Substance Use & Misuse
ISSN: 1082-6084 (Print) 1532-2491 (Online) Journal homepage: http://www.tandfonline.com/loi/isum20
A Misplaced Focus: Harmful Drinking Patterns in South Africa Arvin Bhana To cite this article: Arvin Bhana (2015) A Misplaced Focus: Harmful Drinking Patterns in South Africa, Substance Use & Misuse, 50:8-9, 1089-1091, DOI: 10.3109/10826084.2015.1007658 To link to this article: http://dx.doi.org/10.3109/10826084.2015.1007658
Published online: 11 Sep 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isum20 Download by: [Washington University in St Louis]
Date: 17 November 2015, At: 15:49
Substance Use & Misuse, 50:1089–1091, 2015 C Taylor & Francis Group, LLC Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2015.1007658
ORIGINAL ARTICLE
A Misplaced Focus: Harmful Drinking Patterns in South Africa Arvin Bhana
Downloaded by [Washington University in St Louis] at 15:49 17 November 2015
School of Applied Human Sciences, University of KwaZulu-Natal, Glenwood, Durban, South Africa intrinsically associated with the structural drivers such as poverty and unemployment that is associated with creating and sustaining posited vulnerabilities and makes alcoholic beverages and their consumption an important source of pleasure among a range of other functions. In addition, for many low-income communities, alcohol also serves as a microenterprise opportunity to earn money (especially among women) (Herrick, 2014) amidst conditions of high unemployment (25.4%) in South Africa. It is therefore not surprising that alcohol use is viewed as being a normal and valued part of societal behavior for the individual, family, and social networks and is seldom associated with anything beyond “relaxing and socializing.” No doubt, such a view would not be out of place if the consumption of alcohol followed a moderate pattern of usage. An accompanying perception is that alcohol, an all-too-often empowered substance, and manner and types of its consumption is only a problem for those who cannot control their drinking (alcohol dependent1 ) and who are in need of help, which has become defined as treatment. In part, this is related to perceptions of harmful patterns of alcohol use as being normative. The reality is that a significant proportion of individuals (typically male) are at
Alcohol use in South Africa in 2000 accounted for 7.1% of all deaths and is ranked first (44.6%) in term of alcohol attributed disability relative to interpersonal violence (23.2%) and foetal alcohol syndrome (FAS) (18.1%). The tangible costs of harmful alcohol use alone is estimated to be in the region of $3.5 billion or 1.6% of South Africa’s 2009 gross domestic product (GDP). When intangible costs are added, the figure balloons to an estimated 10–12% of the 2009 GDP. The burden created by this group of individuals does not predominantly fall into those classed as alcohol dependent. Instead, a significant portion of individuals who consume alcohol follow a pattern of drinking that involves heavy episodic drinking, with high usual quantity of alcohol being drunk, typically in public places and at community events. These hazardous patterns of drinking characterize much of the developing subregions as well. This pattern of alcohol consumption reflects a lifestyle behavior and applies to a significant proportion of adult males between 18 and 35 years of age in South Africa and is therefore not a trivial issue. Indeed, in South Africa and in sub-Saharan Africa, alcohol use is generally perceived as being a nonissue because “everyone” drinks. It is also
1 The reader is asked to consider that the recent medicalizing and pathologizing of a range of human behaviors, include categories of substance use, misuse, “abuse, addiction, dependency, habituation, hazardous drinking, etc., is, at best a consensualizing labeling process and not a diagnostic process. Such labeling is based upon the labelers’ criteria whose validity not based upon empirical generalizability. “Alcoholism,” however, defined, was associated for millennia with sin as its etiology. A usable diagnosis, based upon a process of gathering valid, relevant information and accurately interpreting and understanding such “data” (knowledge) in order to make a needed decision needs to supply a minimum of three types of information: etiology, process, and prognosis. A contemporary flaw in this process is associated, most generally, with the reported “explanation” about any type of substance misuse as being a unidimensional, linear either/or description which does not adequately distinguish between initial use, or nonuse, ongoing use, or nonuse, changes in use (patterns, manner of use, meanings, functions of the use, sites of use, frequencies of use, etc.) cessation of use, beginning again which can result in our “knowing” without adequately understanding a phenomenon which is dynamic, nonlinear, complex and not simply complicated, multidimensional, level-phase structured, and bounded (time, place, selected demographics, etc.). This is not a semantic issue. Editor’s note. 2 The reader is asked to consider that concepts and processes such as “risk” and “protective” factors are often noted in the literature, without adequately delineating their dimensions (linear, nonlinear, rates of development, sustainability, decay and cessation, etc.), their “demands,” the critical necessary conditions (endogenously as well as exogenously; micro- to macrolevels) which are necessary for them to operate (begin, continue, become anchored and integrated, change as de facto realities change, cease, etc.) or not to operate, and whether their underpinnings are theory-driven, empirically based, individual and/or systemic stake holder- bound, historically bound, based upon “principles of faith” or what. This is necessary to clarify, if possible, if these terms and their all-too-often stigmatizing labels and implications are not to remain as yet additional shibboleths in a field of many stereotypes and flaws. Editor’s note. Address correspondence to Arvin Bhana, School of Applied Human Sciences, University of KwaZulu-Natal, Mazisi Kunene Road, Glenwood, Durban, South Africa; E-mail: [email protected]
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Downloaded by [Washington University in St Louis] at 15:49 17 November 2015
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A. BHANA
risk2 for developing alcohol dependence and the illusion that it is only those who cannot “control” their drinking who constitute a problem is perpetuated by a public health system that tends to eschew providing any meaningful intervention for those who engage in harmful drinking behavior. Since most individuals who manifest harmful drinking behaviors are likely to use primary health services, especially in the context of unintentional injuries, it would be the logical place to intervene. Unfortunately, ignoring the health consequences of alcohol misuse reaches into the heart of public health services. In South Africa, responsibility for the treatment of alcohol dependence falls within the ambit of both the Departments of Health and Social Development. The latter has the primary mandate to provide specialized services for those “visible” individuals manifesting alcohol and drug dependence. Even if this service was of the best type, it would reach a very small proportion of the population. The misplaced focus on tertiary level intervention by the Social Development ministry, where it spends 55% of its annual allocations on substance abuse, is not assisted in any way by the Health department’s approach to dealing with harmful or hazardous alcohol use. When high levels of alcohol use become normative and constitute an acceptable social and lifestyle behavior, very few health professionals feel comfortable in asking questions about alcohol use. Supporting this behavior is a stigmatizing attitude that if an individual has alcohol problems, it has been self-inflicted as opposed to being a real health issue3 amongst its other parameters and consequences! At least in some low-income countries, such as Uganda and Nepal, this attitude is related to a genuine absence of readily available treatment for alcohol dependence, let alone hazardous and harmful patterns of drinking! In South Africa, where treatment can be made available, it appears that these pathological “disease” patterns of alcohol use for a designated “other” can be, and are, also seen as being normative for another part of the population. For example, the health care providers, among other relevant policy making stakeholders, have similar patterns of use, and traditionally there is little reason to ask about their alcohol use as being an issue. Given the complexities associated with harmful drinking patterns, as well as harmful principles of faith about types of drinking and types of drinkers, as well as nondrinkers, a viable, sustained multiple-pronged effort is needed:
• Creating and transmitting public health messages which are attuned to both the targeted population(s), and their preferred media, and which, when possible, engages
3
The reader is referred to Tilly, Charles (2006). Why. Princeton Univ. Press. Princeton, NJ for a stimulating analysis about generic “causative” reasons given in the West, and to Tilly, Charles (2008). Credit and Blame Princeton Univ. Press. Princeton, NJ for an important analysis about “blame.” Editor’s note.
them in some type of partnership in creating such intervention efforts, and • While “messaging” moderation (behavior, lifestyle, etc.) the intervention needs to be designed to engage a person’s and a system’s (family, network, neighborhood, community, etc.) awareness, expectations, judgments, decision making, learning from and anchoring that which is learned, etc., by enabling the creation of needed exploratory questions and not by the ongoing flaw of inducing too-early-closure with the only correct answers.4 Nevertheless, given that the fundamental purpose of “alcohol policies is to serve the interests of public health and social well-being through their impact on health and social determinants such as drinking patterns, the drinking environment, and the health services available to treat problem drinkers.” (p. 7), (Babor et al., 2010), then serious consideration must be given to rethinking South Africa’s approach to the high burden associated with harmful patterns of alcohol use, rather than just alcohol dependence. In addition, and rarely considered, is the need to actively document ongoing flawed conceptualizations and interventions, which, in addition to harms created as well as not being prevented, misuse scarce human and non-human resources. Declaration of Interest
The author reports no conflict of interest. The author alone is responsible for the content and writing of the article.
4
The interested reader is referred to the following thought provoking works which challenge current contemporary flawed conceptualizations. The cyberneticist Heinz Von Foerster who posited that there are two types of questions; legitimate and illegitimate ones. The former are those for which the answer is not known and is, perhaps, even unknowable during a given state of knowledge and technology-–the effective control of man’s “appetite” for a range of psychoactive substances, whatever their legal status. An illegitimate question is one for which the answer is known, or, at the very least consensualized. An illegitimate question is one for which the answer is known, or, at the very least is consensualized enabling the creation of a state of temporary or more permanent query-closure. The quest within a question becomes guaranteed. The asking of illegitimate questions has been, and remains, by and large, the acculturated norm. Heinz Von Foerster, Patricia M. Mora, and Lawrence W. Amiot, “Doomsday; Friday, 13 November, A.D, 2026,” Science, 132, 1960. pp. 1291–1295. The reader is referred to Pablo Neruda’s The Book of Questions for a poetic exploration of legitimate questions. Rittel and Webber suggested that problems can and should be usefully categorized into two types: “tame problems” and “wicked problems.” The former are solved in a linear, traditional known and tried “water fall paradigm”; gather data, analyze data, formulate solution, implement solution. The latter “wicked problems” can only be responded to individually, each time anew, with no ultimate, repeatable solution. The range of “problem drinking,” which is a socially constructed concept, is usefully considered from their thesis as being “wicked problems.” Rittel, Horst, and Melvin Webber, (1973). Dilemmas in a General Theory of Planning.” Policy Sciences, Vol. 4, pp 155–169.
A MISPLACED FOCUS
THE AUTHOR
Downloaded by [Washington University in St Louis] at 15:49 17 November 2015
Arvin Bhana, PhD, (South Africa), currently Honorary Associate Professor of Psychology at the University of KwaZulu-Natal, obtained his PhD in Clinical and Community Psychology at the University of Illinois, Urbana-Champaign. He is a registered clinical psychologist with the Health Professions Council of South Africa. His current research is focused on understanding the
1091
developmental precursors to mental ill health and personal and contextual aspects that contribute to well-being and resilience. He also has a strong interest in promoting public health interventions for adolescent alcohol abuse.
REFERENCES Babor, T., Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N., Graham, K., . . .Rossow, I. (2010). Alcohol: No ordinary commodity. Research and public policy, New York, Oxford University Press. Herrick, C. (2014). Alcohol control and urban livelihoods in developing countries: Can public health aspirations and development goals be reconciled? Critical Public Health, 24, 361–371.
ISSN: 1082-6084 (Print) 1532-2491 (Online) Journal homepage: http://www.tandfonline.com/loi/isum20
A Misplaced Focus: Harmful Drinking Patterns in South Africa Arvin Bhana To cite this article: Arvin Bhana (2015) A Misplaced Focus: Harmful Drinking Patterns in South Africa, Substance Use & Misuse, 50:8-9, 1089-1091, DOI: 10.3109/10826084.2015.1007658 To link to this article: http://dx.doi.org/10.3109/10826084.2015.1007658
Published online: 11 Sep 2015.
Submit your article to this journal
Article views: 19
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isum20 Download by: [Washington University in St Louis]
Date: 17 November 2015, At: 15:49
Substance Use & Misuse, 50:1089–1091, 2015 C Taylor & Francis Group, LLC Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2015.1007658
ORIGINAL ARTICLE
A Misplaced Focus: Harmful Drinking Patterns in South Africa Arvin Bhana
Downloaded by [Washington University in St Louis] at 15:49 17 November 2015
School of Applied Human Sciences, University of KwaZulu-Natal, Glenwood, Durban, South Africa intrinsically associated with the structural drivers such as poverty and unemployment that is associated with creating and sustaining posited vulnerabilities and makes alcoholic beverages and their consumption an important source of pleasure among a range of other functions. In addition, for many low-income communities, alcohol also serves as a microenterprise opportunity to earn money (especially among women) (Herrick, 2014) amidst conditions of high unemployment (25.4%) in South Africa. It is therefore not surprising that alcohol use is viewed as being a normal and valued part of societal behavior for the individual, family, and social networks and is seldom associated with anything beyond “relaxing and socializing.” No doubt, such a view would not be out of place if the consumption of alcohol followed a moderate pattern of usage. An accompanying perception is that alcohol, an all-too-often empowered substance, and manner and types of its consumption is only a problem for those who cannot control their drinking (alcohol dependent1 ) and who are in need of help, which has become defined as treatment. In part, this is related to perceptions of harmful patterns of alcohol use as being normative. The reality is that a significant proportion of individuals (typically male) are at
Alcohol use in South Africa in 2000 accounted for 7.1% of all deaths and is ranked first (44.6%) in term of alcohol attributed disability relative to interpersonal violence (23.2%) and foetal alcohol syndrome (FAS) (18.1%). The tangible costs of harmful alcohol use alone is estimated to be in the region of $3.5 billion or 1.6% of South Africa’s 2009 gross domestic product (GDP). When intangible costs are added, the figure balloons to an estimated 10–12% of the 2009 GDP. The burden created by this group of individuals does not predominantly fall into those classed as alcohol dependent. Instead, a significant portion of individuals who consume alcohol follow a pattern of drinking that involves heavy episodic drinking, with high usual quantity of alcohol being drunk, typically in public places and at community events. These hazardous patterns of drinking characterize much of the developing subregions as well. This pattern of alcohol consumption reflects a lifestyle behavior and applies to a significant proportion of adult males between 18 and 35 years of age in South Africa and is therefore not a trivial issue. Indeed, in South Africa and in sub-Saharan Africa, alcohol use is generally perceived as being a nonissue because “everyone” drinks. It is also
1 The reader is asked to consider that the recent medicalizing and pathologizing of a range of human behaviors, include categories of substance use, misuse, “abuse, addiction, dependency, habituation, hazardous drinking, etc., is, at best a consensualizing labeling process and not a diagnostic process. Such labeling is based upon the labelers’ criteria whose validity not based upon empirical generalizability. “Alcoholism,” however, defined, was associated for millennia with sin as its etiology. A usable diagnosis, based upon a process of gathering valid, relevant information and accurately interpreting and understanding such “data” (knowledge) in order to make a needed decision needs to supply a minimum of three types of information: etiology, process, and prognosis. A contemporary flaw in this process is associated, most generally, with the reported “explanation” about any type of substance misuse as being a unidimensional, linear either/or description which does not adequately distinguish between initial use, or nonuse, ongoing use, or nonuse, changes in use (patterns, manner of use, meanings, functions of the use, sites of use, frequencies of use, etc.) cessation of use, beginning again which can result in our “knowing” without adequately understanding a phenomenon which is dynamic, nonlinear, complex and not simply complicated, multidimensional, level-phase structured, and bounded (time, place, selected demographics, etc.). This is not a semantic issue. Editor’s note. 2 The reader is asked to consider that concepts and processes such as “risk” and “protective” factors are often noted in the literature, without adequately delineating their dimensions (linear, nonlinear, rates of development, sustainability, decay and cessation, etc.), their “demands,” the critical necessary conditions (endogenously as well as exogenously; micro- to macrolevels) which are necessary for them to operate (begin, continue, become anchored and integrated, change as de facto realities change, cease, etc.) or not to operate, and whether their underpinnings are theory-driven, empirically based, individual and/or systemic stake holder- bound, historically bound, based upon “principles of faith” or what. This is necessary to clarify, if possible, if these terms and their all-too-often stigmatizing labels and implications are not to remain as yet additional shibboleths in a field of many stereotypes and flaws. Editor’s note. Address correspondence to Arvin Bhana, School of Applied Human Sciences, University of KwaZulu-Natal, Mazisi Kunene Road, Glenwood, Durban, South Africa; E-mail: [email protected]
1089
Downloaded by [Washington University in St Louis] at 15:49 17 November 2015
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A. BHANA
risk2 for developing alcohol dependence and the illusion that it is only those who cannot “control” their drinking who constitute a problem is perpetuated by a public health system that tends to eschew providing any meaningful intervention for those who engage in harmful drinking behavior. Since most individuals who manifest harmful drinking behaviors are likely to use primary health services, especially in the context of unintentional injuries, it would be the logical place to intervene. Unfortunately, ignoring the health consequences of alcohol misuse reaches into the heart of public health services. In South Africa, responsibility for the treatment of alcohol dependence falls within the ambit of both the Departments of Health and Social Development. The latter has the primary mandate to provide specialized services for those “visible” individuals manifesting alcohol and drug dependence. Even if this service was of the best type, it would reach a very small proportion of the population. The misplaced focus on tertiary level intervention by the Social Development ministry, where it spends 55% of its annual allocations on substance abuse, is not assisted in any way by the Health department’s approach to dealing with harmful or hazardous alcohol use. When high levels of alcohol use become normative and constitute an acceptable social and lifestyle behavior, very few health professionals feel comfortable in asking questions about alcohol use. Supporting this behavior is a stigmatizing attitude that if an individual has alcohol problems, it has been self-inflicted as opposed to being a real health issue3 amongst its other parameters and consequences! At least in some low-income countries, such as Uganda and Nepal, this attitude is related to a genuine absence of readily available treatment for alcohol dependence, let alone hazardous and harmful patterns of drinking! In South Africa, where treatment can be made available, it appears that these pathological “disease” patterns of alcohol use for a designated “other” can be, and are, also seen as being normative for another part of the population. For example, the health care providers, among other relevant policy making stakeholders, have similar patterns of use, and traditionally there is little reason to ask about their alcohol use as being an issue. Given the complexities associated with harmful drinking patterns, as well as harmful principles of faith about types of drinking and types of drinkers, as well as nondrinkers, a viable, sustained multiple-pronged effort is needed:
• Creating and transmitting public health messages which are attuned to both the targeted population(s), and their preferred media, and which, when possible, engages
3
The reader is referred to Tilly, Charles (2006). Why. Princeton Univ. Press. Princeton, NJ for a stimulating analysis about generic “causative” reasons given in the West, and to Tilly, Charles (2008). Credit and Blame Princeton Univ. Press. Princeton, NJ for an important analysis about “blame.” Editor’s note.
them in some type of partnership in creating such intervention efforts, and • While “messaging” moderation (behavior, lifestyle, etc.) the intervention needs to be designed to engage a person’s and a system’s (family, network, neighborhood, community, etc.) awareness, expectations, judgments, decision making, learning from and anchoring that which is learned, etc., by enabling the creation of needed exploratory questions and not by the ongoing flaw of inducing too-early-closure with the only correct answers.4 Nevertheless, given that the fundamental purpose of “alcohol policies is to serve the interests of public health and social well-being through their impact on health and social determinants such as drinking patterns, the drinking environment, and the health services available to treat problem drinkers.” (p. 7), (Babor et al., 2010), then serious consideration must be given to rethinking South Africa’s approach to the high burden associated with harmful patterns of alcohol use, rather than just alcohol dependence. In addition, and rarely considered, is the need to actively document ongoing flawed conceptualizations and interventions, which, in addition to harms created as well as not being prevented, misuse scarce human and non-human resources. Declaration of Interest
The author reports no conflict of interest. The author alone is responsible for the content and writing of the article.
4
The interested reader is referred to the following thought provoking works which challenge current contemporary flawed conceptualizations. The cyberneticist Heinz Von Foerster who posited that there are two types of questions; legitimate and illegitimate ones. The former are those for which the answer is not known and is, perhaps, even unknowable during a given state of knowledge and technology-–the effective control of man’s “appetite” for a range of psychoactive substances, whatever their legal status. An illegitimate question is one for which the answer is known, or, at the very least consensualized. An illegitimate question is one for which the answer is known, or, at the very least is consensualized enabling the creation of a state of temporary or more permanent query-closure. The quest within a question becomes guaranteed. The asking of illegitimate questions has been, and remains, by and large, the acculturated norm. Heinz Von Foerster, Patricia M. Mora, and Lawrence W. Amiot, “Doomsday; Friday, 13 November, A.D, 2026,” Science, 132, 1960. pp. 1291–1295. The reader is referred to Pablo Neruda’s The Book of Questions for a poetic exploration of legitimate questions. Rittel and Webber suggested that problems can and should be usefully categorized into two types: “tame problems” and “wicked problems.” The former are solved in a linear, traditional known and tried “water fall paradigm”; gather data, analyze data, formulate solution, implement solution. The latter “wicked problems” can only be responded to individually, each time anew, with no ultimate, repeatable solution. The range of “problem drinking,” which is a socially constructed concept, is usefully considered from their thesis as being “wicked problems.” Rittel, Horst, and Melvin Webber, (1973). Dilemmas in a General Theory of Planning.” Policy Sciences, Vol. 4, pp 155–169.
A MISPLACED FOCUS
THE AUTHOR
Downloaded by [Washington University in St Louis] at 15:49 17 November 2015
Arvin Bhana, PhD, (South Africa), currently Honorary Associate Professor of Psychology at the University of KwaZulu-Natal, obtained his PhD in Clinical and Community Psychology at the University of Illinois, Urbana-Champaign. He is a registered clinical psychologist with the Health Professions Council of South Africa. His current research is focused on understanding the
1091
developmental precursors to mental ill health and personal and contextual aspects that contribute to well-being and resilience. He also has a strong interest in promoting public health interventions for adolescent alcohol abuse.
REFERENCES Babor, T., Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N., Graham, K., . . .Rossow, I. (2010). Alcohol: No ordinary commodity. Research and public policy, New York, Oxford University Press. Herrick, C. (2014). Alcohol control and urban livelihoods in developing countries: Can public health aspirations and development goals be reconciled? Critical Public Health, 24, 361–371.
