alcohol misuse and public health:
a 10-point action plan
Dr C. D. H. Parry,
MRC National Urbanisation & Health Research Programme,
PO Box 19070, Tygerberg 7505;
tel.: (021) 938-0419; fax: (021) 938-0342;
Email: cparry@mrc.ac.za

The current policy arena with regard to both alcohol and other drugs in South Africa is in a state of transition. There are no simple solutions, but intervention strategies are available which can significantly decrease the burden of alcohol-related harm over time. These approaches are likely to have a positive impact on both public health and economic/social development. The focus should not just be on those who are alcohol dependent or who are at high risk for alcohol-related problems, but on the general population as well.¹

• Community action programmes serve as a mechanism for providing information to community members and for shaping community attitudes, values and norms about drinking. They also provide a context for environmental interventions such as pressuring local and provincial authorities into restricting the number of liquor outlets and for increasing restrictions on above- and below-the-line advertising of alcohol products.
• Strengthening activities at the primary health care level . The health sector must play a greater role in the detection and prevention of alcohol-related harm and not just the management of alcohol problems at the secondary and tertiary levels. Primary health care workers should be involved in detecting and managing patients with different kinds of drinking problems, setting up day-care programmes for alcoholics, supporting families and self-help groups, and acting as an advocate of public health for local communities.
• Legislative changes regarding excise taxes on alcohol . The excise tax on malt beer and brandy should be increased by 20-25% to bring it up to 1985 levels. Future increases should, at a minimum, be linked to the Consumer Price Index.
• Addressing drinking and driving . Drunk driving should be addressed through a high profile effort aimed at catching and punishing drunk drivers. This should involve increasing random breath testing of drivers, mandatory breath or blood alcohol testing in the case of road-related injuries, and increasing the sanctions for persons caught drinking and driving.
• Encourage work place interventions to address alcohol misuse . Businesses should be encouraged to develop and implement interventions, including developing workplace policies; training supervisors in policy application; setting up employee education and awareness programmes; providing information regarding treatment and support programmes, and where possible setting up employee assistance programmes; initiating drug testing (e.g. for industries where safety is an issue); and addressing practices which might encourage alcohol consumption (e.g. providing access to cheap or free alcohol).

Alcohol use and abuse in South Africa: Situation analysis
Between 1 July 1995 and 30 June 1996 it is estimated that South Africans consumed over 6 billion litres of beverage alcohol, 90% of it being sorghum or malt beer. Adult per capita absolute alcohol consumption per year is close to 10 litres, which places the country among the highest consumers in the world. A recent review by the MRC of studies assessing the extent of problem drinking in South Africa has identified levels of risky drinking as high as 30% among some high-risk groups such as adult, African, urban residents. Other high-risk groups identified include males in general, and youth in both urban and rural settings.

MRC-supported research has shown that the prevalence of alcohol-related trauma (death and injury) is disturbingly high.2,3 The misuse of alcohol also impacts on the family, the workforce, the criminal justice sector, the insurance industry and the economy in general. The best estimate of the economic cost of alcohol misuse, based largely on the experience of other countries, is 2% of the GNP p.a., i.e. R9.5 billion at current levels. The burden of disease and injury attributable to alcohol is likely to rise as development takes place.4

The rate of increase in per capita beverage alcohol consumption between 1978 and 1994 was found to be more than twice the rate of increase in the popuation. This suggests that, at least in the short-term, we will continue to see an increase in per capita beverage alcohol consumption.

• Rigorously enforce existing legislation in the following areas: the ’dop’ system; the minimum drinking age; consumption of alcohol in certain public places, and public drunkenness (particularly by commuters and pedestrians).
• Implementing and enforcing coherent strategies for licensing of liquor outlets . Licensing unlicensed premises may serve as a regulatory measure facilitating control of poor hygiene, quality control, and under-age drinking. The first step is to bring unlicensed operators into the system. To facilitate community involvement, greater power should be granted to elected local authorities in conjunction with elected community forums to make decisions regarding granting of liquor licenses, siting of outlets, and hours of sale. Expanding police powers of local authorities would further strengthen local efforts to shut down unlicensed liquor outlets and enforce liquor trading hours and age restrictions. Local authorities should be permitted to impose special business fees on alcohol outlets to pay for costs of inspection and enforcement.
• Community development . There is a need to ameliorate the general social conditions that may instigate the abuse of alcohol by upgrading infrastructure (e.g. recreational facilities), housing and the general environment. Community development should also include job creation and specific skills training within the community setting.
• Health education programmes aimed at high-risk groups (e.g. teenagers, pregnant women, pedestrians, workers/employers) or persons who work with high-risk groups (e.g. the police, servers at bars, shebeens or taverns). The latter should be trained to detect those drinkers incapable of driving and to refuse service to them and to those intoxicated to the point where they may be a danger to themselves or others. Owners and servers should also be given information regarding regulations such as the minimum drinking age. With regard to youth, successful psychosocial approaches to substance-abuse prevention include components dealing with resistance skills training, psychological inoculation and personal and social skills training.
• Health education programmes aimed at the community at large/counter-advertising/media advocacy . The public must be provided with information regarding personal drinking limits. Greater support should be given to counter-advertising to ensure that the public is able to make an informed choice about use of alcohol products. All forms of media should be considered for health education around alcohol use and for counter-advertising. Warning labels on all forms of advertising and packaging of alcohol products should be mandatory. Warnings should focus on the dangers of drinking and driving, drinking while pregnant, etc. Increased media advocacy is also required to ensure that alcohol use is addressed responsibly in programming and in reporting.

References

1. Parry CDH.Submission to the Gauteng Department of Economic Affairs and Finance on Revisions to Liquor Legislation, 25 October 1996;
2. Lerer L, Matzopoulos R, Phillips R, Bradshaw B. Violence and injury mortality in the Cape Town Metropole 1995. Cape Town: Medical Research Council, 1996;
3. Peden MM, Knottenbelt JD, van der Spuy J, Oodit R, Scholtz HJ, Stokol JM. Injured pedestrians in Cape Town - the role of alcohol. S Afr Med J 1996; 86: 1103-1105;
4. Murray CJL, Lopez AD. Quantifying the Burden of Disease attributable to ten major risk factors. In: Murray CJL, Lopez AD, eds. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and projected to 2020. Cambridge: Harvard University Press, 1996: 295-324;
5. Parry CDH. Translating substance abuse policy into action in South Africa. In: Abdool R, ed. 10th year commemorative magazine of the Idrice Goomany Centre for the Prevention and Treatment of Alcoholism and Drug Addiction: From grassroots initiatives to a global response. Port Louis, Mauritius: Dr Idrice Goomany Centre, 1996: 35-38.

Translating policy into action
While formulating a clear National Drug Control Strategy (including alcohol) should be given priority, specific attention should be given to mechanisms which will aid implementation, including establishing empowered leadership structures to drive the process of policy implementation, ensuring meaningful engagement of community structures, providing adequate funding, and giving support to substance abuse surveillance and policy evaluation.5

The 10-point action plan on this MRC Policy Brief has been endorsed by the Western Cape Alcohol and Drug Abuse Forum and the Gauteng Substance Abuse Forum.