South Africa has one of the highest numbers of unnatural deaths in the world. It is well-known that the majority of all people who die in motor vehicle accidents were under the influence of alcohol. The same applies to people whose lives were taken violently.
The Automobile Association of South Africa (AA) has calculated that the costs of road traffic crashes alone exceed R110 billion annually. As a matter of urgency these facts should be addressed with innovative strategies. If we fail to deal with alcohol related trauma, our whole society will fail.
Ethyl alcohol, the drinkable form of alcohol, is a multifaceted entity. It may be perceived as a social lubricant, sophisticated dining companion or cardiovascular health benefactor but equally it can be seen as an agent of destruction.
For the past 10 millennia, alcoholic beverages have been popular daily drinks. In a world of contaminated water supplies, alcohol earned the medieval title of ‘aqua vitae’ (water of life). However, contrary to the image portrayed in advertisements, the effects of alcohol are detrimental to many people and the present name of alcohol could be more appropriately changed to ‘aqua mortis’ (water of death).
Although international data suggests a trend towards decreasing consumption in most developed countries since 1980, a steady rise in alcohol consumption in most developing countries has been recorded, albeit from a low base. The negative effects of alcohol usually take place through intoxication, misuse and dependence.
Besides chronic health and social problems associated with alcohol dependence, intoxication is a major mediator for acute negative outcomes such as motor vehicle injuries and interpersonal violence. South Africa suffers particularly heavily from negative consequences associated with the use of alcohol.
Trauma is the leading cause of admission to hospitals in all provinces and the leading cause of childhood deaths between the ages of one and 18 years. A South African multi-centre study demonstrated that over half of all patients presenting to trauma units were victims of violent injuries. Across sites and for each respective year of the survey, between 35.8% and 78.9% of patients tested positive for alcohol.
It was concluded that efforts to combat the abuse of alcohol are paramount in reducing the burden of injuries on healthcare services. According to the third annual report of the National Injury Mortality Surveillance System, over 50% of patients who die in transport-related incidents had an elevated blood alcohol content. Over 90% of these cases were at levels above 0.05g/100ml.
Pedestrians and drivers had the greatest percentage of positive blood alcohol levels. Of all homicides, the most common cause of non-natural death (44% as opposed to 27% for transport-related injuries), also over 50% were alcohol-related. Of these, 89% had blood alcohol levels above 0.05g/100ml. 43% of firearm-related deaths were alcohol-related, with 77% of all deaths due to sharp objects having positive alcohol levels, compared to 54% for assaults with a blunt instrument, 26% for strangulation and 45% for burns.
Recently, the strong correlation between partner abuse and alcohol abuse by males has also been reported. Alcohol is also an important co-factor for risky sexual behaviour and HIV transmission, a wide range of social problems within the Welfare system and violent crimes affecting all departments in the Justice and Protection cluster. Effects of alcohol on the South African society are enormous, and exceed the effects of alcohol on many other countries in more than one way.
Although the total amount of alcohol consumed is not extremely high, the so-called “binge” drinking is common and about one-third of drinkers indicate that they drink to the level of intoxication. The problems are aggravated by a very poor public transport system after hours and over the weekends, resulting in an unacceptably high number of drunken drivers.
According to the AA, road traffic accidents cost the country in excess of R110-billion annually. It is estimated that at least half of these are related to alcohol, which means the Alcohol Beverage Industry should take responsibility for at least R50- billion annually. However, being generally known as efficient tax evaders, it is unlikely that their combined tax excise even compensate a fraction of this amount.
Presently, South African Breweries are under investigation by the African Tax Administration. In South Africa approximately half the population is under 21 years of age. This means that all advertising in South Africa targets predominantly youth, simply because there are more children.
Research shows that young children respond to advertising at an emotional level, and change their beliefs and expectations about alcohol. The alcohol beverage industry is extremely sophisticated in developing marketing, and exposure of alcohol advertising and alcohol enjoyment in the media predicts more frequent and heavier drinking among young people.
Alcohol advertising continues to spread untruths: “Alcohol drinking is normal”; “Alcohol is used by attractive, successful and healthy people, who are sexy, popular, charming, independent and strong”; “Drinking is safe, why else would so many people drink?” and “Drinking is relaxing”.
However, it is sad that a great percentage of children who start drinking young (especially if under 14) will end up as alcoholics, that alcohol-related accidents are one of the main killers of young people and that up to 70% of interpersonal and domestic violence is alcohol-induced.
To link alcohol and sport, as the alcohol beverage industry is accustomed tends to do, should in essence be regarded as a crime. How can we link a sporting event to a substance which is addictive, toxic and has the potential to kill the user as well as destroy his socio-economic environment?
In 2002 a conference was held in Valencia, where 22 countries were represented. Alcohol marketing and promotion to young people was analysed and it was concluded that the alcohol beverage industry presents a very one-sided view of alcohol and actively masks the contribution of alcohol to morbidity, mortality and social harm.
They recommended that: (1) legislation and regulations regarding alcohol needed to be improved in order to protect young people form promotional messages; (2) it is necessary to create more awareness among young people about the great level of sophistication of the marketing from the alcohol beverage industry; and (3) young people need to be activated to protect their own health.
Existing government programmes and interventions have been insufficient to address the extent of alcohol-related trauma. A robust and comprehensive government programme to tackle this large public health problem should be based on interventions, which have been demonstrated internationally to be effective. These include dealing with under-age access to alcohol and decreasing access through a coherent liquor outlet policy (also bringing shebeens into a regulated framework).
Greater use should be made of random breath testing of drivers and in cases of trauma, addressing drinking and driving more aggressively through increased random breath testing and a graduated driver licencing policy (much lower legal alcohol levels in first three years after obtaining a licence). Internationally, price has been widely shown to be an important determinant of consumption and excise taxes are a key factor in price.
Price elasticity of demand for different forms of alcoholic beverage are between -0.3 and -0.98 (i.e. a 10% price increase results in a 3%-9.8% decrease in quantity demanded). The two main justifications for increasing excise taxes on alcohol are to correct externalities associated with alcohol consumption that are not currently being paid for by alcohol consumers, and to raise revenue for programmes to reduce the social burden associated with alcohol abuse.
We argue that such taxes should present individuals and firms with the true social costs of their actions. Expenditure on a range of intervention programmes needs to increased. Primary prevention activities, drug and alcohol treatment and rehabilitation units and other effective interventions are often non-existent or operating at far below required levels.
Trauma units filled with pathologies associated with alcohol have insufficient equipment and resources. Since 2003 we have been motivating for the establishment of an Alcohol Injury Fund (along the lines of the Road Accident Fund) to specifically compensate victims of trauma by paying for medical costs and other damages suffered. Such victims are frequently poor and have little recourse to legal action or compensation.
A prerequisite for claiming from such a fund would be proof that the perpetrator was under the influence of alcohol while inflicting the injury. This could be performed by a breathalyser test, followed by a blood test for alcohol if positive (performed by a district surgeon on instruction from the police). This will encourage alcohol testing and create a climate of more awareness.
An Alcohol Injury Fund for victims of alcohol-related trauma will be able to provide a broader base of funding for victims as well as for equipment for beleagured trauma units, funding for substance abuse treatment centres and for primary prevention at a community level aimed at reducing the burden to society associated with alcohol-related injuries. This would also be in accordance with the point made in the Draft National Liquor Policy that we should move towards a “polluter pays” policy.
On the basis of all the aforementioned, we would like to propose a ban on all alcohol advertising and a total withdrawal of alcohol sponsorship from sport, as well as a ban on all financial support from the alcohol beverage industry towards all government and political party-related social functions, since we cannot expect any far-reaching political actions against the alcohol beverage industry from people who are benefiting themselves.
During his first address to Parliament in 1994, former President Mandela specifically singled out alcohol abuse as a major cause of crime, poverty, reduced productivity, unemployment, dysfunctional family life, political instability, the escalation of chronic diseases such as AIDS and TB, injury and premature death. The ill effects of alcohol abuse reach across social, racial, cultural, language, religious and gender barriers and affect all of us.
Nearly two decades after this declaration it is now high time society starts pressing government in dealing more effectively with alcohol-related trauma.
Prof AB (Sebastian) van As is the head of the Trauma Unit at the Red Cross War Memorial Children’s Hospital and president of Childsafe South Africa
This article originally appeared in the Mail & Guardian newspaper as a sponsored supplement