De Aar, which has the world's highest rate of foetal alcohol disorders, has shown that something can be done to fight alcoholism.
The convoluted political history of South Africa over the past 400 years has contributed to the alcohol-abuse epidemic at all levels of society.
With the development of the Cape sea route, Cape Town became the major refurbishing station for seafarers and passing ships to stock up fresh supplies of food and wine. And the local production of wine was fortuitously boosted by the arrival of Huguenot settlers fleeing religious persecution in France.
Viticulture developed in the customary European fashion in the Cape and the dop or tot system of partial remuneration of vineyard workers with wine became established.
The dop system has been outlawed for several decades and several research studies undertaken by the Foundation for Alcohol Related Research have shown that it is seldom practised these days. Interviews with more than 3 000 pregnant women showed that fewer than 3% had ever been exposed to the dop system, but it has been replaced by illegal, unregistered taverns or shebeens.
Apartheid laws discriminated against people of colour regarding the sale of alcohol. They were banned from most legal alcohol outlets (the exceptions were beer halls and housing facilities attached to mines). But cheap liquor was nevertheless used by farmers in the Western Cape to regulate and manage their labour force.
Elsewhere, illegal outlets for liquor, the shebeens, sprang up in black townships. An estimated 230 000 of them now sell alcohol and there are few restrictions on opening or closing hours, service to underage clients or pregnant women, or providing already inebriated clients with more drinks. A further 250 000 legal alcohol dispensers are registered, which means that for every 100 South Africans – including children and those abstaining from alcohol – there is at least one legal or unregistered outlet.
Other statistics demonstrate the harm of alcohol abuse among South Africans. Death as a result of drunk driving is three times higher than other nations. The country's domestic abuse figures are frighteningly high and violence among men who abuse alcohol is 10 times higher than those of other countries.
South Africa also has a high prevalence of foetal alcohol spectrum disorders in at-risk communities.
Foetal alcohol syndrome is the tip of the iceberg. It occurs because of maternal alcohol abuse during pregnancy. It affects foetal growth and childhood and even adulthood through its negative effect on brain development, intellect and human behaviour. The heart, skeleton and kidneys of children who suffer from the syndrome may be severely malformed, but most of the consequences (90%) are on the brain and central nervous system.
Some maternal risk factors are heavy binge drinking (five or more drinks at a time), poor maternal education, small maternal body mass, poor nutrition, concomitant tobacco and recreational drug abuse and heavy alcohol consumption among the mother's close friends or relatives.
The very high prevalence of the syndrome and the spectrum of disorders in South Africa has been thoroughly researched by the foundation.
Consecutive studies on school-entry children were undertaken in all the primary schools in Wellington in the Western Cape in 1997, 1999 and 2002. The studies found that, respectively, 45, 65 and 88 of every 1 000 children had foetal alcohol syndrome. Similar studies in four communities in Gauteng showed a very high prevalence of foetal alcohol syndrome, even in Soweto. Other studies were undertaken in Upington (75 children in every 1 000) and De Aar (120 in every 1 000), both in the Northern Cape, which is the highest reported prevalence of foetal alcohol syndrome in the world.
South Africa's high rate of foetal alcohol syndrome affects its economy, education and health and social services.
In a large study in Seattle in the United States, several thousand children were evaluated from birth well into their adulthood. Of those exposed to alcohol in the womb, more than half had been in trouble with the law by the age of 21. The implications for crime and criminal activities in South Africa are obvious.
Two final comments should be emphasised. First, the wheel of misfortune has four spokes – the most critical factors in the health and welfare of South African families. They are the HIV/Aids epidemic, malnutrition, tuberculosis and low birth weight. These rotate around an axle of alcohol and drug abuse and the faster the wheel rotates, the faster health and social circumstances deteriorate.
Any intervention that slows down the rotation, such as food supplementation, vaccination and diminishing alcohol and drug use, improves immunity and resistance to infection and malignancy, increases birth mass and improves health and wellbeing, particularly for the most impoverished sector of society. It is probable that where risky behaviour is common, the wheel of misfortune will be most active.
The foundation has instituted prevention and intervention strategies in several centres. De Aar was selected to test and formulate policies for several reasons. Communities asked the foundation to begin its research there because of the strong local evidence of alcohol abuse. A building was donated in which a community centre could be established. This enabled a team of field workers, guided by specialists, to implement the Institute of Medicine's recommendations for the prevention of the spectrum of foetal alcohol disorders.
The foundation's initial research showed a very high prevalence of foetal alcohol disorders and the communities were among the poorest in the country. Unemployment among adults was at 80%, the communities had high rates of HIV/Aids and tuberculosis infection, suffered from poor standards of education and were isolated from tertiary services in Kimberley and Bloemfontein.
The recommendations of the institute were instituted between 2006 and 2009. They included:
- Universal prevention and awareness through public education, including the use of the press, radio and television, posters, public meetings, community activities such as awareness walks, International Foetal Alcohol Spectrum Disorder Day events and an interactive workshop, and an industrial theatre production The Love Child (in partnership with TakeAway Theatre) to engage the high-risk groups in experimental learning;
- Prevention strategies that targeted communities and families at high risk (the unemployed, HIV- and tuberculosis-infected persons, single mothers, individuals with low education levels and heavy drinkers). The healthy mother, healthy baby programme was instituted and all mothers were invited to participate. At registration (before 20 weeks gestation), the pregnant women were screened for risk factors such as alcohol or substance abuse, malnutrition and other health and social problems. They were allocated to four risk groups and received two to six brief motivational counselling sessions to facilitate a healthier pregnancy and the birth of a baby free of foetal alcohol disorders. This programme has been so successful that it is now used in all the foundation's project; and
- The development of the FAStrap course to help community members to embrace healthier lifestyles and to take action against foetal alcohol disorders. They are trained and mentored to become agents of change in their communities.
The intervention has resulted in a 30% decrease in the prevalence rate of the disorders in De Aar, the first ever reported drop in a community rate, indicating that concerted community participation programmes can work.
Professor Denis Viljoen is chairperson and Leana Olivier is chief executive of the Foundation for Alcohol Related Research. Click here for more information.