alcohol
action plan briefing to SA Department of Health
Charles
Parry, PhD
Medical Research Council,
10 March 1997
Introduction
Minister Zuma has made a positive stand on the need to address
alcohol abuse from as early as 1994. As recently as 25/2/97,
she was quoted in the Cape Times as saying that the Government
is very worried about the ill effects that flow from alcohol
abuse. Within the Department of Health she has taken various
positive steps. In 1995 she convened a consultative meeting
in the substance abuse area. Later that year, a strategic plan
to address mental health and substance abuse was completed and
a report written. Early in 1996, the document “Towards
a National Health System” was released. This set out broad
policy direction in the substance abuse area. Later in 1996,
the post of Deputy-Director for Substance Abuse was filled.
Outline
I will first provide a brief situation analysis of the nature
and extent of alcohol use and misuse in South Africa. Secondly,
I will put forward a plan for action, firstly setting out interventions
which can be implemented within the health sector, and then
look at ways in which the Health Department can support interventions
by other sectors. I will highlight the importance of establishing
mechanisms for translating policy into action, and then set
out a few mechanisms that are, I believe, crucial for translating
policy into action both within the health sector and within
the broader environment. Finally, I will refer to the role of
substance abuse surveillance and evaluation research in the
policy process.
Situation
analysis
General Background
South Africans consume over 6 billion litres of beverage alcohol
per year. This is close to 10 litres of absolute alcohol per
adult per year, and places us among the highest alcohol consuming
nations in the world. 90% of the alcohol consumed is malt or
sorghum beer. Risky drinking is as high 30% among certain groups
such as adult African urban residents. This has been demonstrated
from various studies looking at consumption. Other risk groups
include males, youth (both urban and rural), persons in certain
occupations such as mining, and poor women of child-bearing
age in rural areas. Researchers at UCT have found that 26% of
women from various poorer socio-economic communities in the
Western Cape consume sufficient alcohol to place their babies
at risk for Foetal Alcohol Syndrome.
The Global
Burden of Disease and Injury Attributed to Selected Risk Factors,
1990
An article published by Murray & Lopez (1996) refers to
the global burden of disease and injury attributed to selected
risk factors in 1990. Percentages are based on Disability Adjusted
Life Years Lost (DALY’s) as a percentage of total DALY’s.
The percentage for malnutrition is 15.9%, for water and sanitation
is 6.8%, for alcohol is 3.5%, for unsafe sex is 3.5%, etc. The
percentage for tobacco is 2.6% and illicit drugs 0.6%. The percentages
are averaged over both developing and developed societies. In
Sub-Saharan Africa, the percentage for alcohol is 2.6%. For
developed regions of the world the global burden of disease
and injury attributed to alcohol is 9.6%. The implication is
that the burden of disease and injury from alcohol misuse may
increase as development takes place in South Africa.
MRC Research
on the Burden of Disease and Injury from Alcohol Misuse The
misuse of alcohol clearly has a large effect on the health sector,
principally through the use of trauma services and direct treatment
costs. I’d like first to refer to Pedestrian and Driver
Pyramids prepared by the MRC’s Trauma Programme. With reference
to the Driver Pyramid, research undertaken by the CSIR after
office hours found that 7% of uninjured drivers have alcohol
levels in excess of .08gms/100ml. The percentages for injured
drivers and fatally injured drivers are 29% and 40% respectively.
Turning to the Pedestrian Pyramid, 10-13% of adult pedestrians
whose alcohol levels were randomly sampled after office hours,
were found to have alcohol levels in excess of .08gms/100ml.
Research undertaken at hospitals has found that 51% of pedestrians
treated for minor injuries and later discharged had blood alcohol
levels above .08gms/100ml, compared to 61% for those who had
severe injuries and were admitted, and 70% of those pedestrians
who were admitted to hospital and who died in hospital.
Over the
past three years the MRC has been involved in research to assess
blood alcohol levels for all non-natural deaths in the Cape
Metropole. In 1995, over half (50.5%) had blood alcohol levels
above .1gms/100ml. Only 40% of cases were alcohol negative.
Our best
estimate of the economic cost of alcohol misuse, based largely
on the experience of other countries, is 2% of the Gross National
Product or R9,5 billion per year. Pedestrian deaths in South
Africa alone cost the State R1,2 billion per year and at least
half of these are alcohol related. I am currently completed
a study at a hospital in the Free State which serves six mines
to look at the link between blood alcohol levels and hospital
expenses and lost production. This should shed further light
on the economic costs of alcohol misuse.
A
plan of action
Implementing Health Sector Interventions
Only summary information is provided. Further details are available
both in a manuscript titled ‘Alcohol Policy and Public
Health in South Africa’ and in several short briefing documents.
The first step is to identify alcohol problems at the primary
health care level. Health workers need to ask patients about
their drinking practices in a way which will illicit honest
answers. Secondly, there is a need to institute brief interventions
for heavy drinkers at the primary health care level. I am not
referring here to ‘alcoholics’. Ongoing research in
this area has been undertaken by the WHO in various developing
countries including Zimbabwe. This research has stressed that
the target should be on consumption of alcohol itself and the
focus should be on responsible drinking rather than abstinence.
Two strategies have been proposed, first very brief interventions
of 5-10 minutes of advice giving as well as provision of leaflets.
The advice should focus, for example, on encouraging people
to drink more slowly, to drink smaller quantities each time
and on how to avoid intoxication. On the other hand, brief intervention
takes longer and comprises a form of condensed cognitive/behavioural
therapy that includes the use of a self-help manual as well
as follow up visits. Pregnant women should be encouraged not
to drink.
The Department
of Health also needs to engage in health promotion with regard
to substance abuse. Information needs to be provided to the
public at large with regard to responsible, hazardous, and harmful
levels of alcohol consumption for males and females. People
should be encouraged to drink in moderation, to use food when
they drink alcohol and to have at least two alcohol-free days
per week. They should be instructed not to drink when taking
medication, and not to drink when driving or using other kinds
of machinery. Health promotion efforts also need to be aimed
at specific populations, such as pregnant women and youth. The
Department of Health should also support counter-advertising
efforts to ensure that the public can make informed choices
about the use of alcohol products. Currently the liquor industry
holds the monopoly regarding the amount of information that
is provided to the public. Counter advertising should be prepared
for radio and television. Consideration should also be given
to putting warning labels on alcohol containers as has been
done for tobacco. They could contain messages such as on the
dangers of drinking and driving and drinking while pregnant.
Investigation is needed into the need for greater restrictions
on sport sponsorship by the alcohol industry. Attention should
also be given to media advocacy to ensure that alcohol is addressed
responsibly by the media in programming and reporting.
At a primary
health care level, mechanisms need to set up for managing and
referring patients with more chronic and acute problems. Protocols
for assisting patients to withdraw safely from alcohol should
be developed. Detailed facilities should be established at regional
hospitals and appropriate referral mechanisms set up. Support
should be provided to community structures to address alcohol-related
problems, including setting up support groups for families and
day care programmes for alcoholics. Work place interventions
should also be encouraged. The MRC has provided a resource on
this topic.
Finally,
there is a need to set up longer-term inpatient programmes (eg.
14 days) especially for rural and peri-urban populations.
Lobbying/Supporting
Intervention for Other Sectors
The Department of Health should lobby the Department of Finance
to increase excise taxes on beer and brandy by 20-25% to bring
it back to 1985 levels. Future increases should at a minimum
be linked to the Consumer Price Index. International research
has shown that the price of alcohol does have an effect on consumption
and not only among moderate drinkers. The Department of Trade
and Industry needs to be lobbied to implement and enforce coherent
strategies for licensing liquor outlets. The Department of Housing
needs to be encouraged in its efforts to upgrade housing, and
especially to create recreational facilities as part of development
initiatives. The Department of Health should work with the Department
of Education in developing and implementing appropriate life
skills programmes in the schools. The Department of Health also
needs to act as a watchdog with regard to the Police and Justice
sectors, for example to ensure the enforcement of existing legislation
in areas such as the “dop” system, with regard to
the minimum drinking age, with regard to public drunkenness,
and with regard to drinking and driving. The Department should
also consider working more closely with the Department of Welfare
to establish a national clearing house of substance abuse information.
Clearinghouses have provided useful information to community
organisations and professionals in countries such as Canada
and the USA.
Translating
policy into action
Within the Health Sector
There is firstly a need to address the training needs of health
care workers in detecting, managing, and referring persons with
alcohol problems. This could take place via basic training which
could include courses in alcohol assessment, handling withdrawal,
brief intervention techniques, and referral mechanisms. It could
also take place via in-service training, and through the use
of written training materials. The National Institute on Alcohol
Abuse and Alcoholism in the USA for example, has prepared a
guide for general practioners on how to address alcohol abuse
among their patients. There is also the need to change the attitudes
of health workers towards patients with alcohol problems. There
is a need to allow more time for direct patient care and in
general to increase the focus on preventive as opposed to curative
medicine. Particularly important will be the establishment of
effective supervision and support structures for health workers
who deal with substance abusing patients.
Within
the Broader Environment
There is a need for greater involvement of the Department of
Health in efforts to develop an intergrated substance abuse
strategy, cutting across Government Departments such as Health,
Welfare, Justice, Safety and Security, Foreign Affairs, Agriculture,
etc. with yearly action plans. The Department should support
the creation of a central agency with executive powers and full-time
staff to direct this strategy. There is widespread feeling that
the Drug Advisory Board should be reconstituted as an executive
body outside of Welfare under the Deputy President’s office.
Also important are improved mechanisms for engagement of community
structures and adequate funding.
The
role of substance abuse surveillance and evaluation research
I was encouraged that areas such as trauma, cancer, and drug
abuse featured so highly at the Essential National Health Research
Priority Setting exercise in November 1996. I hope that in whatever
way the Department of Health decides to proceed in addressing
alcohol abuse, that resources will be set aside for programme
evaluation. There are three reasons why an ongoing substance
abuse surveillance/monitoring system is required:
- To inform
policy and planning, especially by acting as an early warning
system;
- To broadly
evaluate the effectiveness of interventions; and
- For
advocacy purposes, eg. to lobby for resources.
The Medical
Research Council has set up a network of stakeholders in Cape
Town and Durban. Indicators have been agreed upon and these
are being collected on a six-monthly or yearly basis in three
areas, namely the nature and extent of alcohol and other drug
use, the consequences of alcohol and other drug use, and thirdly,
resources to address alcohol and other drug abuse. Data were
collected from a variety of sources between July and December
1996, and in February this year we held the first report back
meeting. Funding was received from the United Nations Development
Programme and the Medical Research Council and technical support
was provided by the World Health Organization and the National
Institute on Drug Abuse.
There were
both primary and secondary data sources. By secondary we refer
to the use of existing data. During Phase 1 (July-December 1996)
information was collected from the following sources: specialist
treatment centres, acute psychiatric admissions units, the police,
mortuaries, the provincial drug and alcohol abuse forum’s
working groups, newspaper articles and ethnographic research
on drug users, outreach workers and pharmacists. During Phase
2 (January-June 1997) data will be collected from the same sources.
In addition, we will be undertaking school surveys and a study
of trauma patients (using biological markers). We would like
to add a study of arrestees using biological markers. This will
depend on the availability of funds.
Selected
Findings (July-December 1996)
We noted changes in the nature of consumption towards drugs
like crack, cocaine, Ecstasy and heroin. We also noted an increase
in juvenile arrests. In Cape Town the percentage of juveniles
arrested in the first half of last year was 8% as compared to
26% for the second half. It is clear that youth are being used
in drug distribution. With regard to treatment data, we noted
that 6% of patients in Cape Town in specialist treatment centres
were under 20 years of age, versus 11% in Durban. It is also
apparent that new routes are opening up with regard to drug
distribution. For example, heroin is now coming in from Columbia.
We also noted a gap in drug treatment services in disadvantaged
communities. There also appears to be increased availability
of illicit substances, both in terms of price and access. With
regard to alcohol, this is still the drug for which the most
persons are seeking specialist treatment: 77% in Cape Town and
75% in Durban. We also noted an increase in police arrests for
drinking and driving by 29% from the last quarter of 1996 as
compared to the last quarter of 1995.
We need
trend data to keep track of the epidemic just like we would
for infectious diseases. This drug surveillance system has proven
useful in the USA over the past 21 years in acting as an early
warning system and in influencing policy. In the USA it involves
20 cities. Similar systems exist or are being set up in North,
South and Central America, the Caribbean, West, East and Central
Europe, South and East Asia and Australia. Ongoing state funding
is required to ensure that the surveillance system continues
beyond Phase 2 (January-June 1997) and to facilitate its expansion
to Gauteng and elsewhere.
Conclusion
To recap, I have provided a situation analysis of the extent
of the problem, a plan of action which can be implemented within
the health sector as well as ways in which the Health Department
could influence and support interventions by other sections.
The Action Plan has been endorsed by the Western Cape Alcohol
& Drug Abuse Forum and by the Gauteng Substance Abuse Forum.
A plea was made for establishing mechanisms for translating
policy into action, both within the health sector and within
the broader environment. The role of ongoing substance abuse
surveillance and evaluation research in the policy process was
stressed. We have therefore come full circle. Research plays
a critical role in defining the situation, and research is also
important in the ongoing efforts to direct policy in this area.
Briefing
documents provided
- Alcohol
misuse and PHC (by Charles Parry & Anna Bennetts, MRC).
-
Work site interventions to address alcohol misuse (by Charles
Parry & Anna Bennetts, MRC using material from the US
Join Together programme).
-
The physician's guide to helping patients with alcohol problems
(NIAAA).
Additional
References
-
Parry CDH. Submission to the Gauteng Department of Economic
Affairs & Finance on revisions to Liquor Legislation,
25 October 1996.
-
Lerer L, Matzopoulos R, Phillips R, Bradshaw B. Violence and
injury mortality in the Cape Town Metropole 1995. Cape Town:
Medical Research Council, 1996.
-
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.
-
Murray CJL, Lopez AD. Quantifying the Burden of Disease attributable
to ten major risk factors. In: Murray CJL, Lopez AD, editors.
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.
-
Parry CDH. Translating substance abuse policy into action
in South Africa. In R. Abdool (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 (pp. 35-38). Port Louis,
Mauritius: Dr Idrice Goomany Centre, 1996.
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