Alcohol Harms Reduction

A strategy to reduce binge drinking and its harms in society

Our fight is not against all alcohol consumption; it is against industry and societal practices that promote excessive drinking.

 

Did you know: Although the liquor industry contributes significantly to the GDP of South Africa (around 3% or R68 billion[1]National Treasury. 2014. A review of the taxation of alcoholic beverages in South Africa: A Discussion Document.) of the total GDP), the negative effects of alcohol costs the nation more than what the industry contributes. The combined cost of productivity losses from absenteeism, welfare cost, direct costs to the fiscus and the lost value of life and health totals R227 billion.[2]Matzopoulos, R., Truen, S., Bowman, B. & Corrigall, J. 2014. The cost of harmful alcohol use in South Africa. South African Medical Journal, Vol. 104 (2): p127-132

What

According to the World Health Organisations (WHO) data, relatively few South Africans (39%) drink alcohol compared to people in other countries (43%). However, those South Africans who do drink tend to drink far more and heavier than their global counterparts. South Africans also have the dubious honour of engaging in binge drinking at higher rates than the global average. Binge drinking is defined as having five or more standard drinks in one sitting. The global average is 50% of those who drink alcohol. In South Africa, the average is 59%, with 38% of woman drinkers engaging in binge drinking and, alarmingly, 70% of male drinkers engaging in binge drinking. The statistics from WHO also identify that 80% of male drinkers aged 18-35 engage in binge drinking.[3]World Health Organisation. 2018. Global Status Report on alcohol and health.

“People are shocked when they are rated as binge drinkers and high-risk drinkers. We try to make them understand that alcohol results in many losses and that there are many gains to be made by reducing their drinking. Then we set goals towards achieving that reduction.”
Nokwanele Mbewu, Philani Senior Programme Manager and Mentor Mother Trainer

The question that many South Africans may ask, both citizens and those in government, is: “How bad are the effects of harmful drinking really?”

To answer that we have to take a look at stats around harmful drinking. About 40 000 deaths per year are caused by people under the influence of alcohol[4]Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Incidence, Prevalence, and Years Lived with Disability 1990-2016. Seattle, United States: Institute for Health Metrics and Evaluation (IHME ), 2017. ; 40% of men admit to raping a woman while under the influence of alcohol[5]Jewkes, R., Sikweyiya, Y., Morrell, R. & Dunkle, K. 2011. Gender inequitable masculinity and sexual entitlement in rape perpetration South Africa: findings of a cross-sectional study. PLoS One, Vol. 6(12): e29590.; we have the highest femicide rates in the world at 8.8 per 100 000. [6]World development report 1993: Investing in Health. New York: World Bank, Oxford University Press; 1993; 54% of homicides and violence cases are associated with alcohol, and 56% of road deaths.[7]SAMRC-UNISA. 2009. A Profile of Fatal Injuries in South Africa. Alcohol contributes to South Africa’s burden of diseases as alcohol abuse is an underlying cause of both interpersonal violence and unsafe sex. Alcohol harm (7%) is third only to unsafe sex (32%) and interpersonal violence (8%) in contributing to the national risk profile (expressed as disability-adjusted life years or DALYs).

A further consequence of alcohol misuse in South Africa is the extremely high prevalence of Foetal Alcohol Spectrum Disorder (FASD). In the Western Cape, the prevalence among Grade 1 learners in high-risk, rural communities is as high as 18-26%.[8]May, P., de Vries, P., Marais, M. et al. 2016. The continuum of foetal alcohol spectrum disorders in four rural communities in South Africa: Prevalence and Characteristics. Drug & Alcohol Dependence, Vol. 159: 207-218. Even when it does not lead to FASD, alcohol abuse often contributes to situations where parents are not there for their children, and in extreme cases, it is linked to child abuse and neglect. Children whose parents abuse alcohol (or other substances) are significantly more likely to have medical and behavioural problems, including substance abuse.

Read more:
Gender-based violence is one of the most searing of South Africa’s complex challenges. A significant factor fuelling this situation is alcohol abuse. Dr David Harrison explores how limiting access to alcohol, and the introduction of other alcohol abuse reduction programmes, can help choke the raging fire of GBV in South Africa. Originally published by published by the Daily Maverick on 02 October 2019. Read it here.

These alarming statistics paint a grim picture of the effects of alcohol on South Africans.

 

Call for responsible drinking masks the big lie

In our new podcast series, UpSouth, we explore ideas, approaches and social innovations that can push us forward towards creating a South Africa where every person has the opportunity to fulfil their potential. In the first episode, we discuss the ‘sensitive’ issue of alcohol use (or rather abuse) in South Africa. We investigate why we have this problem in the first place, and we challenge the alcohol industry line that individuals should simply drink more responsibly. We also consider what can be done to minimise the effect of harmful drinking on people and the economy.

Listen to UpSouth here

Infographic facts about alcohol abuse among South Africa’s youth

View an infographic detailing the facts about alcohol abuse among South Africa’s youth. This infographic appeared in our Learning Brief titled ‘One step forward, two steps back: How alcohol abuse diminishes the work of civil society and what we can do about it’. Read it here.

Why

South Africa has a painful history when it comes to alcohol. It was used to oppress the majority and empower the minority. South Africa’s drinking culture was influenced by factors such as the migrant labour system, the ‘dop’ system practised on wine farms, and the pre-democratic government’s use of revenue from alcohol sales in townships to build the apartheid infrastructure.

SA alcohol history

An illustrated timeline of the socio-economic marginalisation driven by alcohol policies and practices in South Africa.

Although the liquor industry contributes significantly to the GDP of South Africa (around 3% of the total GDP [9]National Treasury. 2014. A review of the taxation of alcoholic beverages in South Africa: A Discussion Document., the negative effects of alcohol costs the nation more than what the industry contributes. If we look at the cost of productivity losses from absenteeism, welfare cost, direct costs to the fiscus and the lost value of life and health, the cost to the economy is R227 billion.[10]Matzopoulos, R., Truen, S., Bowman, B. & Corrigall, J. 2014. The cost of harmful alcohol use in South Africa. South African Medical Journal, Vol. 104 (2): p127-132 In other words. The industry contributes 3% to GDP yet the loss to GDP is 10-12%. The industry takes more than it puts back.

The liquor industry controls the narrative around alcohol consumption and overstates the benefits while downplaying the disadvantages. Very few civil society organisations can go toe-to-toe with the alcohol industry from a communications spend perspective. A systematic review conducted by Anderson et al. (2009)[11]Impact of Alcohol Advertising and Media Exposure on Adolescent Alcohol Use A Systematic Review of Longitudinal Studies aimed to assess the impact of alcohol advertising and media exposure on future adolescent alcohol use. Thirteen longitudinal studies that followed over 38 000 young people were included. The review found consistent evidence to link alcohol advertising with the uptake of drinking among non-drinking young people, and increased consumption among their drinking peers. Twelve of the 13 studies found evidence that adolescent exposure to alcohol advertising and promotion and drinking predicts both the onset of drinking among non-drinkers and increased levels of consumption among existing drinkers.

Smith & Foxcroft (2009)[12]The effect of alcohol advertising marketing and portrayal on drinking behaviour in young people Systematic review of prospective cohort studies evaluated the relationship between exposure to alcohol advertising, marketing and portrayal on subsequent drinking behaviour in young people. Their systematic review of seven cohort studies on over 13 000 participants shows some evidence for an association between prior alcohol advertising and marketing exposure and subsequent alcohol drinking behaviour in young people. 

Three of the studies showed that onset of drinking in adolescent non-drinkers at baseline was significantly associated with exposure to alcohol advertising.  In studies on mixed groups of drinkers and non-drinkers, increased frequency of television viewing and music video viewing was significantly related to the amount of alcohol consumed while going out.

Binge drinking culture is further sustained through ineffective regulatory measures allowing alcohol to be easily available, cheaply sold, and behaviour related to risky drinking having weak consequences. Poverty, depression and hopelessness coupled with a lack of social, and recreational opportunities in many communities drives binge drinking among many South Africans, particularly the vulnerable communities DGMT’s strategies are aimed at. Research and anecdotal evidence from community interventions shows that stress, depression and trauma make individuals more inclined to alcohol abuse. Because alcohol is cheap and easily accessible in South Africa and we have a weak and poorly enforced regulatory environment, shebeens and taverns provide easy access to communities that are inclined to alcohol abuse because of the systemic stress and trauma they have experienced, and the apartheid structures designed to encourage binge and heavy drinking.

Heavy drinkers and young people are sensitive to changes in the price of alcoholic beverages. For this reason, the World Health Organisation (WHO) has identified pricing policies as a key strategy to reduce underage and heavy drinking.[13]WHO. (2010).  Global Strategy to Reduce the Harmful Use of Alcohol.  Available here

Among the policy interventions proposed by the WHO as part of this strategy are: the establishment of a system for domestic taxation on alcohol accompanied by efficient enforcement; regular review of prices in relation to level of inflation and income; and establishing minimum prices for alcohol.

South Africa has a long history of imposition of excise taxes on alcoholic beverages but has, to date, not imposed minimum prices for alcohol. The introduction of Minimum Unit Prices (MUP) for alcohol has, however, recently been proposed in the Alcohol-related Harms Reduction White Paper, which was adopted by the Western Cape Provincial Cabinet in August 2017.

The White Paper explains that a MUP is considered to be the most targeted way to tackle the affordability of cheap, strong alcohol consumed by heavy drinkers without penalising moderate drinkers, and that it averts the possibility of alcohol being sold below cost, given away or subsidised.[14]Western Cape Government. (2017).  Western Cape Alcohol-related Harms Reduction Policy White Paper.  Provincial Gazette Extraordinary 7824, 11 September 2017.

During the height of the lockdown, the alcohol industry published an op-ed opposing the alcohol ban using facts of a dubious nature.

READ OUR REPONSE HERE

How

The Alcohol Harms Reduction programme is geared toward raising awareness of the effects harmful drinking on South Africa and recommending policy changes to the South African government. These reforms are based on the World Health Organisation’s 5 ‘best buys’:

World Health Organisation’s 5 Best Buys

  1. A ban on advertising of alcohol (except on the site of sale, where it should not be visible to those under 18 years).
  2. Increase the price of alcohol, both through excise taxes and by introducing a minimum price per unit of pure alcohol in liquor products.
  3. Reduce the legal limit for drinking and driving to a blood alcohol content of 0.02% or below.
  4. Reduce the availability of alcohol, especially in residential areas (by limiting the density of liquor outlets, shorter trading hours, and ending the sale of alcohol in larger containers like 1 litre bottles of beer).
  5. Intensify the availability of counselling and medically assisted treatment for persons struggling with dependence.

This is done by:

  • Commissioning research: We work with subject matter experts and researchers, for example, the SA Medical Research Council and the University of Cape Town, to ensure our recommendations are evidence-based and can demonstrate the extent to which our proposed solutions will contribute to the change we are seeking to make.
  • Partner with government:  We currently have Memorandums of Understanding with the Department of Social Development and the Western Cape Government. But our intention is to establish collaborative relationships across all provinces and engage closely with all public institutions that have a role to play in the field of alcohol-related policy and its implementation. These partnerships are critical in ensuring impact and reach.
  • Grant-making: Through our grant-making, we are able to partner with civil society organisations that are already doing important work in this area – work that that we can either learn from and take to scale, or to test out new approaches to innovatively change behaviours related to alcohol.
  • Advocacy and lobbying: DGMT – together with SAMRC, the Chronic Disease Initiative of the University of Cape Town and the Public Health Association of South Africa – submitted a petition to the President, Speaker of Parliament, Ministers of Health, Social Development and Trade, Industry and Competition, as well as the Premiers and parliaments in all nine provinces during the height of the lockdown instituted in 2020 to combat the spread of the Coronavirus.

A part of the petition read: “The Covid-19 epidemic has shone a light again on the value of each human life, and the message from our leaders is that lives must be saved through urgent and radical action. In his speech to the nation on Wednesday 17 June 2020, President Ramaphosa stated that, especially in the light of the unbridled violence against women and children, “we will also need to look at further, more drastic measures to curb the abuse of alcohol”. Gender-based violence is driven by gender inequality, made worse by social and economic marginalisation, failures of policing and justice, and the abuse of drugs and alcohol. No single intervention will address it, and we must tackle all of these factors at the same time. We note the steps that have been taken as part of the National Strategic Plan to combat Gender-Based Violence. We also agree with the President that it “is not alcohol that rapes or kills a woman or a child. Rather, it is the actions of violent men. But if alcohol intoxication is contributing to these crimes, then it must be addressed with urgency”. 

The petition noted that binge drinking is a strong proximate risk factor for violence against women and children – alcohol being an acknowledged factor in the perpetration of more than 40% of rape and a notable contributor to intimate femicide. It cited evidence that 50-60% of South African men who drink alcohol, drink in heavy, episodic ways (> 5 units at one time) – the definition of binge drinking – which is strongly associated with interpersonal violence, motor vehicle accidents and risk taking behaviour. These associations are even stronger in poorer communities than wealthier ones.

The petition was signed by 166 academics, researchers and community activists, and called for government to implement the WHO’s 5 Best Buys to curb the abuse of alcohol:

READ THE APPEAL HERE AND VIEW THE LIST OF SIGNATORIES

The measures described above have been shown to significantly reduce the societal harm of alcohol and should be supported by other interventions shown to be effective, including raising the legal drinking age to 19 years and ensuring that product tracking and tracing is in place to close the supply routes to illegal vendors. These provisions are included in the Draft Liquor Amendment Bill. With this petition the signatories and supporters across South Africa call on the government to proceed with the implementation of this Bill and other legislation aimed at reducing alcohol harm such as the Control of Marketing of Alcoholic Beverages Bill. 

Equally critical is effective enforcement of national and provincial legislation and local by-laws, including adherence to trading hours, prevention of underage drinking, confiscation of alcohol sold at illegal outlets and restrictions on public drinking.

  • For more details on these 5 measures read our policy advocacy document here.
  • Read our learning brief on alcohol harms and binge drinking here.
  • Read our learning brief on community level interventions to combat harmful drinking here.

Read more:

  • Dr Grieve Chelwa and Professor Corné van Walbeek discuss why it is important to revisit alcohol taxation as a tool to curb harmful drinking. Originally published by BusinessLive on 04 March 2019. Read it here.
  • Dr Grieve Chelwa and Professor Corné van Walbeek discuss the introduction of a minimum unit price and how it could curb harmful drinking. Originally published by BusinessLive on 14 April 2019 Read it here.
  • Dr David Harrison, CEO of the DG Murray Trust, lays out the 5 Measures to curb harmful drinking and makes the case for why they should be urgently implemented. Originally published by the Daily Dispatch on 25 June 2020. Read it here.

Progress

The appeal to government to adopt the World Health Organisation’s 5 ‘best buys’ to curb the abuse of alcohol was sent to various government departments, parliamentary portfolio committees and political parties. One such recipient was Ms Thandi Modise, Speaker of the National Assembly of South Africa. Subsequently, upon invite, presentations were made to the Department of Social Development Parliamentary Portfolio Committee and to a webinar convened by the Minister of Women, Youth and Persons with Disability in direct response to the public appeal.

Read some of the replies from recipients in government to the appeal. Read it here.

We presented to the NEDLAC Covid-19 Rapid Response Task Team where we made recommendations. Our engagement with NEDLAC and various government departments continues.

On 20 August 2020 DGMT CEO, Dr David Harrison, presented to the Portfolio Committee on Gender-Based Violence in the Ministry of Women, Youth and Person with Disability around the five measures we propose to curb alcohol abuse and how that abuse is linked to gender-based violence.

On 24 August 2020 a webinar was convened by the Minister of Women, Youth and Persons with Disabilities, Minister Maite Nkoana-Mashabane in direct response to the public appeal collated by DGMT and signed by over 160 researchers, academics and other interested parties, calling on government to implement five measure to address the binge drinking and alcohol abuse problem in South Africa.

What happened during the 2020/2021
lockdowns and alcohol bans?

Alcohol banned during lockdown

The Level 5 lockdown in 2020 in response to the Covid-19 pandemic included a ban on alcohol sales and a national curfew. It presented health officials and those working in civil society to combat harmful drinking a perfect opportunity to conduct a natural experiment. What are the effects of alcohol and its harmful use on South Africa and the medical health system? It has long been known that alcohol-related injuries and deaths are inordinately high in South Africa. The statistics show that before lockdown and the alcohol ban, there were 34 615 trauma cases per week. Of these, around 40% were alcohol related, which translated to at least 13 846 patients presenting to hospital per week, across the country.[15]Mitchley, A. 2020. FACT CHECK | Were 34 000 hospital beds occupied by alcohol related incidents after liquor ban lifted? 30 Jun 2020. Access here In a study published in 2018 by BMC Medicine, it is estimated that one in 10 deaths in South Africa can be attributed to alcohol abuse in some way – with men in low income groups the most at risk.[16]Staff Writer. 2018. South Africans are drinking themselves to death. 15 Jul 2018. Access here “Overall, approximately 62 300 adults died from alcohol-attributable causes of death in South Africa in 2015. With a total of approximately 529 400 deaths from all causes, roughly one in ten deaths was attributable to alcohol use,” the researchers said.[17]As described here

With a large influx of Covid-19 patients expected, hospitals needed the capacity to deal with the pandemic, and not be bogged down with alcohol-related trauma. During Level 5 lockdown, the number of reported cases of domestic violence cases in South Africa, as opposed to elsewhere in the world, decreased by 69.9% between March and April 2020.[18]Gould, C. 2020. Why is South Africa not showing the rise in domestic violence cases reported elsewhere in the world? Institute for Security Studies, 11 May 2020. Available here During Level 4 of the lockdown, reports of murder, rape and common assault plunged by 40% between April and June 2020, while non-contact crimes such as arson and malicious damage to property dropped by 30%.[19]Al Jazeera News. 2020. South Africa’s crime rate falls 40 percent during lockdown, 15 August 2020. Available here

Alcohol sales resume lockdown

On 1 June 2020, during Level 3 Lockdown, the alcohol ban was lifted. The number of cases in the Chris Hani Baragwanath Hospital trauma unit in Soweto almost doubled within 24 hours with alcohol-related cases.[20]Zulu, S. 2020. Trauma cases almost double 24 hours after alcohol ban lifted – Bara Hospital. 02 Jun 2020. Access here Over the course of a few weeks, 21 women and children were murdered.[21]Ellis, E. 2020. Gender-based violence is South Africa’s second pandemic, says Ramaphosa. 18 June 2020. Access here In light of this increased cases of trauma and violence directed towards women and children, a second alcohol ban was introduced unexpectedly on 12 July. Stats showed that murders still rose by 6% compared to the same period in 2019. Possibly traders and tavern-owners stockpiled liquor as rumours swirled ahead of the second sales ban; but it also shows that firearm-related violence is endemic in many areas of our country.[22]Faull, A. 2020. Lockdown lessons on violence and policing in South Africa, 2 September 2020. Institute of Security Studies: Available here

Alcohol banned during lockdown

During the second alcohol ban, the Western Cape saw a 48% weekend and 32% daily drop in alcohol-related traumas.[23]Smith, G. 2021. Western Cape Health department: Trauma-related cases on NYE dropped by 65% due to alcohol ban. Eyewitness News. Available here Soon after the reinstatement of the alcohol ban, trauma admissions for casualties linked to alcohol dropped again by 47% on weekends and by 58% in the Western Cape. On New Year’s Eve and New Year’s Day, there was a 65% drop in trauma cases linked to liquor abuse – compared to the same period in 2019.[24]Smith, G. 2021. Western Cape Health department: Trauma-related cases on NYE dropped by 65% due to alcohol ban. Eyewitness News. Available here

Furthermore, for the first time in the history of the Chris Hani Baragwanath Hospital in Soweto, the hospital trauma rescue area had no patients on the first day of the new year, while some of the busiest hospitals in KwaZulu-Natal were also virtually empty on this day.[25]Duma, N. 2021. After Bara’s good news, KZN hospitals also report fewer new year’s trauma cases. Eyewitness News. Available here

Alcohol banned during lockdown

Considering these stats around the banning of alcohol during lockdown, it is clear that better controls can influence drinking behaviours and alleviate the effects of harmful drinking on society. What is needed now is political will and industry buy-in to ensure that these controls are not only implemented in disasters but is instead implemented on an ongoing basis. Truth be told, we are in a continuous disaster that is brought on my harmful drinking.

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