On holidays, I could spot them on the beach, market places, or on the verandah of unopened shops, sitting with plastic bag containing a bundle of tender shoots of qat and a big container of water nearby. They sit through long evenings either alone or in company, usually with an arm pillow to rest, one cheek ballooned with qat. Drivers chew it to keep awake; masons and plumbers to get ‘energy’ to work. Merchants chew qat in their shops or stalls, drivers and their passengers in vehicles, and afternoon workers at their job sites.

Legend is that the property of qat was discovered long back in Ethiopia, when shepherds found their sheep unusually active after eating some particular leaves. Though available in most African countries, it is banned in many countries, including USA and Saudi Arabia.

The Experience

Our Chinese anesthesiologist narrated his experience. He said it tasted bitter and he couldn’t keep it more than an hour in his cheek. (The tender leaves and shoots are stripped off the twigs, wiped clean, smacked by the fingers and gently placed between the molars, chewed and moved into the cheek, the fingers busy getting the next leaf ready. The juice is swallowed with water or carbonated beverages. The accumulating ‘cud’ is spat out only after the session lasting 4-5 hrs is over) He couldn’t sleep either that night or next. And mucosal ulcers developed in the cheek mucosa. He hasn’t used it ever since. A nurse from Russia, married to a Yemeni said she uses it on weekends so that she doesn’t feel tired by the extra household work.

Our Yemeni pharmacist tells us it gives ‘good mood’, and that he chews it regularly every evening. He said it is mentioned in Pharmacology books, and narrated the ‘qat ritual’ every Thursday evening. (The weekend here is Thursday and Friday) The master of the house will sit down in the tidied up room with the arm pillow to his side, his wife would have washed and dried the tender qat leaves for her hubby. After a bath, she is already in a beautiful dress, and well perfumed, hair well combed and usually wears a garland of jasmine. There is a twig of some plant with exotic smell tucked into her hair. She sits near him to chat, and pour the water or soda for him. She may or may not use qat herself. He is euphoric, and children find it the best time to get hard demands sanctioned.

In one study 60% of men and 35% of women in Yemen have been found to use qat. Men get together for consumption of qat in the traditional social setting on some afternoons, starting after a heavy lunch. The juice is washed down with water or soda, while animated discussions go on. This provides for interaction and the structuring social life. It is said qat flares imagination and gives "fantasies of personal supremacy." There was an item in newspaper about medical students using this to keep awake and to remember what they read. There are many who acclaim its virtues, while others disapprove the habit. And reports vary regarding the use of qat as an aphrodisiac. There are health hazards.

The Plant

The botanical name of this exotic plant known for its stimulant properties is Catha edulis. It is a shrub or small tree. It is known as Mirra in Kenya, and Chat in Ethiopia and Jad in Somalia. It is used as a recreational drug in the countries which grow them. It is used by farmers and laborers for reducing physical fatigue, and by drivers and students for improving attention. I understand Coca leaf is used in South America similarly. (Remember “Papillon”?)

One should know…

The stimulant property is attributed to the alkaloid cathinone in the plant. It breaks down into cathine and noradrenaline. No wonder it behaves as a sympathomimetic, increasing blood pressure and pulse rate. In the United States, cathinone is listed with heroin and cocaine as a Scheduled drug.

Qat consumption is known to produce euphoria and excitement. It is also said it can induce manic behaviour and hyperactivity. The effects of qat include alertness, energy and euphoria. Some say one relaxes and get intellectually focused. One may undertake skilled tasks and the creatively talented may write poetry. A psychological dependence may develop, but is not considered as an addictive drug. There are no medically accepted benefits of qat. More than the physical high, there is a cultural side to qat -- the qat chewing sessions. In many houses, there are well furnished qat chewing rooms or halls, a show-piece of the house.

Money, money, money..

Qat is cultivated in mountain terraces and most such areas in Yemen are used exclusively for qat. The farms are guarded by armed personnel. Everyday the harvest is transported to the various geographical areas for sale, which will be over by afternoon. The qat chewing session starts after lunch. One bunch can cost about 500 YR to 7000 YR, depending upon the quality. (1 US dollar = 200 YR approx) One bunch will last for one session, lasting about 3-4 hrs. They say the 7K ones are bought by the very rich to offer to their important guests. Government gets a sizeable amount as tax from qat. Yemenis spend a great part of their income on this pleasure. It is said the harvest is not enough to satisfy the domestic need. So, nobody cultivates ‘cash crops’ to fetch dollars.

Many consider this a social evil. An American soldier writes in www.al-bab.com: “Qat is the drug that made the Somalians feel they were invincible to our US Rangers and Delta Forces. ... Because of our military, they overcame this famine. However, this drug made the Somalians unappreciative of our efforts to help. They felt as if they could conquer the world. … Today, their people are still starving. I'm sorry, but we tried.”

Back to square one

As for us medical staff here, the average employee chews qat and don’t sleep at night, comes to the hospital next morning requesting medical leave, as he is “tired”. WHO has listed qat as a "dependence producing drug" The users will attempt to get daily supplies to the "exclusion of all other activities." It is said qat chewing is a near-daily activity for those who can afford it - and sometimes even for those who can't. When the poor man willingly foregoes food in favor of buying qat, his wife and children get neglected thus. So, some request the government to extend the work day in an effort to reduce qat consumption. But advocates of qat feel that Yemenis are not lazy, there is just not enough work to be done.

Qat chewing distinguishes Yemenis from the other Arabs. It is well woven into Yemen culture through the centuries, and affects its economy and happens to be its life.

Headache and the Otolaryngologist

Headache and the Otolaryngologist

Headache is the second most common chronic complaint which general practitioners see in their routine work. It may be the same in ENT outpatient as well. The busy ENT surgeon sees little surgical opportunity in a headache case and pushes the patient to a neurologist. The latter has no excitement in what happens outside the cranium and limit their survey to intracranial causes for headache. Various investigations including Xray PNS, CT scan & MRI scan are usually done to serve the purpose of exclusion, with little benefit to the patient. Since the otolaryngologist clears ‘most’ extracranial causes, the patient may end up with a label of tension/vascular headache. The average doctor is not enchanted by the complaint of headache. Very few medical practitioners take interest in the patient to relieve him of the malady. Headachology is an emerging term as well as the term headachologist [1]

Who manages headache? Usually it is the doctor to whom the patient presents initially, although much depends on the cause of the same in a given patient. If the reason for headache is readily obvious, the patient may be referred to the concerned specialist. There are many specialists who share the territory with Otolaryngologists. Neurologists, Dental Surgeons & Ophthalmologists maynot complete the list. Since the sensation of pain is centrally processed, apart from the Neurologist, Psychiatrist has a role. Systemic infections can cause headache, where an Internist alone can help. All see the same anatomy but may not come to the same conclusions. However, the otolaryngologist remains the single medic who is trained to look into the various nooks and niches of head and neck, which gives him an edge over. To him it is well-nigh easy to rule out ENT causes, and further proceed to look for other reasons for the headache and refer the patient accordingly.

At the turn of the millennium, acquiring a wealth of knowledge and surgical experience in the complex anatomy, ENT surgeon has evolved as the Head and Neck Surgeon. The nasal endoscope, which paved the way to functional endoscopic sinus surgery, has given enlightening information. The otolaryngologist now finds himself in the limelight. It is a historical necessity that he takes a fresh look at what can cause pain in head and neck.

Headache due to infection of the nose and the sinuses is associated with signs that the ENT surgeon knows too well. Septal impaction headache, due to the pressure on the nasal mucosa, between septal spurs or deviations and the lateral wall of the nose, is also familiar to him. So is headache due to mucosal contact in nose. A routine otolaryngological examination may reveal unusual causes of headache as well. When these are excluded, one feels unsure ground. An overview of headache is therefore helpful.

The sad truth is that we donot know enough about headache, with the result that nobody can claim to be an expert. It happens to be the most frequent and ill-understood symptom. There are two international journals viz. “Headache” and “Cephalalgia” dedicated to the subject. Various explanations, theories and classifications have neither been all-inclusive nor conclusive. The terms migraine, vascular headache, tension headache etc have become almost cliché. ‘Migraine’ occasionally has responded to Functional Endoscopic Sinus Surgery.[2]. Maybe, definitions have to be modified. The “International Headache Society” constituted the Headache Classification Committee who has laid down the Classification & Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain. [3] Interest in the entity cervicogenic headache, has given rise to “World Cervicogenic Headache Society” [4]

In simple words, headache [or headache and facial pain] is pain in the Trigeminal territory with contributions from glossopharyngeal, vagus and the first three cervical nerves. The causes of such pain are extracranial or intracranial. The extracranial causes are the stimulation of skin, subcutaneous tissue, muscles, arteries, periosteum of skull, structures of eye, ear and nasal cavity. Intracranial causes are traction and displacement of venous sinuses, large veins or their dural envelopes, or distension, dilatation and traction of arteries. The brain substance is not sensitive to pain. Part of the dura at the base of the brain, is sensitive. Irritation of the 5^th, 9^th and 10^th cranial & and first three cervical nerves too generate pain. The pathophysiologic mechanism varies. A detailed discussion of the same is beyond the scope of this communication.

The patient may present at the time of headache, or with just history. Good history and clinical signs help diagnosis and management. As a rule localised headache is of greater significance than diffuse headache. The patient may not tell about the duration, character, intensity, relieving and aggravating factors or associated symptoms, unless specifically asked for. The clock-work pattern of sinus pain, episodic nature of migraine, constant or evening worsening of tension headache, the projectile vomiting of ICSOL and bizarre nature of psychogenic headache are all clues to watch for. In refractive errors the headache follows office work, studies or movies.

Is it the first ever or recurring? Either way, symptoms & signs of intracranial and extracranial disease have to be searched for.

One has to be vigilant about the first ever headache. A subarechnoid haemorrhage has to be ruled out. Classically, such headache tends to be explosive and intense & spreads to the back of the neck. There will be photophobia, projectile vomiting and neck rigidity. A leak may not show up in CT scan until 6 hours have passed. A space occupying lesion can give localised headache in the early stage and later, signs of intracranial tension. The headache associated with an expanding intracranial lesion is usually relatively mild; the associated symptomatology is often more prominent than the headache. Occipital headache on waking suggests ICSOL. The headache due to intraventricular and posterior fossa tumors maybe accentuated by changes in head position, coughing, and Valsalva maneuver. Headache with alteration in the level of consciousness definitely demands neurological evaluation. A subdural haematoma may show up only 3 mths after a blow; the incident long forgotten. If there is no clue in symptoms and signs, CT scan can come to the rescue. Meningitis, epidural haematoma, glaucoma and sinusitis also have to be excluded in a first time headache.

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Lesions of the cervical spine and its ligaments can give occipital, sometimes frontotemporal headache; examination of the neck is therefore necessary. Myofascial pain of head and neck will show local tenderness. A chronic bifrontal, bitemporal or occipital headache, always or towards evening, is more often muscle contraction headache; sustained contraction of neck and eye muscles occur in faulty posture. Tension headaches are described as pressing, squeezing, tight or heavy. The contracted muscles may be tender.

Among neuralgias, trigeminal neuralgia is the most common and is evident by the history, and presence of trigger zones. Dental infections and impacted tooth can give unilateral headache and referred otalgia. So do temporomandibular joint disorder. Temporal arteritis is rare; usually it is an elderly female. The scalp arteries are tender and thrombosed, ESR is high. Cluster headache also is rare and affects males. It is intense, non-throbbing with unilateral orbital localization frequently occurring 2-3 hours after falling asleep, although it may occur in working hours. It is described as a cluster of attacks lasting a few weeks. Accompaniments are lacrimation, blocked nostrils, rhinorrhoea and sometimes flush and oedema of face. The headache tends to recur after many months or years.

Migraine also is a recurring headache found more in teenagers and young adults. Prodrome and aura can occur in migraine. Vascular headaches are usually throbbing or pounding. The patient is normal between attacks. There may be a strong family history too. Severe hypertension is also known to cause headache. Psychogenic factors like anxiety and depression can cause poorly localised headaches. Sleep disorders point to such ailment. Finally, headache may be a symptom of even schizophrenia.

It has been said that except for auscultation of a bruit and palpation of thickened arteries, examination of the head during or between headaches yields little useful information. The Otolaryngologist, as mentioned earlier, is well adapted to examine head and neck. He can draw his own unbiased conclusions. So, after getting the history, the ENT examination should rule out deviated nasal septum and spurs, mucosal contact in the nose, and signs of involvement otherwise, of nose and sinuses. Apart from sinus tenderness, a stoop may worsen the headache or give a weighing down feel on forehead or face, when the sinuses are infected. If presenting at the time of headache, a Xylocaine test can be done, provided there is no sign of infection. This is done by inserting a cotton wool probe soaked in Xylocaine [2% or 4%], between the lateral wall and the nasal septum where they touch each other, to see if the same aborts headache. [Examination of the neck for limitation of movements, neck rigidity, and myofascial tenderness of temporalis or nuchal muscles, recording of blood pressure, and fundoscopy for papilloedema can also be routinely done.] He can supplement his findings with endoscopic examination of nose and sinuses. Xray PNS and Coronal CT of nose and sinuses give more information when required.

Management depends on the cause of headache; a full discussion is beyond the scope of this article. Suffice to say there are situations when surgical treatment is offered by the otolaryngologist for the relief of headache. Functional Endoscopic Sinus Surgery treats many rhinogenic & sinu-genic headache. A septal surgery takes care of a septal impaction headache. Sometimes operation on a sinus, or removal of a growth or polyp in the nose is what is required to relieve headache. It may even be an unusual procedure depending on a surprise finding at head & neck examination. A multidisciplinary approach is needed to deal with headache, but the role of the otolaryngologist has so far been underestimated. Evaluation of a headache patient is never complete without an otolaryngological opinion. The article on Facial Pain by Philip H. Golding-Wood is well worth reading over and again.[5]

Dr.Thomas Antony

Otolaryngologist

References:

[1] Communication from North American Cervicogenic Headache society and World Cervicogenic Headache Society.

[2] Dean M. Clerico, [July 1996]: Pneumatized Superior Turbinate as a cause of Referred Migraine Headache

Laryngoscope 106: p 874-879

[3] [Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias, and Facial Pain, First Edition. Headache Classification Committee of the International Headache Society. Cephalalgia, Vol. 8. Supplement 7 1988]

[4][World Cervicogenic Headache Society c/o Rothbart Pain Management Clinic 16 York Mills Road, Unit 125, Box 129North York, Ontario, Canada, M2P 2E5Phone: -[416] 512-6407 Fax-[416] 512-6375] [Http://www.cervicogenic.com/about.htm]

[5] Philip H Golding-wood. Facial Pain. In. John Ballantyne, John Groves, editors. Scott Brown's Diseases of Ear, Nose and Throat, 4th Edn, Vol 3, Butterworths. 1979: p385- 424

[6] Sidney Durman, Stanley H. Ginsburg. [1979]:Headaches and Facial Pain, in. H. Harold Friedman. Editor. Problem-Oriented Medical Diagnosis, 2^nd Edn, Little, Brown and Company, Boston.,p321-325

The above article appeared in the Indian Journal of Otolaryngology and Head & Neck Surgery in 2000. The author is currently working as ENT Surgeon, at ARC Hospital, Aden, Rep of Yemen. Can be contacted by email tomsant@gmail.com