the illegal narcotics trade in southern Africa:
a programme for action
Charles DH Parry, PhD
Medical Research Council

Presentation to the South African Institute of International Affairs
Johannesburg: 6 June 1997

Introduction
I welcome the invitation to speak today on a topic of vital importance to South Africa and to our neighbours. Given the title of this workshop, the focus of my presentation will be solely on illicit drugs. However, aneffective approach to addressing the problems of substance abuse in the sub-continent will require giving attention to all drugs, including alcohol, tobacco, volatile solvents, over-the-counter and prescription drugs, as well as to the so-called "illicits" (WHO Expert Committee on Drug Dependence, 1993). As I am speaking in a session on South Africa I will take this country as my focal point, but shall also be directing attention to our neighbours in the Southern African Development Community (SADC).

I will address four questions:

• Why do we need a new drug strategy or master plan in South Africa?
• What factors should guide the formulation of a new drug master plan?
• What components could be considered for inclusion in such a plan?
• What conditions are needed to support the implementation of a drug master plan in South Africa?

Why do we need a new drug strategy or master plan in South Africa?
South Africa currently does not have an integrated drug control strategy or master plan, though the Department of Welfare’s Drug Advisory Board is currently drafting a strategy document for discussion. A drug master plan has been defined by the United Nations Drug Control Programme as:

...the single document adopted by a government outlining all national concerns in drug control. It summarizes authoritatively national policies, defines priorities and apportions responsibilities for drug control efforts." (UNDCP, 1995, p. 2)

An integrated national drug strategy or master plan is one way of organising collective efforts to reduce drug abuse. At least two factors highlight the urgency of making a new response at this time. First, the increasing burden of harm associated with the abuse of illicit drugs and drug trafficking, and second, the changing global, regional and local environment.

Burden of harm associated with drug use
Time does not permit me to go into much detail regarding the burden of harm associated with the drug trade and the use of illicit drugs. However, brief mention of this is required to situate the need for specific action at this point in time.

Internationally, as a result of the work of Murray & Lopez (1996) a clearer picture is emerging of the burden of harm associated with the use of substances such as alcohol, tobacco and illicit drugs. Figure 1 provides an indication of the burden of harm from alcohol, tobacco and illicit drugs based on disability adjusted life years lost (DALY’s) in 1990 as a proportion of the global burden of harm for the world, fordeveloped regions, for developing regions and for Sub-Saharan Africa. In terms of mortality, the burden of harm from illicit drugs is still fairly small in comparison to alcohol and tobacco, but worldwide it is estimated that in 1990 100 000 deaths could be attributed to illicit drug use. While the proportion of deaths that can be attributed to illicit drug use in Sub-Saharan Africa is low (0.2%) one may be able to infer from the data from other regions of the world that the burden will increaseas development takes place.

Figure 1: Global burden of disease and injury attributable to selected risk factors, 1990 (y-axis logarithmic scale)

Although causation is difficult to prove, there is now local empirical support for a link between drug use and mortality. In a study which allowed for an assessment of alcohol, cannabis and Mandrax (methaqualone) in the blood of a sample of fatally injured pedestrians and homicide victims seen at the Salt River Mortuary in Cape Town in 1996, Foster (1996) found that of the 70% of homicide victims who were alcohol positive, 80% were also were found to have other drugs in their system (33% cannabis, 10% Mandrax and 37% cannabis/Mandrax in combination). Of the 78% of fatally injured pedestrians who were alcohol positive, 64% were found to have other drugs in their system (34% cannabis, 19% Mandrax and 11% cannabis/Mandrax in combination). In terms of health-related morbidity, Peden & van derSpuy (1996), following a review of the local literature on drug use and trauma argue that while alcohol is still the most important determinant of crash risk, injury severity and outcome, drugs use is related to crash causation.

The burden of harm from drug use is likely to have a greater impact on the social and economic sectors of society than on the health sector. A recent paper by Ryan (1997), which was profiled in the Mail & Guardian in May 1997 (Garson, 1997), reviews the relationship between illicit drugs, violence and governability in South Africa. The authors conducted a Delphi survey of key informants from various sectors (Health, Research, Law Enforcement, Justice, etc.) and also reviewed local newspaper articles and international sources. They came to the conclusion that the illicit drugs trade has the potential for significantly destabilizing South African society and that further community initiated confrontation with drug dealers and traffickers is viewed by many as a necessary catalyst for government action.

The link between drug use and crime has been demonstrated most clearly by research conducted in the USA. One review (US Department of Justice, 1994) concluded that drug users in the general population are more likely than non-users to commit crimes, arrestees frequently test positive for recent drug use, incarcerated offenders were often under the influence of drugs when they committed their offenses, and offenders often commit offenses to support the drug habit. Local research suggests that just under half of male prisoners (or parolees) take alcohol/drugs at the time of, or before committing their most recent offense (Rocha-Silva & Stahmer, 1996).

While there is consensus that certain substances such as stimulants and hallucinogens may be associated with violent behaviour, most psycho-pharmacologically induced violent crime involves alcohol rather than illicit drugs (De La Rosa, Lambert, & Gropper, 1990). On the other hand, there is considerable evidence of a relationship between drugs and economic compulsive violence. That is, the high cost of drug use often causes users to commit economic compulsive violent crime to support their drug habit (Collins, 1990). In terms of the link between drugs and violence, however, violence resulting from the drug distribution system is thought to be more pervasive than economiccompulsive violence (Collins, 1990). This systemic component refers to the violence intrinsic to the lifestyles and business methods of drug traffickers and distributors and, for example, comprises disputes among rival distributors and arguments and robberies involving buyers and sellers. Other forms of violence can also be linked to the drug trade, including violent confrontations between community activists/vigilantes and drug dealers/drug lords,violence between the police and vigilantes, and violence between police and drug dealers/drug lords. The Western Cape saw much of this type of drug-related violence in the last quarter of 1996 and in the beginning of 1997 (Parry, under review).

One area which has been little studied in South Africa is the effect of substance use on school performance. This is especially important given the proportion of young people consuming alcohol and other drugs (Flisher, Ziervogel, Chalton, & Robertson, 1993) and given the priority afforded young people in the government’s Reconstruction & Development Programme (RDP). Yamada, Kendix, & Yamada (1996) in a study using data from the US National Longitudinal Survey of Youthfound that increases in the incidence of frequent drinking, liquor and wine consumption, and frequent cannabis use significantly reduced the probability of high school graduation.

The best estimate of the economic cost of alcohol misuse to South Africa, based largely upon the experience of other countries, is 2% of the Gross National Product per year, that is R9.5 billion at current levels or R230 per person per year (Parry & Bennetts, under review). In comparison, according to the United Nations International Drug Control Programme, inappropriate use of narcotic drugs is estimated to cost countries between 0.5%-1.3% of their Gross Domestic Product annually (Chawla, personal communication) For South Africa this would amount to R2.4 billion to R6.3 billion.

The changing situation globally, in the sub-region and in South Africa
A further motivation for formulating a drug master plan is the need to respond appropriately to the changing patterns of drug use and in the supply of illicit drugs. At a global level the drug scene has been shown to be extremely dynamic. In terms of production, changes have been noted both in the site of production as well as in the substances being produced. Globally, for example, there has been an increase in production of substances such as heroin, cocaine and amphetamines.In Southern Africa, laboratories where Mandrax is being produced have been discovered in South Africa and in Zambia. In terms of distribution, according to the US International Narcotics Control Strategy Report, South Africa has now become significant cocaine and heroin transhipment point. South Africa is now also seen as a market for drugs such as crack cocaine, heroin and Ecstasy and as a producer of high quality cannabis destined for the European market (US State Department, 1996).

Countries are also affected by the varying responses of other countries to drug trafficking and the production of narcotic substances (US State Department, 1996). As some countries, for example in Europe and North America have set up improved demand and supply reduction strategies, drug traffickers have turned their sights on developing new markets and trafficking routes in other parts of the world, including Southern Africa and Eastern Europe (Grové, 1994). South Africa’s advanced banking and communication systems also makes it anattractive site for laundering the proceeds of drug sales and for coordinating the onward distribution of drugs (Atkins, 1997).

The current policy arena with regard to both alcohol and other drugs in South Africa is in a state of transition. On the one hand, this reflects the fact that public officials and others have recognised the need toproactively reassess policy and practice in this area as part of the process of instituting changes in the broader policy arena. On the other hand, it reflects a need to respond to the effects of certain changes that have occurred in recent years which have impacted upon substance use and abuse. Such changes include, for example, the effects of reductions in internal controls following the collapse of Apartheid and increased air- and land-travel to and from South Africa. Pressure for change is likely also to reflect external pressure from countries like the USA, international bodies such as the United Nations, regional bodies such as the Southern African Development Community (SADC), as well as from local groups such as People Against Gangsterism and Drug Abuse (PAGAD), the Drug Advisory Board, and provincial substance abuseforums.

What factors should guide the formulation of a new drug master plan?
There are several factors that should guide the formulation of a drug master plan for South Africa:

• Epidemiological and other research into groups at risk and possible future trends
• An understanding of factors associated with drug use
• The aims and specific objectives of such a master plan
• A review of past and current initiatives to address substance abuse locally, and an understanding of their strengths and weaknesses.
• International experience regarding approaches that are likely to be productive/unproductive.

Epidemiological and other research into groups at risk and possible future trends
This area has been addressed by the previous speaker (Rocha-Silva, 1997) in her presentation "Drug use in South Africa". Research conducted by the Medical Research Council and our colleagues as part of the South African Community Epidemiology Network on Drug Use (SACENDU), an ongoing drug monitoring system which has initially been set up in Cape Town and Durban, has also highlighted the dominance of alcohol, cannabis and Mandrax in both cities. This system integrates data across various sectors such as health, welfare,justice, police and education on a six-monthly/yearly basis. The research, furthermore, suggests several possible changes in the drug scene, including a move away from the use of drugs such as cannabis and Mandrax towards crack cocaine, heroin and Ecstasy (MDMA), especially by younger populations; an increase in the availability of drugs; increasing involvement of youth in drugdistribution; and changes in drug trafficking routes. It also highlighted differences in treatment resources between the two cities, as well as possible limitations on access to treatment by disadvantaged sectors of society (Parry & Bhana, 1997, in press).

Understanding of factors associated with drug use
An understanding of the factors that contribute to and maintain substance abuse is important in guiding policy formulation. Plant & Plant (1992) have provided a list of factors which have been linked with various forms of psychoactive drug use among youth (Table 1). The factors have been put into three categories: individual factors, environmental factors, and constituent factors. Most of these factors are also likely to influence drug use by the adult population. Due the fact that drug use is occurs as a result of multiple, interacting factors, a drug master plan should ideally be comprehensive, focusing on issues at the individual, environmental, and even biological levels.

Table 1: Factors associated with drug use and misuse (Plant & Plant, 1992, p. 11)

Objectives
An important element in preparing an effective drug master plan is a well thought out aim and specific objectives. These need to be decided on following some sort of consultative process. Most national drug strategies or master plans have as their aim the reduction of drug use and drug-related harm. Table 2 sets out the goals of the US 1995 National Drug Control Strategy (ONDCP, 1995) and the English drug strategy (HMSO, 1995).

Table 2: Goals of the US 1995 National Drug Control Strategy (ONDCP, 1995) and the English 1995-1998 "Tackling drugs together" strategy (HMSO, 1995)

Review of past and current initiatives to address substance abuse locally
In the past, efforts to address drug abuse by the State have focused largely on "control" measures falling under the jurisdiction of the Departments of Police and Justice. In addition, the State, through welfare agencies such as the South African National Council on Alcoholism & Drug Dependence (SANCA), has provided resources for the treatment of persons having substance abuse related abuse problems (Parry, 1996). More recently other departments, for example, Health and Education have started to become more involved in addressing substance abuse.

Interdiction and supply reduction mechanisms
The Drugs and Drug Trafficking Act, Act 140 of 1992 makes it an offense to supply certain substances to any person knowing or suspecting that the substances will be used for the manufacture of illegal drugs, prohibits any person from converting property that they know or suspect to be gained from the proceeds of drug trafficking, and makes dealing in dangerous and undesirable drugs an offense punishable by up to 25 years imprisonment.

Various administrative and legislative changes have been introduced since 1995 by the police and justice sectors which should improve the ability of the country to reduce the supply of illicit drugs and to apprehend drug dealers/traffickers:

• In May 1995, the South African Narcotics Bureau (SANAB) was restructured and divided into two divisions, one dealing with international drug syndicates and the other policing localised drugs and vice.
• In November 1995 new regulations were announced by the Minister of Justice which would strengthen international cooperation in the fight against drug trafficking by setting up an administrative framework whereby confiscation and restraint orders made in certain designated countries can be enforced in South Africa and visa versa.
• In May 1995 the National Crime Prevention Strategy was approved by Cabinet. This strategy draws together a range of government departments to develop a holistic approach to fighting crime. Organised crime was listed as one of seven priority areas.
• In August 1996 the first of three bills aimed at combatting international drug trafficking and at sharpening extradition laws was tabled in Parliament: the Proceeds of Crime Bill, the International Cooperation in Criminal Matters Bill and the Extradition Amendment Bill. The first of these will enable courts to confiscate from criminals the proceeds of crime and will prohibit money laundering.
• In April 1997 the Minister of Safety & Security announced that the government is to introduce strict measures to tighten South Africa’s ports of entry in a bid to stem the influx of drugs and arms (Rantao, 1997). He stated that bulk commercial traffic would be cleared through only 19 of the 52 existing border posts and that cargo would be cleared at only eight of the 36 airports.

Furthermore, South Africa has placed itself at the centre of regional counter-narcotics efforts by playing a key role in the establishment of a Protocol on Combatting Illicit Drug Trafficking in the Southern African Development Region signed by 12 Southern African countries. South Africa has also entered into a number of formal and informal agreements with various countries (USA, UK, Brazil, etc.) with regard to mutual legal assistance, intelligence sharing, cooperation in counter narcotics efforts and training.

Treatment, rehabilitation and prevention
The State has provided resources for the treatment of persons having substance abuse related abuse problems. Unfortunately, funding for treatment has been inadequate and treatment facilities were poorly distributed throughout the country. They also tended to be concentrated in large, urban areas. Under the Apartheid system there were major disparities in the resources spent on substance abuse for the different races. There has been minor involvement by the Health, Education and other sectors in addressing substance misuse, and scant resources have been spent on prevention (Parry & Bennetts, under review).

In 1988 the National Plan to Prevent and Combat Alcohol and Drug Abuse in South Africa was formulated by the National Advisory Board on Rehabilitation Matters in collaboration with experts in the private and public sectors. In late 1992 the Minister of National Health and Population Development convened a colloquium to facilitate implementation of a revised version of the 1988 Plan, now termed a National Strategy Against the Abuse of Alcohol and Other Drugs (National Advisory Board on Rehabilitation Matters, 1992).

The Prevention and Treatment of Drug Dependency Act, Act 20 of 1992, provides for the establishment of the Drug Advisory Board (DAB) to "advise" the Minister of Welfare on matters pertaining to alcohol and drug abuse. Its specific mandate was to plan, coordinate and promote measures relating to the prevention and combatting of drug abuse and the treatment of drug dependent persons. The DAB has revised and accepted the National Strategy Against the Abuse of Alcohol and Other Drugs (Drug Advisory Board, 1994). The National Strategy has four aims:

• To promote the development and utilisation of appropriate information, education, development and prevention programmes needed for a healthy lifestyle free of drug abuse.
• To promote the development and utilisation of multi-dimensional and multi-professional programmes for identification, assessment, treatment and aftercare and thereby achieve the effective reintegration of the abuser/dependent person into the community.
• To promote the development of appropriate programmes in the field of combatting drug abuse through research and the introduction, dissemination and implementation of relevant research results
• To promote a community free from drug abuse through effective control over the availability of dependence-producing and related substances and through law enforcement with regard to drug-related offences.

Unfortunately this national strategy was not implemented to any significant degree. While no investigation has been undertaken to assess why this occurred, likely explanatory factors include the failure, (1) to provide dedicated leadership to oversee the implementation process, (2) to provide resources to carry out the implementation, and (3) to bring on board the African National Congress and other political parties at the policy development stage. The failure to successfully implement a coherent strategy at national and other levels has resulted in fragmentation of effort. A new DAB was formed in 1995. The efforts of this Board have been limited by many of the same problems that hampered its predecessor (Parry, 1996).

During the second quarter of 1995 the Department of Welfare completed a lengthy series of consultative meetings and released the second draft of its White Paper titled National Substance Abuse Strategy (Department of Welfare, 1995). The final draft of the White Paper for Social Welfare was released for comment in the second half of 1996. It is likely that an amended Prevention and Treatment of Drug Dependency Act will be promulgated by the end of 1997. The White Paper provides general guidelines for how the welfare sector will address substance abuse, but is short on specifics, particularly the role of provincial and district level structures. Amongst other things it calls for an intersectoral approach. It stresses the importance of international networking. In terms of prevention it calls for communities to take greater responsibility. It stresses that media campaigns are needed for public education. Education programmes will be targeted at school-going children, youth and parents. The focus of secondary prevention will be on high-risk groups using mechanisms such as employee assistance programmes and youth forums. In terms of tertiary prevention it states that the focus should be on vulnerable and high risk groups and disadvantaged communities, and that there is a need to develop and promote community-based treatment approaches, especially those that promote empowerment and self-help. Specialised accredited training units will be established to provide adequate training for allied personnel and volunteers. The White Paper also supports the establishment of substance abuse forums at national, regional and local levels which amongst other things will lobby for the establishment of effective services, as well as for the establishment of a representative consultative and coordinating body which will foster partnerships and ensure the implementation of a national strategic plan for combatting substance abuse (Department of Welfare, 1996).

1996 was a difficult year for both provincial departments of welfare and for NGOs working in the area of substance abuse. For example, the substance abuse section within the Western Cape Department of Social Services was ranked second to last in terms of priorities and state funding to NGOs and state treatment centres was substantially cut. On a more positive note, following on from the launch of the Department of Welfare’s "I’m Addicted to Life" anti-drug educational campaign in May 1995, a 13 part TV programme was produced and distributed.

With regard to the health sector, 1995 also saw restructuring within the Department of National Health. Its Mental Health Directorate was reorganised to include substance abuse. In February 1995 the Department convened a consultative meeting to look at how the health sector could become more involved in addressing substance abuse, and by the end of June 1995 the Department completed its strategic plan to address mental health and substance abuse (Mental Health & Substance Abuse Committee, 1995). This report builds upon the Welfare White Paper and previous initiatives, including the Consultative Workshop. It sets out the role of the Department of Health, sets out clear national objectives to be reached and a number of strategies for achieving these objectives. Like the second draft of the Welfare White Paper, it is not, however, an integrated strategy and as a result fails to properly describe the role of provincial and district level structures and the public sector. Scant details are provided in important areas such as primary prevention (Parry & Bennetts, under review).

For a variety of reasons, including vacancies in important national posts such as the Deputy Director: Substance Abuse Policy and in senior Mental Health posts at provincial levels, there has not been significant movement in terms of substance abuse policy development and implementation within the health sector. In terms of services, 1995/6 saw the closure of substance abuse treatment facilities, including the Drug Unit at Lentegeur Hospital in Cape Town. It does not appear that substantial changes have yet taken place at a primary health care level to ensure the adequate training of primary health care staff in the detection, management and referral of substance abuse cases.

A document titled Towards a National Health System sets out in more detail the policy formulations of the Department of Health’s Directorate: Mental Health & Substance Abuse. This documents serves as the basis for the development of the Health White Paper. In terms of implementation strategies (§12.1.1), this document indicates that at the national level functions of the Directorate include evaluating the prevalence of mental health problems and the promotion of strategies for addressing the problems identified, coordinating the restructuring of mental health services (including the development of norms and standards, as well as the integration of mental health services into primary health care), promoting intersectoral coordination and the multidisciplinary team approach, developing norms and standards for the education and training of mental health and human resources, monitoring and evaluating mental health services nationally, and developing and promoting specific programmes addressing substance abuse. Functions set out for the provincial health authorities include facilitating intersectoral coordination, and ensuring the comprehensive integration of mental health and substance abuse services. District health authorities are tasked with providing substance abuse prevention, promotion and rehabilitative services at district and community levels, planning and implementing in-patient and day-patient care for substance abusers at district and community levels, training health facility staff, and health education programmes in communities (Department of Health, 1995).

The Departments of Welfare and Health have also played an important role in the setting up of the South African Alliance for the Prevention of Substance Abuse (SAAPSA) which was established to facilitate networking amongst organisations concerned with substance abuse in South Africa with a view to optimise cooperation around prevention of substance abuse (Yach, Parry & Harrison,1995).

The National Department of Education is currently involved in an ambitious curriculum reform programme (Curriculum 2005) due to be launched in 1998. This programme also involves a life skills education component which will seek to address adolescent risk behaviours such as drug use and teenage sexuality as part of a holistic initiative aimed at the healthy development of young people. Certain police departments (e.g. in the Western Cape) have also become involved in educating school-age students about the dangers of drug use.

Summary
In summary, on many fronts the country is actually moving forward in terms of developing a coherent policy platform to address substance abuse. For example:

• As a result of recently approved legislation, including laws on asset forfeiture, extradition, and international cooperation on criminal matters South Africa should finally be able to accede to the 1988 UN Convention Against Illicit Trafficking of Narcotic Drugs and Psychotropic Substances.
• SANAB has been restructured to increase its efficiency in apprehendig larger drug syndicates and staff members have undergone further training with the assistance of the US Drug Enforcement Administration
• Administrative changes have been made to reduce the number of ports of entry for bulk commercial traffic and cargo.
• The Department of Welfare’s "I’m addicted to life" programme is reaching many young people.
• The Department of Health has appointed a Deputy Director for substance abuse policy
• The Department of Education’s curriculum reform programme will include a life skills education component which will seek to address adolescent risk behaviours such as drug use.
• The Drug Advisory Board is moving ahead with its own initiative to develop a drug strategy and has also broadened its base to include young people.

On the negative side:

• The primary health care (PHC) system does not appear to be functioning to the point that significant numbers of persons with substance abuse problems are being detected and managed at the PHC level.
• Within the Welfare sector, resources for addressing substance abuse appear to be reducing.
• Law enforcement efforts aimed at detecting drug trafficking and arresting drug dealers are severely hampered by the lack of human and other resources.
• Substance abuse activities are not guided by an overall national framework. As a result intervention activities are fragmented and not adequately resourced.
• State funding has not been set aside to support the monitoring of substance abuse trends over time and the evaluation of the effectiveness of existing policy interventions.

International experience regarding approaches that are likely to be productive/unproductive
In preparing a drug master plan we also need to learn from other countries’ successes and failures in designing and implementing drug control strategies. Below are set out several broad principles, drawn from a fairly wide reading in the area:

• Have a multi-faceted approach focusing on all psychoactive drugs, including alcohol and tobacco.
• Do not be overly focused on "control" strategies aimed at reducing supply. While law enforcement and supply reduction strategies are important, a significant amount of effort needs to go into reducing the demand for drugs.
• Within supply reduction approaches it is important to look beyond border control and internal policing to money laundering and issues such as police corruption
• Within demand reduction approaches it is useful to put a high priority on young people. In general, community-based approaches have an important role to play and is helpful to support the development of partnerships between professional/state agencies and community organisations. Families of users as well as drug users must be involved.
• In expanding prevention services, treatment and rehabilitation must not be neglected

What components could be considered for inclusion in such a plan?
Process issues
Before setting out certain key components for possible inclusion in a drug master plan I would like to stress that such a plan should not be the work of one person or even a group of persons, but should rather involve a consultative process involving those stakeholders most likely to be involved in its implementation. Certain key groups such as community-based organisations (including youth organisations and religious bodies), political parties, and the business community must not be excluded from this process. While the consultation process is itself a useful part of the whole process of bringing together different stakeholders involved in substance abuse, it should not, however, be seen as a license to unreasonably delay development of a master plan. Preparation of a draft plan may well serve as a useful departure point.

Overview
Substance abuse is only likely to be successfully addressed if a comprehensive approach is implemented (Yach et al., 1995). Such an approach needs to focus on three areas of activity: (1) supply reduction (including the suppression of illicit trafficking), (2) demand reduction (including prevention, treatment, and rehabilitation), and (3) research. In each of these areas specific activities need to be targeted at local, provincial, national, and international levels. Within each area it may be helpful to set short-, medium- and long-term goals. A framework for organising activities has been set out in Table 3 below.

Table 3: Framework for organising drug intervention activities

There are no simple solutions to reducing illicit drug use and minimizing the harm associated with such use. Within each of the 16 areas indicated there are a range of activities that could be initiated or further developed. I will provide specific examples (goals) for each of these areas. Some of these activities have been suggested by other governments and international bodies (e.g. HMSO, 1995; Southern African Development Community, 1996; United National International Drug Control Programme, 1988, 1995; ONDCP, 1996; WHO Expert Committee on Drug Dependence, 1993), as well as by local and international role-players (Atkins, 1997; Drug Advisory Board, 1994; Ryan, 1997; Yach et al., 1995). Unfortunately only a few of these strategies have been "empirically" tested, mostly in the prevention and treatment area at the local level, and largely in the USA and Europe (see for example, Botvin & Tortu, 1994; Lorion & Ross, 1992; NIDA 1997). However, many of them have been tried elsewhere and been found to be useful. The specific choice of activities and the setting of priorities is should be left up to the government and other key role players. A further iteration of the activities listed below would be needed to get them to a state where they are specific and measurable. It should be noted that activities have begun in many of the areas listed below. What has been missing is an overall national framework within which to situate a coordinated programme of action.

Supply reduction
International level [1]

• Increase collaboration and communication with international drug control agencies in controlling illicit production of drugs and in drug trafficking (Interpol, UNDCP, member states within SADC, etc.). This could be facilitated, for example, by mounting joint police exercises across national boundaries to stop drug smuggling, and by holding regional conferences on drug trafficking.
• Establish bilateral and sub-regional agreements on drug supply reduction to cover issues such as the harmonisation of laws and penalties
• Exert diplomatic pressure on countries in Africa and elsewhere which are known conduits for drugs to the sub-continent
• Continue and expand the practice of posting Drug Liaison Officers to key countries e.g. Thailand and Brazil

National level [2]

• Amend the National Crime Prevention Strategy to give greater prominence to activities related to addressing drug abuse by the Departments of Correctional Services, Justice, Safety & Security, South African Police Services, Welfare and Health
• Reduce the number of points of entry into the country
• More active involvement of Defence Force in border control
• Introduce stricter controls on controlling chemicals (precursors) used in the manufacture of substances found in illegal drugs
• Deport non-citizens who are involved in drug trafficking
• Improve coordination of different agencies (Police, Defence Force, Customs, etc.) through, for example, improving communication systems
• Address staffing, training, and equipment needs of SANAB and Customs and Excise
• Increase capacity of Receiver of Revenue to go after tax evasion by suspected drug dealers
• Increase capacity of police/prosecutors to pursue money launderers

Provincial level [3]

• Train prosecutors and magistrates to deal with drug cases
• Set up special drug courts
• Improve training of police in drug supply reduction
• Increase efforts to detect and combat fraud and corruption by government officials
• Increase rewards for persons giving information leading to conviction of drug dealers and improve witness protection programmes
• Implement testing for drugs in cases of serious road-related injuries
• Drug testing for parolees and prisoners prior to release
• Eradication of cannabis crops

Local level [4]

• Continue to focus efforts on drug traffickers, not minor users
• Improve community collaboration with law enforcement on drug issues via community policing, local drug action teams, and/or establishing hotlines through which residents can provide information to the police
• Increase police patrols in high intensity drug trafficking areas
• Where appropriate divert those arrested for drug misuse from the penal to the health/welfare systems
• Institute strong measures to reduce under-age drinking

Demand reduction
Prevention
International level [5]

• Strengthen the exchange of information on successful/unsuccessful initiatives with international role players (academic organisations; NGOs; international agencies, e.g. WHO, NIDA) through exchange of personnel, stimulating conference attendance, running regional workshops, and increasing access to resources (programme material, publications, etc.) Support regional crop substitution initiatives in areas where cannabis is cultivated (e.g. South Africa, Swaziland, and Lesotho)
• Pay close attention to the impact of economic liberalisation on drug consumption and trafficking

National level [6]

• Establish a National Institute for Substance Abuse Training and Development to develop and evaluate model curriculums for providing accredited training in substance abuse prevention (at various levels)
• Support crop substitution initiatives in areas where cannabis is cultivated
• Develop and implement drug testing and treatment/rehabilitation programmes in prisons and effective aftercare/parole services
• Develop life skills programmes in schools for preventing substance abuse. For an example of initiatives which have been extensively studied over time see the Life Skills Training Program (Botvin et al., 1995a/b), the Seattle Social Development Project (Hawkins et al., 1992)
• Establish a 24-hour national hotline to provide support and advice on drug misuse
• Establish a clearinghouse for collecting and distributing substance abuse information
• Develop and implement effective media campaigns (targeted to specific audiences and linked to other initiatives)

Provincial level [7]

• Provide opportunities for treatment staff to receive accredited training at a provincial level
• Establish a clearinghouse for collecting and distributing substance abuse information
• Implement life skills education programmes in schools
• Establish mechanisms for training professionals, community workers and others in designing and implementing prevention programmes, e.g. education programmes (targeted at students, teachers and parents), anti-drug rallies, and recreation programmes
• Develop health education programmes aimed at youth, parents, etc.
• Establish early intervention programmes designed to assist young people (advice, counselling, treatment)
• Assist schools in formulating substance abuse policy guidelines
• Establish provincial forums for prevention which support networking and further training of persons working in the field

Local level [8]

• Develop after school-programmes for youth-at-risk. The Reconnecting Youth Programme (Eggert et al., 1994) is an example of a programme that has been evaluated
• Provide assistance to communities in developing comprehensive substance abuse prevention programmes aimed at reducing substance abuse among young persons (e.g. involving parents, schools, churches, businesses, and other government agencies). For an example of an initiative which has been extensively studied over time see the US Project STAR programme (Pentz, 1995)
• Develop and implement programmes designed to strengthen families (e.g. competency programmes for parents). See for example the Focus on Families Program (Spoth, in press) and the Adolescent Transitions Program (Dishion et al., in press).
• Provide drug education programmes on local radio stations and in local newspapers (targeted to specific audiences and linked to other initiatives)
• Encourage the establishment of local forums/coalitions to prevent substance abuse
• Put substance abuse on the agendas of other initiatives e.g. local government, RDP Forums, and housing development committees
• Encourage the establishment of workplace and school policies on managing drug-related incidents and drug-free workplace and school programmes

Treatment and rehabilitation
International [9]

• Strengthen exchange of information on successful/unsuccessful initiatives with international role players (academic organisations, NGOs, international agencies, e.g. WHO, NIDA) through exchange of personnel, stimulating conference attendance, running regional workshops, and increasing access to resources (programme material, publications, etc.)

National level [10]

• Address the crisis in funding of treatment and rehabilitation facilities
• Set up the policy framework needed to ensure that substance abuse problems can be adequately addressed at the primary health care level (e.g. improve training opportunities for nurses, doctors and social workers in diagnosis, management and referral of drug cases; develop training manuals; address constraints on staff time; and attitudinal issues)
• Improve drug treatment programmes for hard-core drug users, e.g. in prisons
• Establish a National Institute for Substance Abuse Training and Development to develop and evaluate model curricular for providing accredited training in substance abuse treatment and rehabilitation (at various levels)

Provincial level [11]

• Address the crisis in funding of treatment and rehabilitation facilities
• Provide opportunities for treatment/rehabilitation workers to receive accredited training and continuing education
• Actively promote the early identification of substance abuse problems by primary health care workers (including general practitioners)
• Ensure adequate access for persons to a diverse range of treatment responses (short-term inpatient treatment at specialist treatment centres/regional hospitals, outpatient treatment, detoxification, day-patient rehabilitation centres, etc.) and establish an appropriate mechanism for matching different modalities to individual’s needs
• Develop backup services (e.g. a 24-hour hotline) for primary health care staff involved in managing patients with substance abuse problems
• Establish forums for persons working in drug treatment and aftercare which support networking

Local level [12]

• Establish a network of after-care services in the community, including half-way houses for recovering addicts
• Strengthen and support the development of self-help organisations working in the area (including religious organisations)
• Make available a range of intervention options, including those designed to reduce the impact of drug use, such as needle exchange programmes, oral methadone maintenance for heroin addicts -- in a way that does not condone use

Research
International level [13]

• Strengthen the exchange of information on research methods, training approaches, research priorities and funding sources with international role players (academic organisations, NGOs, international agencies, e.g. WHO, NIDA) through exchange of personnel, stimulating conference attendence, running regional workshops, and increasing access to resources (programme material, publications, etc.)
• Review drug intervention strategies that have been undertaken and evaluated in other parts of the world
• Lobby for regional access to funding from international agencies such as UNDP, WHO, UNDCP
• Set up regional drug surveillance networks, for example based on the methodology of the South African Community Epidemiology Network on Drug Use (Parry & Bhana, 1996, 1997).

National level [14]

• Establish performance indicators to monitor and evaluate the effectiveness and progress of implementation of a national drug master plan
• Provide greater coordination between agencies conducting research in the drug field to reduce duplication and the increase the quality of research
• Establish a special task-team to investigate the use of drugs such as heroin, crack cocaine and designer drugs and to come up with specific recommendations for prevention. This team could also be tasked with looking into injecting drug use
• Increase funding for strategic research in areas such as drugs surveillance, community-based interventions and treatment/outcome research
• Strengthen mechanisms for dissemination of the findings of key research
• Provide funds for building capacity among researchers from previously disadvantaged backgrounds in substance abuse epidemiology, programme evaluation, etc. (via internship programmes, special training courses, etc.)

Provincial level [15]

• Establish performance indicators to monitor and evaluate the effectiveness and progress of implementation of provincial drug intervention strategies
• Establish provincial research forums which can be used for stimulating research at a provincial level and for building research capacity

Local level [16]

• Implement specific ongoing drug surveillance systems in selected urban and rural settings

Several "needs" are reflected across the lists:

• broad policy changes
• training and staff support/supervision
• information gathering and dissemination
• addressing deficiencies in infrastructure and equipment
• improved networking and coordination
• commitment by both government and NGO sectors
• specific action to address supply/demand reduction in targeted areas

What conditions are needed to support the implementation of a drug master plan in South Africa?
Last month I read an article which contained an interview of Dr Theo Veldsman, an organizational development expert who specialises in organizational effectiveness and who acts as a consultant to many national and international companies operating in this country. In the article Dr Veldsman stated that .....

South African organizations are good at initiating business strategies, and are aware of the need to transform, restructure and reshape. Where they fall down is that the implementation tends to be fragmented; there is often limited consultation with various stakeholders and in particular not enough investment is made in people development to meet these changes. [Mitchell, 1997, 4-6]

What I want to address now, is various mechanisms for translating policy into action. What I will set out is not an exhaustive list of conditions, merely those that I think to be most important.

Increase political will to address substance abuse
Despite imperfections in past national plans or strategies to combat alcohol and drug abuse, the major shortcoming has been failure at the level of implementation (Parry, 1996). Several reasons can be put forward to explain this, including competing priorities, a lack of legitimacy, and most especially human and other resource constraints. Political will is key. Getting the support of high profile political leaders, including members of important Parliamentary Portfolio Committees; major trade unions; big business; political parties; and the media will be essential. Youth and other forms of community involvement are also crucial. In terms of increasing political will, it will be particularly advantageous to link any drug master plan with other national planning tools (UNDCP, 1995). In South Africa these include:

• the RDP and particularly to areas such as youth development,
• the government’s macro-economic plan,
• the Department of Safety & Security’s National Crime Prevention Strategy,
• the Department of Education’s Curriculum 2005 initiative, and
• the Department of Justice’s Vision 2000.

Committed, empowered leadership
At all levels there is a need for improved coordination to ensure that resources are used effectively. At a national level it is recommended that a Parliamentary Sub-Committee be established to bring together politicians from various political parties to work together in addressing substance abuse. This Sub-Committee could oversee efforts to formulate a national drug strategy. It could also serve as a watchdog to monitor the implementation process.

There have been calls by the Attorney General of the Western Cape (Barnes, 1996), the Department of Health’s Mental Health & Substance Abuse Committee (1995) and even the Drug Advisory Board for the establishment of a new, central anti-drug body which would coordinate the activities of all government departments in combatting drug abuse. A body is needed with executive powers to implement the drug strategy. This should go way beyond inter-departmental liaison. The body, which could perhaps be called the Office of National Substance Abuse Policy should have a full time, high profile head and a Secretariat. It could have sections with full time coordinators dealing with Supply Reduction (local and international); Demand Reduction; and Policy, Research and Evaluation (Figure 2). One proposal is that this body should report to the President or Deputy President’s Office (Parry, under review). Alternatively, a Ministerial Sub-Committee of Cabinet could be set up to ensure adequate inter-departmental coordination, to oversee the process and to ensure that appropriate levels of funding are provided. Such a council has been set up in England (HMSO, 1995).

There may still be a need an advisory body along the lines of the present Drug Advisory Board to set overall policy direction, and specifically to set annual or bi-annual goals. This body could perhaps be called the Substance Abuse Advisory Council. In England The Advisory Council on the Misuse of Drugs and comprises 36 members (HMSO, 1995). However, the composition of the present Board would need to be modified to ensure adequate representation of leading NGOs, community-based organizations, provincial drug forums, and research/policy agencies.

Figure 1: Possible structure for drug policy formulation/implementation (national level)

Given the devolution of certain powers to the provinces, we also need to consider formulating provincial drug master plans. Provincial drug forums also have a key role to play in this process and in implementing a national/provincial drug control strategies. The development of initiatives at a town, city or local level to address substance abuse should also be encouraged. Furthermore, substance abuse initiatives should be placed on the agendas of Health City Projects, RDP forums, rate-payers associations, etc. A part of the English national drugs strategy, Drug Action Teams of senior representatives from the police, probation and prison services, local authorities (including education and social services) and health authorities have been set up at the local level. In addition, Drug Reference Groups will be established to provide additional expertise and to harness local community action to tackle drug misuse. Membership comprises drug service users, voluntary and statutory service providers, doctors, school governors, and local business interests.

Adequately funded
Successful implementation of a national drug strategy will also require adequate and sustained funding at all levels. As a start adequate funding should be provided to support the activities of the central anti-drug body as well as for the implementation of specific programmes. Several sources have been identified including RDP funds, increasing the excise tax on alcohol products (which have been falling in real terms relative to the consumer price index), and money obtained as a result of the seizure of the assets of drug dealers (Parry, 1996). In addition, it will be important to access health sector funding previously not available for addressing substance abuse and to influence those public (e.g. education, correctional services) and private sector bodies with an investment in addressing substance abuse to use their own financial and other resources to bear on the problem to a much greater extent than before. Serious consideration should be given to having a separate line item in the Budget relating to substance abuse supply and demand reduction initiatives. In general, there needs to be a balance in spending between demand and supply reduction, with a minimum of 50% being spent on demand reduction efforts (including treatment and rehabilitation). Roughly 3%-5% of the substance abuse budget should be should be spent on research, evaluation and policy formulation. Strict financial accountability must be ensured.

Information driven
Implementation of an effective drug master plan will also require the development and maintenance of a sophisticated information systems at various levels:

• Across different sectors (e.g. police, customs, health, welfare, education, etc.) to ensure accurate and timely information transfer from an operational point of view.
• Within each of the focus areas (supply reduction, demand reduction) there is the need for setting up a clearinghouse of local and international information regarding intervention approaches. This information could be provided to "practitioners" via a national and/or provincial distribution network.
• Ongoing (longitudinal) information on substance abuse trends from various quarters (treatment centres, the police, emergency rooms, schools, mortuaries, etc.) is also required to identify changes in the nature and extent of consumption patterns, negative consequences associated with substance abuse. It is also required to assess the efficacy of public health interventions, as well as to monitor the nature and extent of initiatives and resources directed at addressing substance abuse (Parry & Bhana, 1996, 1997).
• Management-type information is also needed monitor activities undertaken as part of the national drug master plan and to account for money and other resources expended.
• Also required is an evaluation of the outcome of intervention activities associated with the master plan and after some time has passed (3-5 years) an evaluation of the impact of (sub-components) of the master plan. For this to be effective key performance indicators for each goal will need to be specified in advance. The master plan must be seen as an instrument of intervention which itself needs to be evaluated.
• Finally, there is a need for information to be provided on an ongoing basis to a broad range of stakeholders, including government and the public at large.

Dynamic
Establishing a drug master plan should not be seen as the end of a process, but rather the beginning. Furthermore, while the overall master plan may direct national efforts to address drug abuse for many years, there should be certain components of such a plan that will need to be modified on a regular basis. The US National Drug Strategy for example makes provision for setting specific 12-month targets for different focus areas (see ONDCP, 1995)

Recognition and support for persons working in the substance abuse field
In this country and in countries to the north of us there are men and women who have worked for years in the substance abuse field in government departments of Welfare, Health and Justice; in public and private treatment centres; in community-based organizations; in universities and research agencies; in the police; and in schools and religious organisations. If we are to implement a drug master plan in South Africa, we must not neglect those who will carry the burden of its implementation. We should ensure that they are well trained, adequately funded and even recognised.

Conclusion
The abuse of substances such as alcohol and illicit drugs currently has an enormous negative impact upon on the social and economic state of South African society. In the longer term, the failure to adequately address substance abuse could jeopardise the attainment of real reconstruction and development in South(ern) Africa, which goes far beyond the provision of houses, toilets, water, electricity, and even schools and jobs (Parry, under review).

Part of the solution to substance abuse will come from macro-level development (indirect strategies). However, of greater importance is the policy process aimed at directly addressing substance abuse. Unfortunately this process appears to be proceeding in an ad hoc and fragmented manner. While advances are being made, particularly in the areas of interdiction, the lack of real commitment across the political spectrum to addressing substance abuse, the absence of a well thought out (intersectoral) national drug strategy or master plan, the lack of dedicated and empowered leadership at the provincial and national levels to drive such a strategy, the failure to effectively engage grassroots structures in the process, and the apparent lack of commitment to putting adequate resources into research and policy evaluation, is seriously undermining our ability to successfully combat substance abuse.

References

• Atkins, A. (1997). The illegal drugs trade and development in South Africa: some observations. London: Catholic Institute for International Relations.
• Barnes, L. (28 June 1996). Call for national anti-drug body: A-G says state hasn’t done enough to fight abuse. Argus.
• Botvin, G.J., Baker, E., Dusenbury, L., Botvin, E.M., & Diaz, T. (1995a). Long-term followup results of a randomzed drug abuse prevention trial in a white middle-class population. Journal of the American Medical Association, 273, 1106-1112.
• Botvin, G.J., Schinke, S.P., Epstein, J.A., Diaz, T., et al. (1995b). Effectiveness of culturally focused and generic skills training approaches to alcohol and drug abuse prevention among minority adolescents: Two-year followup results. Psychology of Addictive Behaviors 9, 183-194.
• Botvin, G.J., & Tortu, S. (1994). Preventing adolescent substance abuse through Life Skills Training. In R.H. Price, E.L. Cowan, R.P. Lorian, & J. Ramos-McKay (Eds), 14 ounces of prevention: A casebook for practitioners (pp. 98-110). Washington: American Psychological Association.
• Collins, J. J. (1990). Summary thoughts about drugs and violence. In M. De La Rosa, E.Y. Lambert, & B. Gropper (Eds.), Drugs and violence: Causes, correlates, and consequences (pp. 265-275). NIDA Research Monograph 103. Washington, DC: U.S. Government Printing Office.
• De La Rosa, M., Lambert, E.Y., & Gropper, B. (1990). Introduction: Exploring the substance abuse-violence connection. In M. De La Rosa, E. Y. Lambert, & B. Gropper (Eds.), Drugs and violence: Causes, correlates, and consequences (pp. 1-7). NIDA Research Monograph 103. Washington, DC: U.S. Government Printing Office.
• Department of Health. (1995). Towards a national health system. Pretoria: Author.
• Department of Health (1996). National Health Bill (Draft 9). Pretoria: Author.
• Department of Welfare (1996). White Paper for Social Welfare. Pretoria: Author.
• Department of Welfare (1995). National Substance Abuse Strategy (Second Draft). Pretoria: Author.
• Dishion, T.J., Kavanagh, K., & Kiesner, J. (In press). Prevention of early substance abuse among high-risk youth: A multiple gating approach to parent intervention. In NIDA Research Monograph.
• Drug Advisory Board. (1994).National Strategy against the abuse of alcohol and other drugs. Pretoria: Author.
• Eggert, L.L. Thompson, E.A., Herting, J.R., Nicholas, L.J., & Dicker, B.G. (1994). Preventing adolescent drug abuse and high school dropout through an intensive school-based social network development program. American Journal of Health Promotion, 8, 202-215.
• Flisher, A. J., Ziervogel, C. F., Chalton, D.O., & Robertson, B.A. (1993). Risk taking behaviour of Cape Peninsula high school students: IV. Alcohol use. South African Medical Journal, 83, 480-482.
• Foster, M.E. (1996). A comparative study of the incidence of ethanol, methaqualone and cannabis in homicide and pedestrian transport accident victims in the Western Cape metropole area. Unpublished B.Sc. Med. (Hons) degree. University of Cape Town, Faculty of Medicine, Department of Pharmacology.
• Garson (18 May 1997). Dire warning on drugs and violence. MaiL & Guardian.
• Grové, W. (1994). The drug trade as a national and international security threat. Paper presented at the Institute for Strategic Studies and Security Association Security 94 Conference, Pretoria.