The Political Ecology of Alcohol as “Disaster” in South Africa’s Western Cape Abstract
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FIGURE 1 HERE- FIGURE 2 HERE -
Figure 2 shows that the root causes of alcohol-as-disaster are to be found in the economic importance of the national liquor industry, the co-existence of high poverty rates and rising incomes, inequalities (i.e. health, education, gender, income), racial and residential segregation, and worklessness. The fundamental political economic tension at the heart of alcohol-as-disaster is that while alcohol-related harm poses significant costs to state and society, the liquor industry contributed R92.4 billion to the national economy (4.4% of GDP) in 2009. SABMiller provides 355,000 jobs nationally, in the Western Cape the liquor industry provides jobs for 275,000 people and the wine trade is at the centre of regional tourism. Public health responses to alcohol control have long argued that the control of supply represents the ‘best buy’ for policy (World Health Organisation 2011a). As the WHO highlights in its recent report on social equity, ‘the most important way that the broader socioeconomic context impacts alcohol-attributable health outcomes is by shaping the overall availability of alcohol’ (Blas and Sivasankara Kurup 2010, 19). Moreover, it contends that ‘the dynamics of increasing affluence and alcohol availability are a particular concern for countries throughout the developing world’ (ibid). The policy focus on supply-side interventions has proved politically popular in that it avoids the need to try and address individual behavioural choices. In SA policies such as the Western Cape Liquor Bill (WCLB) have targeted the prolific number of unlicensed township shebeens, threatening them with closure, seizure of goods and often-aggressive policing (Steinberg 2011). However, the focus on controlling liquor supply does little to address the political economic system. Shebeens close temporarily and reopen elsewhere as their owners need to make a living and their patrons want to drink. Elsewhere, licensed city bars continue to grow in number as the redevelopment of the downtown areas continues apace. Yet, the inequalities and gross unemployment remain as intact as the systems of alcohol production and retailing, ensuring that demand for drink remains. An additional root cause is the compartmentalised and disaggregated nature of governmental departments (Parry 2005) such that, as the Cape Town Drug and Alcohol Strategy notes, ‘historically... there has been little interaction between Health, Law Enforcement and Welfare; departments have worked in silos, thus causing fragmentation and often duplication of services’ (City of Cape Town 2007b). This not only causes institutional inefficiency, but may also reinforce the compartmentalised problematisation of alcohol where the demands of, for example, the Department of Trade and Industry’s concern with tax revenues may be diametrically opposed to the Department of Social Development’s remit of poverty reduction and social integration. The PAR model thus demonstrates a clear need for policy integration and multi-sectoral working. Such collective working is also necessary in order to meet the latest objectives of the WHO’s ‘Health in All Policies’ (HiAP) strategy which argues that ‘government objectives are best achieved when all sectors include health and well-being as a key component of policy development… because the causes of health and well-being lie outside the health sector and are socially and economically formed’ (World Health Organisation and the Government of South Australia 2010, n.p.). More specifically, the approach argues that ‘health is a positive concept emphasising social and personal resources, as well as physical capacities’ and, as such, health promotion needs to extend to ‘wellbeing and supportive environments’. The Cape Town Alcohol & Drug Action Committee (CTADAC) is a case in point here, where this interdepartmental local government/ municipal initiative is chaired by City Health and is composed of municipal Safety and Security; Social Development and Early Child Development; and Strategy and Planning. The Committee is also composed of provincial government counterparts from: Provincial Dept of Health, Social Development; Education; South African Police Services; Department of Justice & Constitutional Development; and the Department of Community Safety. Even at a national level, the differing distance of government departments from the liquor industry has precipitated ‘an inter-ministerial committee…to create a homogenised message from the national government’ (Payne 2012). Given this, the PAR model is a helpful step in collectivising the thinking needed to realise the ‘Health in All Policies’ aspirations, as well as tackling the embedded root causes of alcohol-related harm. One clear root cause of risky drinking behaviours and the harms that result are persistent social and economic inequalities that have been identified not only as worsening since the end of apartheid, but also driving additional inequities in health outcomes. The relationship of alcohol to absolute and relative poverty are complex, especially given that increased affluence is found to result in increased rates of drinking. Epidemiological research drawing on macro-scale health survey data (often of varying accuracy) shows that income is proportional to alcohol consumption (Blas and Sivasankara Kurup 2010). Thus the poorest tend to drink the least by total volume. However, when inequalities drive the aspiration of consumption, then entrepreneurial systems conspire to provide a solution to an absolute lack of money. Shebeens and taverns offering credit is one reason why people can and do drink beyond the limits of poverty. In SA, however, the focus on inequality is important as holds the potential to shift attention away from prevailing racial/ cultural/ class stereotypes that may ascribe risky drinking practices to non-white (or “previously disadvantaged”) South Africans, rather than interrogating how current disadvantage drives and sustains drinking practices. It is notable that ‘relatively few [alcohol harm reduction] interventions are designed to target social inequities within societies or between societies’ and, as a result, recent WHO work suggests that ‘there remains plenty of unexploited terrain for applying existing and evolving evidence-based approaches to groups of low socioeconomic status’ (Blas and Sivasankara Kurup 2010, 25). The assertion that risky practices are located within those of low socioeconomic status masks the social normalisation of heavy episodic drinking among the educated and wealthy who, it should be remembered, are more likely to get in a car and add to SA’s extreme rates of road traffic accidents. Thus, tackling both relative poverty and the relativity of socially normalised drinking practices is essential. A first step in addressing this would be to challenge both public and political perceptions of the differences in drinking patterns and habits among South Africans. The class, cultural, geographical and racial stereotyping that often accompanies risky behaviours is no less potent for alcohol consumption. Recent sociological and geographical work exploring, for example, women’s drinking (Measham and Ostergaard 2010), drinking by ethnic minorities in the UK (Valentine, Holloway et al. 2010) or drinking at home (Holloway, Jayne et al. 2008) has challenged some of these assumptions. In SA, stereotypes are partly sustained by a paucity of national, regional and local morbidity, mortality or census data broken down by demographic categories (Bradshaw, Groenewald et al. 2003). While very limited in its temporal scope, the 2003 South African Demographic and Health Survey (SADHS) is of some use here. However, it should be noted that only data concerning volume of alcohol consumed is collected at a provincial scale. Moreover, where data is collected by racial category (at a national scale), this retains Apartheid categorisations (i.e. white/African/Coloured/Indian), without acknowledging the variations within these. However limited, the data does show that whites in SA are most likely to have had a drink in the past year (70% of men and 51% of women) and past week (53% of men and 31% of women) and that coloured and Indian respondents are the next most likely to drink. Nationally, the highest rates of hazardous1 drinking occurs among men aged 35-44 (31.4%) and among women aged over 65 (42.3%). Urban African and coloured men are most likely to be “irresponsible” drinkers (28.6% and 28.4% respectively), whereas coloured women are most to take this title (38.7%). It is interesting to note that even though whites form the largest group of drinkers they are more likely to self-define their drinking as “responsible”. Yet, CAGE (Ewing 1984; Ewing 1998) scores greater than two - the cut-off point for alcoholism/ alcohol dependence - remain highest among white women (50.9%) and coloured men (31.2%). This would again mark a point of contradiction given the low prevalence of harmful and hazardous drinking among white women both at weekends (4%) and on weekdays (0%), in contrast to the enhanced likelihood of coloured men exceeding responsible drinking limits (27%). The prevalence of risky drinking among certain groups not only marks where resources should best be allocated, but also indicates that it is not always the most “vulnerable” (or in post-Apartheid language, the ‘previously disadvantaged’) that are the riskiest drinkers. Instead vulnerability to the effects of drinking (rather than to be a drinker) are more important for mitigating alcohol-related harms. Thus, policies that address only supply, rather than empowering non-drinkers in ways that strengthen the ability to evade alcohol-related harms (e.g. domestic violence), may leave root causes untouched.
Dynamic pressures translate root causes into unsafe conditions, transposing macro-scale factors into the micro-scale conditions that produce disaster and, as a result, are temporally and spatially dynamic. Two particular sets of unsafe conditions stand out in relation to alcohol vulnerability in the Western Cape: unequal and poor quality living; and political economic forces that shape consumption. To turn to the first, significant rates of rural-urban migration (legal, and illegal) and cross-border migration from neighbouring countries have swollen Cape Town’s population from 2.56 million to 3.5 million in the decade to 2007 (City of Cape Town 2010). The resultant sprawl has further undermined the development of ‘integrated’ human settlements that enable residents to access social and economic opportunities by low cost, safe public transport systems (Kingdon and Knight 2004). Within poor (and often spatially isolated) settlements, social and ethnic tensions, crime and the fear of violence are rife (Lemanski 2004; Samara 2005; Lemanski 2006). This ‘alcohol crime/injury nexus’ (2006, 4) is of clear importance here as 46% of non-natural deaths were alcohol-related in 2002 (Ibid). With 68,000 sexual crimes in 2009, the assertion that alcohol ‘increases the risk of women being raped, because it reduces their ability to interpret and act on warning signs to effectively defend themselves’ (Jewkes and Abrahams 2002, 1240) indicates a clear dynamic pressure. The political currency attached to crime rates means that this motivates alcohol harm reduction policies at the expense of considering the numerous interlocking factors that condition not just vulnerability to crime, but also criminogenic vulnerabilities. For example, recent thinking promulgated within the WCLB argues for the vulnerabilities induced by the infiltration of residential areas by shebeens. The necessity to traverse spaces made risky by poor lighting, shebeens that often remain open until their patrons leave or collapse, and insufficient policing from transport hubs to home dramatically increases the likelihood of falling victim to the consequences of drunkenness. In this reading of disaster, rates of harm could be improved by structural fixes such as lighting and land-use zoning. The second set of dynamic pressures concern the tensions within national and regional political economies of alcohol. For example, the Western Cape Liquor Bill (WCLB) focuses on the regulation of the unlicensed trade at the same time as the city promotes the liquor industry and the night-time economy as part of its urban renewal and tourism strategies (Samara 2005). Shebeens (unlicensed township bars) have been viewed as problematic sites of vice, criminality and violence - especially in relation to HIV/AIDS transmission, drug selling and antisocial behaviour - since their inception as a response to apartheid laws prohibiting Africans from consuming alcohol (Mager 2004; Mager 2010). However, in recent years, this concern has honed in on the threats posed by the broader unlicensed trade. Yet, as many have been swift to point out in the SA media, shebeens and their associated supply chains have long been an important source of income for those whose legitimate livelihood opportunities may be limited. However, shebeens’ residential locations are deeply problematic for residents dealing with persistent noise, irritations such as public urination, fears over underage drinking, drugs and prostitution. As such and despite mixed reactions from industry, the WCLB has focussed on bringing shebeens into the formal economy. While investment has increased in new and established entertainment quarters in the more affluent City Bowl, Atlantic Seaboard, Southern Suburbs and Northern Suburbs; alcohol control policies are being deployed most vigorously across the poorest parts of the city. The liminal status of the shebeen represents, however, a clear dynamic pressure that is rarely brought out within existing policy. The supply-side concerns of alcohol control policy focuses on public drinking through controls on, for example, outlet density or licensing restrictions (e.g. through zoning). However, ‘the effect of restrictions on individual behaviour depends partly on whether the regulated behaviour is public or private’ (Blankenship, Bray et al. 2000, S17). Public health advocates are quick to downplay the effectiveness of health promotion or educational interventions in changing drinking behaviours, although these have traditionally been one of the few ways of altering the behaviours undertaken in private. However, given that shebeens straddle the public and private realms of drinking – especially since their nature and form means that they are often undetectable from the outside – interventions that fail to address the roots of behavioural choices will also fail to reduce alcohol-related harm. This may further reaffirm the vulnerabilities that perpetuate the unsafe conditions that characterise drinking practices examined in the next section.
Unsafe conditions are inextricable from the broader conditions of poverty that produce vulnerabilities, but there are particular expressions in the case of Cape Town that warrant more detailed exploration. In the first instance, existing poor health - often due to the intersection of poor sanitation, inadequate and unsafe housing, overcrowding, high rates of infectious disease, maternal and infant mortality, HIV/AIDS and TB - renders people more vulnerable to the chronic and acute health effects of drinking. Additionally, ‘diseases of comfort’ also affect the poor in SA, with diabetes rates now at 29% amongst older coloured residents of Cape Town and average obesity rates of 29% among men and 57% among women (Rheeder 2006). These conditions may not only encourage drinking as a form of coping, but also magnify their health risks (e.g. alcohol increases the risk of hypoglycaemia where diabetes is poorly managed) (Turner, Jenkins et al. 2001). The ways in which NCDs and alcohol intersect are complex and understudied. But under conditions of poverty, it is clear that household resources spent on alcohol (most often by men, but increasingly by women among some groups in the Western Cape) are those made unavailable to pay for healthcare and medication. As an example, at present, there is mounting concern among policy makers and the alcohol industry about the economic and health effects of industrially-brewed, unregulated ‘ales’. As there is no definition of what constitutes an ‘ale’ in the National Liquor Products Act, the beverage falls between legal terminologies and so these illicit brews have started to permeate (technically legitimately) the licit supply chain. Ales are sold in five-litre plastic bottles, are of varying strengths and their provenance is mysterious. Few chemical analyses have be done on their content, but they are known to have various addictives that are uniquely addictive and can have, in some cases, catastrophic health impacts. The unsafe condition in this case is the way in which these products are presented as legitimate and sold through legitimate channels (e.g. “spaza” township shops and bottle shops), their ubiquity and the increasing normalisation of their consumption. This is especially so when household budgets are squeezed and individuals are forced to trade down to cheaper drinks, with the attendant health risks, and furthermore, the financial burdens that accompany them. Unsafe conditions also exist in the realm of risk, blame and prejudice which are often perpetuated by short-termist (or ‘present biased’) risk horizons which, in turn, have marked effects on behavioural choices and their legacies. These short-term risk horizons are further sanctioned by the normalisation of intoxication within South African culture. Since the end of apartheid, South African life expectancies have fallen. As a result, attitudes towards risk can often be ambivalent (see for example Room 1976; Broemer 2002) even if the risks themselves hold personal relevance or resonance. Simply put, when you are statistically unlikely to live past 52 (or 43 for men in Kwa-Zulu Natal), then avoiding behaviours that might have long-term, chronic consequences may seem less important (Statistics South Africa 2010). These ambivalent risk horizons (or an unwillingness/ inability to mitigate against the likelihood of disaster) thus not only perpetuates ‘heavy episodic drinking’, but may also increase the likelihood of associated behaviours such as unsafe sex, drug taking and violence. The temporal discounting of risk is further reinforced by the lack of enforcement of existing liquor laws and the weaknesses inherent within the criminal justice system. Even though roadblocks to test for drink driving are now common across Cape Town, the weaknesses within the blood alcohol testing system (i.e. that it has to be done in a lab and the time delay associated with this) and the court backlog means that only a fraction of drunk drivers are ever prosecuted. Again, when risk horizons are undented by a linkage of cause and effect within the policing or criminal justice system, then it is little wonder that heavy episodic drinking is prevalent across the social spectrum. South African drinking is characterised by weekend binges, the magnitude and duration of which varies across city spaces. Traditionally, drinking has started with the Friday pay-check and ended with the shebeen’s closure in the early hours of Monday morning. However, the popularisation of the idea of ‘Phuza’ (the isisZulu word for drink) as a synonym for binge drinking not just on a weekend, but creeping into the rest of the week, marks a possible narrowing of class differences in drinking. The WHO has noted that: Individuals in higher socioeconomic groups are more likely to be drinkers, and they tend to have more drinking occasions, particularly more light-to-moderate drinking occasions, than their counterparts in lower social strata, while the proportion of drinking occasions that involve binge drinking is typically greater for drinkers of low socioeconomic status (Blas and Sivasankara Kurup 2010, 17) However, with ‘Phuza Thursdays’ a marketing-ploy-turned-cultural-norm, SA challenges the ascription of binge drinking purely as a preference of the poorest. In almost all cases, however, the poor regulation and policing of drinking places means that what starts as “sanctioned” drinking often ends up later affecting people at a distance, whether this is through accidents, violence or more mundane drunken behaviours. The one exception to this in Cape Town may be the visible presence of private security officials up and down the city’s main drinking hub, Long Street, acting as a deterrent against crime and violence and supported by an army of CCTV cameras. However, for those whose immediate environment renders them vulnerable by virtue of poor personal health, mobility and power, short-termist risk horizons can be disproportionately afflictive. Moreover, the attitudes to risk generated by a lack of political and economic power renders fatalism a logical response to danger, and risk a logical outcome of such fatalistic purviews. And, sadly, alcohol strategies rarely deal with fatalism.
Disaster occurs when unsafe conditions intersect with hazards, which Blaikie et al envisage as ‘extreme natural events’. However, a political ecology of health might instead consider hazards as the intersections of the physiological and psychological effects of alcohol interlaced with factors influencing both supply and demand. Alcohol is a ‘mind-acting chemical’ composed of carbon, oxygen and hydroxyl that is both ‘drug and social fact’ (Edwards 2002, 1). While alcohol’s drug-like status (e.g. addiction, intoxication etc) is convincingly argued (Babor, Caetano et al. 2010), it is the ‘social fact’ that remains so contested. This is especially the case given the alarmist paternalism often associated with analyses of alcohol consumption in the GS (see, for example Caetano and Laranjeira 2005), which remains at odds with the conviviality and cultural importance of drinking, regardless of geographic location. The attractions of intoxication in SA are reinforced by alcohol’s affordability, availability and aspirational lifestyle connotations (e.g. through advertising, sponsorship and product placement), but this also reinforces underage drinking (Parry, Bhana et al. 2002), raising fears of associated absenteeism, drug misuse and sexual risk-taking (Parry, Myers et al. 2003). The WHO’s Global Strategy thus argues for supply-side restrictions and fiscal measures to reduce demand (e.g. increasing tax and duty) as being the most effective ways to reduce alcohol-related harm in the GS. However, these strategies may ‘discriminate between individuals and groups that have different demand and supply elasticities’ (Black and Mohamed 2006, 132). In other words, the poorest drinkers may be tempted to switch to cheaper, poorer quality (or illicit) drinks should prices rise, thus increasing the likely health costs and household burden of drinking. There is also a fear that clamping down on shebeens will drive them further underground, exacerbating the nature of disaster by increasing the possibility of shebeens becoming enmeshed in gang and drug activities. The disastrous nature of alcohol-related harm is thus inextricable from the unintended consequences of alcohol control policy. These may, in turn, perpetuate the inequitable distribution of vulnerabilities that can emanate from the most well-intentioned policy choices. Alcohol as disaster has numerous expressions that reinforce the institutional complexity of reducing harm. As figure 2 demonstrates, the risk of disaster occurs when unsafe conditions and hazards collide and are expressed through actions that have a profound effect on wellbeing including: interpersonal violence; homicide; rape; drink driving; addiction; and co-usage of drugs (e.g. methamphetamine or “tik” in Cape Town). The potential severity and costs of these risks are further compounded by the enormous household and state burden posed by chronic illness and, in particular, Foetal Alcohol Syndrome (FAS). Such high provincial rates of FAS (May, Gossage et al. 2007) are thought to be a result of heavy episodic maternal drinking and a direct legacy of the historic “dop” (literally meaning “tot”) agricultural payment system in which rough alcohol supplemented low wages in the wine trade until relatively recently (Croxford and Viljoen 1999; Warren, Calhoun et al. 2001; May, Gossage et al. 2007). The lingering popularity of five litre papsakke – cheap wine in foil pouches – also represents a further political economic driver of risky drinking in the Western Cape. Disaster therefore reflects indelible lines of power and vulnerability and is inseparable from the places and contexts within which it is lived and experienced. For this reason, disaster unfolds as layers of vulnerability come to bear on unsafe conditions and is entrenched when root causes remain unchallenged. Such acknowledgment is crucial when trying to bring about what Blaikie et al (1994, 233) have called the ‘sustainable reduction of disasters’. How, therefore, might the PAR model inform alcohol harm reduction policy in SA and, in the process, help reverse the progression of vulnerability that incites disaster? Yüklə 171,49 Kb. Dostları ilə paylaş:
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