“It is time to have an honest conversation about alcohol and violence in our country.” This is the view of three experts from the South African Medical Research Council (SAMRC)…
“We need our citizens, our government and the liquor industry to play ball. It cannot be business as usual.”
The experts released a statement on Thursday detailing the devastating effect of alcohol abuse on society in South Africa. From horrific trauma and injury statistics to increased levels of domestic violence. The abuse of alcohol is a clear issue in the country.
At the same time, however, it is an industry which supports thousands of jobs. The hospitality and tourism industries in the country rely heavily on the availability of alcohol. Banning it indefinitely is not a solution.
Professors Glenda Gray, Charles Parry and Richard Matzopoulos from SAMRC suggest that South Africa take notes on how change has been implemented in other countries for the benefit of society. They have outlined a detailed plan for government to follow once the ban on alcohol is lifted.
Here are some of the key observations from their statement:
Among the devastating epidemics the country faces, South Africa also has an injury epidemic, which places an enormous burden on our health system and society at large, let alone on those injured and those near to them.
We are among the most violent countries in the world. Last time we checked, our country had twice the global average for injuries and five times the global average for homicides. This is in addition to having one of the worst HIV and TB epidemics in the world, and an emerging new threat of non-communicable diseases.
These epidemics bring death, despair and tragedy to our households and families.
To prevent and control this epidemic we need our citizens, our government and the liquor industry to play ball. It cannot be business as usual.
Alcohol consumption in South Africa is off the charts
Although only 43% of adult men in our country drink and about one in five women, consumption per drinker is so high that per capita consumption, which includes non-drinkers, is higher than most other countries.
That is because of the culture of drinking to intoxication, especially over weekends.
Adult per capita consumption in grams of absolute alcohol (AA) consumed per drinker is 64.6 g of AA per day – the 6th highest globally according to the World Health Organization (WHO).
This is between 5 and 6 standard drinks of 12 g of AA (or 15 ml) per day, and substantially higher than the average for countries in the WHO Afro region (40.0 g/drinker/day) and the global average (32.8 g/drinker/day). Heavy episodic or binge drinking is normative in our country.
There are consequences to harmful drinking:
- liver cirrhosis
- road traffic injuries
- Gender based violence
Alcohol also plays a role in the transmission of infectious diseases and the progression of infectious diseases like TB and HIV.
The road traffic fatality rate is more than 33 per 100,000 population – nearly double the global average – and mortuary surveillance data indicate that approximately half are alcohol-related.
These deaths are most common at night-time, particularly on weekends and, as most of the deaths are adults, this translates into a considerable loss of livelihood for affected households.
Gender based violence (GBV) is a particularly vexing problem, with between 25% and 40% of South African women having experienced sexual and/or physical violence in their lifetime. Harmful alcohol use is a well-documented driver of GBV, and drinking, especially binge drinking by men, appears to increase both the frequency and severity of partner abuse.
Unnatural deaths plummeted during Level 5 lockdown
The level 5 lock-down which included both a prohibition on alcohol sales and a curfew presented the country with a natural experiment. For those of us who have an obsession with tracking mortality, got the surprise of our lives: unnatural deaths plummeted, providing us with evidence that alcohol control coupled with a curfew was a significant intervention to control un-natural deaths in our country.
This significant impact was reversed when alcohol sales were allowed and people could move about at night. The decline in unnatural deaths has again occurred following the recent temporary ban on alcohol and the re-introduction of a curfew.
This intervention has taught us that South Africa needs to introduce strategies to reduce the harmful use of alcohol. This will save both lives and livelihoods.
Our recommendation is that South Africa be informed by the best available evidence, such as that reflected in:
- The 2010 WHO Global Strategy to Reduce Harmful Use of Alcohol,
- The WHO NCD Global Action Plan 2013-2020,
- The WHO SAFER initiative (2019),
- Alcohol No Ordinary Commodity (2010),
- Alcohol Policy in Developing Societies (2000),
- Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol (2009),
- Are the “Best Buys” for alcohol control still valid? An update on the Comparative Cost-Effectiveness of Alcohol Control Strategies at the Global Level (2018),
- Alcohol Policy and Public Health in South Africa (1998), and Do alcohol control policies work? An umbrella review and quality assessment of systematic reviews of alcohol control interventions (2006-2017) (2019).
It has been done effectively in Russia
While there is often pessimism that much can be achieved, one just has to look to how Russian turned around declining mortality from 2002 using among other things a basket of alcohol control measures.
These included gradually raising taxes on alcohol; introducing a minimum unit price policy on vodka as far back as 2003, and then increasing the minimum price over the years, before expanding this policy to other alcoholic beverages; introducing a real-time tracking system on the production and sale of alcohol; beginning a comprehensive night ban on off-premise sales of alcohol nationally, with even stricter availability in some regions; as well as strict policies on alcohol-free public space, and on alcohol marketing.
We propagate the SAFER strategy currently being promoted by WHO:
- S: Strengthen restrictions on alcohol availability
- A: Advance and enforce drink-driving counter measures
- F: Facilitate access to screening, brief interventions and treatment
- E: Enforce bans or comprehensive restrictions on alcohol advertising, sponsorship and promotion
- R: Raise prices on alcohol through excise taxes and pricing policies
The table below sets a number of specific interventions for South Africa to consider implementing in the short, medium and long terms as it seeks to chart a new way forward for alcohol.
The first five tally with the SAFER measures proposed by WHO with an additional measure as it has become patently obvious that we need to have more reliable data on, that is alcohol-related trauma admissions.
This is to have a measure of how well we are making progress in terms of turning this around.
Multi-sectoral national plan needed
In conclusion, South Africa needs a clear, multi-sectoral national plan to guide action going beyond DTI’s Liquor Policy (2016). We need competent and empowered leadership to drive the plan and we need to ensure the plan is properly funded.
The industry needs to move away from its role as a commercial determiner of ill health and align itself to a new harm reduction paradigm.
This will necessitate a reduction in an overall consumption as the country moves away from the current pattern of risky drinking.
The industry needs to distance itself from the aggressive lifestyle marketing.
This is characterised in the current business model for the beer industry that depends on
- a large proportion of drinkers engaging in heavy episodic drinking (given the size of the beer market),
- the distribution of 70-80% of beer products through unlicensed outlets,
- and the marketing and sale of alcohol in larger containers (like 750 ml and now 1 liter beers) that encourage sharing and have been linked to HED.
The alcohol industry must support the notion not to perpetuate harmful drinking patterns and put people before profits.
South Africa has a unique opportunity to create a safer drinking environment. We should not squander it.