The Political Ecology of Alcohol as “Disaster” in South Africa’s Western Cape Abstract

Policy applications and impact

One of the most effective ways to prevent alcohol-attributable disease is by reducing the overall availability of alcohol, which can generally impact the average amount of alcohol consumed. Alcohol control policies, which involve alterations in legal rules for producing, distributing, taxing, marketing and pricing alcohol, are some of the most effective tools in the public health arsenal and may disproportionately impact populations of low socioeconomic status (Blas and Sivasankara Kurup 2010, 20)

The PAR’s clear utility lies in its ability to identify the upstream causes of disaster, thereby avoiding the common policy trap of focussing simply on downstream effects. The same critique might also be levelled at the field of health research more broadly which has tended to ‘under-theorise’ the role of socioeconomic and political inequality in the creation of ill-health precisely because it avoids ‘researchers having to deal with the implications of a critique of the power relations that lie at the heart of contemporary liberal-democratic capitalist states’ (Labonte, Polanyi et al. 2005, 13). In other words and as Bryant suggests, political ecological approaches demonstrate that ‘politics should be “put first” in the attempt to understand how human-environment interaction may be linked to [in this case, the negative externalities of alcohol]’ (1998, 80). This is especially important given the role that unequal power relations play in the creation and perpetuation of unsafe conditions, and the role of unsafe conditions in producing disaster. Political ecologies of health are valuable in that they can systematise the progression of vulnerability and highlight the structural inequalities that must be tackled to mitigate unsafe conditions. The PAR model, when integrated with a post-structural awareness of how vulnerabilities are constructed through discourse, popular belief and lay knowledge is a significant tool for the political ecology of health called for by King (2010). Furthermore, the PAR’s concern with how the chains and processes of causality might be reversed also draws attention to the bigger questions that lie at the heart of alcohol-as-disaster. To “release” the model, therefore, requires a return to the root causes of vulnerability, however unpalatable these have long been to politicians and policy makers in SA.
To return to the impact agenda, it is hoped that in communicating in simple, structural terms, the PAR model could (1) Shift governmental agendas from treating effects to identifying, acknowledging and addressing the causes of hazardous drinking and its (intended and unintended) consequences, and (2) inject development aspirations into alcohol control policy and, no less importantly, alcohol control into development policy. These two aims come together in two potential mitigating strategies that, interestingly, would hope to reduce vulnerabilities and strengthen coping mechanisms, which, in turn, would have positive externalities beyond the risks associated with drinking itself. The first would be improve access to education and improve school retention rates. However, two confounding factors need to be considered. First, education seems to offer little protection against alcohol problems among women given that the SADHS reveals that 32.6% of respondents with a higher education qualification had a CAGE score greater than two, compared to only 15% of those reaching grades 8-11. Among men, these patterns are different, with the highest rates of alcohol problems among those with the lowest levels of educational attainment (e.g. 25% of those with no education and 29% of those reaching grades 1-5 only). However, given that Millennium Development Goals 2 and 3 pertain to gender equality in primary, secondary and tertiary education and that alcohol problems increase in line with female educational attainment, the compatibility of these health and development agendas not only needs further research, but also far more integrated thinking (and working) between government departments than is currently the case. Despite the tensions inherent within this goal, it is raised as an example because mitigating these contradictions at a policy level is crucial if the causes of alcohol-related harm are to be sustainably addressed.
The second would be to institutionalise more equitable and sustainable paths to social and economic development. However, here also lies the space for further interrogation at a causal level when applied to alcohol. As Choi et al (2005, 1030) contend, ‘public health needs to be more passionate about the health issues caused by human progress and adopt a health promotion stance, challenging the assumptions behind the notion of social “progress” that is giving rise to the burden of chronic disease’. In this reading “progress” (i.e. development) can enhance as well as reduce vulnerabilities (e.g. through obesity or diabetes). Indeed, affluence influences drinking patterns, the brands consumed and the places in which this is done. This is further borne out in the idea that ‘drinking is often portrayed as a response to poverty and misery, but the global patterns remind us that drinking is also associated with good times and relative affluence...the general rule is that increased income is generally accompanied by increased consumption’ (Room, Graham et al. 2003, 166). It must be further noted, that this income does not necessarily need to be sustained, but can also be episodic as work opportunities come and go. Thus, while alcohol consumption might be highest amongst the most affluent, alcohol-related mortality and morbidity is usually highest among the poorest for, as this paper has explored, ‘some of the harms related to drinking are aggravated by poverty’ (Room, Graham et al. 2003, 167). When alcohol is construed as disaster, it opens a conversation as to the fundamental assumptions that often guide alcohol policy. In the case of the multi-dimensional and multi-causal relationship between drink, poverty and development, the controversial assertion put forward by the WHO is an important one: ‘otherwise beneficial decreases in socioeconomic inequity can lead to an increased burden of alcohol-attributable health problems in low-income populations (Blas and Sivasankara Kurup 2010, 12). If development increases purchasing power which, in turn, promotes increased or riskier drinking habits, then development policies themselves need to be attuned to the micro- and macro-scale ways in which alcohol consumption springs from wealth as much as poverty. As such, the overriding concern with supply is insufficient and, instead, the root causes of demand must be given prominence. This is important because, in spite of the paternalistic tone often adopted in the lexicon of Global Health, even the poor have the right to choose.

Conclusion

Alcohol problems often creep into debates over poverty and inequity for symbolic reasons. In some cases, the public debate over an alcohol policy may be more important than its actual implementation for the policy-makers involved (Blas and Sivasankara Kurup 2010, 23)

This paper has argued for a political ecology of health and, in particular, the value of a “disaster” approach to the study of alcohol. While the PAR model is doubtlessly limited by its hope of capturing an impossible systematic totality, it nonetheless serves as a valuable tool for communicating and systematising the complex, multi-level factors that produce alcohol-related harms. It further demonstrates that compartmentalised models of governing alcohol will only provide unsustainable policy solutions. Moreover, it makes ignoring the fundamental drivers of alcohol-related harm (e.g. rising inequality) seem short-sighted when the causes of crime, drink driving and domestic abuse are so firmly rooted in these very same inequalities. This means that it also serves as an organising tool for interrogate the fundamental limits of development policy in relation to alcohol. In the 17 years since the end of apartheid, life has become progressively more unequal in SA and lines of difference that were once delineated by race alone are increasingly being marked out by social class. It seems that SA ‘has witnessed the replacement of racial apartheid with what is increasingly referred to as class apartheid—systemic underdevelopment and segregation of the oppressed majority through structured economic, political, legal, and cultural practices’ (Bond 2004). Moreover, ‘consumption practices and processes are increasingly important in the contemporary marking off of social class boundaries’ (Ibid, 5) and alcohol plays a clear (if under-acknowledged) role in these changing social norms. It is important that health survey data needs to also reflect this shift by moving away from racial categories to incorporating the role of socio-economic differences (i.e. income, profession) in alcohol consumption trends at a variety of spatial scales. With such information, not only would racial stereotyping in policy (and the spatial connotations that inevitably accompany this) be challenged, but a far more nuanced engagement with the ‘punitive ecologies’ highlighted in the PAR model might also be made possible.
This way of theorising alcohol as “disaster” stands in marked contrast to current public health interventions which have often emphasised and judged ‘the role of individuals and their behaviours’ rather than setting individual actions ‘in the wider social context to illustrate that behaviour and its social patterning is largely determined by social factors’ (Marmot 2007, 1159). The PAR model demonstrates that identifying the structural drivers of inequality are necessary to reorient individual behavioural choices, and should, therefore, recalibrate the domain of blame from an individual burden to a collective endeavour. Moreover, with “disaster” a long-wave phenomenon, this approach makes it clear that any solutions will be equally gradual, spanning timeframes that go beyond administrative lifetimes. The problem is that when individual behaviours are deemed too entrenched or attempts to change them are thought to be publically and politically unpalatable, then abrupt supply-side policies become the norm. However, alcohol policy needs to engage with the interface between behaviours and contexts in order to identify causal influences in ways that open up public conversations about the acceptable limits of intervention. Doing so will not necessarily make it any easier to dismantle ‘the structural drivers of inequity in behaviour’ and therefore, to ‘tackle the contribution of these behaviours to health inequity’ as well as newly-enshrined class differences (Ibid). However, such actions would have benefits that would extend far beyond alcohol harm reduction and should ensure that implementing an equitable alcohol control policy remains as important as the public debate on shebeens that has dominated the South African press coverage of alcohol in recent years.
SA has a mercifully unique recent history which ‘exemplifies how social determinants such as politics and race can powerfully shape the health of people’ (Chopra, Lawn et al. 2009, 8). However, beyond SA’s particularities, mitigating alcohol-related harms speaks to issues faced by not just low and middle-income countries, but also those categorised as high income. This multi-dimensionality further sanctions this paper’s call for a political ecology of health that is mindful of the importance of integrating the structural and post-structural to re-think current alcohol strategies. To cast alcohol as disaster is not, therefore, to fall into the hyperbolic trap that often characterises media accounts of drinking, but rather to invite critical consideration of the nature and constitution of disasters themselves. Drinking has complex temporal dimensions in which disaster can be ‘long-wave’ (i.e. unfold gradually as in the case of liver cirrhosis) or abrupt and acute (e.g. accidents). From a policy standpoint, the difficulty is that short and long-term threats co-exist even though individual risk horizons may be irreparably desensitised to long-term risks by the prioritisation of immediate needs under unsafe conditions. Thus, while the combination of short and long-term harms lend drinking its disastrous dimensions, strategies to encourage individual risk reduction may face apathy if they focus on horizons that for many seem impossibly distant. There is therefore a need to challenge what Room (1984) describes as the ‘problem deflation’ tendencies of ethnographic research to explore the lived and situated realties of drinking in the GS that, in turn, shape the punitive ecologies that challenge policy. These realities not only form the unsafe conditions envisaged by Blaikie et al, but represent the first step in tackling those root causes that ensure that some Capetonians enjoy the pleasures of alcohol, while others will only ever suffer the consequences.


Figure 1 - Original PAR model (Blaikie, Cannon et al, 1994, 23)
Figure 2 - PAR model as applied to alcohol as “disaster” in Cape Town, South Africa

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