In this presentation for the IDS seminar 'Global demographic shifts: The 21st century burden of disease', Clare Herrick explores the emergences of non-communicable diseases (NCDs) in South Africa, focussing on harmful use of alcohol as a risk factor for developing NCDs.

1. NCDs, alcohol and development:
South Africa
Clare Herrick
Department of Geography
King’s College London

2. Outline
• NCDs and development
• NCDs and alcohol
• NCDs, alcohol and development in SA
• Concluding thoughts

3. 1. NCDs and development

4. The lack of data showing the interplay of
risk factors, NCD burden and poverty has
contributed to the neglect of NCDs by
policymakers in developing countries
(Schneider et al, 2009: 176)

5. Why NCDs?
• Social determinants of health agenda
• Burden of disease calculations
• Socio-spatial complexity of epidemiological
transition(s)
• Calculations of economic cost of NCDs to low
and middle income countries - $7 trillion
2011-2025
• No longer "diseases of comfort"
(Choi, 2005), but ones of poverty and “past
and cumulative risks” (Beaglehole and
Yach, 2003)

6. WHO's Epic Tool - development?
Labour
Economic
NCDs
Output
Capital
Source: Abegunde et al (2006)

7. Institutional momentum
• WHO Global Status Report on the burden of
NCDs
• UN high level meeting September 2011
• NCD Alliance lobbying - Global Health agenda?
• Critique of failure to realise MDGs - cannot
work without inclusion of NCDs
• Targets currently under debate

8. But
• NCDs as "market failure" or a "result of
defective process of industrialisation that has
given priority to economic growth over human
welfare" (Frenk et al, 1989: 31)
• Role of Geographic “luck“ or fate? (Kearns and
Reid-Henry, 2010)
• Wellbeing, quality of life and rights - income
spent on healthcare is proportionally greatest
for poorest.

9. 2. NCDs and alcohol

10. • Four major risk factors for NCDs: salt intake;
exercise; smoking; drinking
• Alcohol contributing factor to: cancers; CVD;
liver disease and T2 Diabetes
• Globally, 3rd most significant cause of DALYs
lost
• But 1st in middle income countries
• Significant lack of data - habitual under-
reporting of drinking. Especially among
men, North Africa and Middle East.

11. For a given amount of
consumption, poorer populations
may experience disproportionately
higher levels of alcohol-attributable
harm
(Blas and Sivasankara Kurup, 2011: 21)

12. • WHO target = reduction of alcohol consumed
per capita by 10% by 2020.
• Long history of WHO engagement with
alcohol, but only recent acknowledgment of
NCDs and potential role in undermining
developmental aspirations
• May require fundamental re-conceptalisation
of how and why alcohol is a problem and the
potential solutions to this.

13. 3. NCDs, alcohol and
development in SA

14. SA and NCDs
• Mayosi et al (2009): quadruple burden of
infectious, NCDs, perinatal and maternal
• Why? Rising life expectancies and effects of
urban poverty - poor diets, sedentarism, high
salt intake, smoking (ie among coloured),
drinking
• Cause 40% mortality and 35% burden of
disease
• Rooted in inequalities in service provision,
poverty and poor health literacy

15. South African drinking
• Dual economy -formal and informal
• One of riskiest patterns of drinking in world -
heavy episodic as social norm
• Liquor production and retailing long been
form of state revenue and social control
• Focus on formalisation of illegal sector
• Significant market and world's second largest
industry player

20. Phuza...
• Phuzagrain
• Phuza-face
• Phuza Thursday

21. Many companies are saying to me Monday is
our biggest problem. I’m saying I know there’s
a fish Friday you know it’s Monday or
Wednesday it’s the fish Friday but Monday
there’s something that is going on. Go to the
townships it’s happening .
(Interview, 2011)

22. SA and alcohol policy
• 2003 National Liquor Act
• Need to update 1989 Provincial Acts
• 2012 Western Cape Liquor Bill promulgated
• City of Cape Town municipal by-laws
• Multi-sectoral team from health, social
development, liquor board, SAP, metro police
etc.
• Still tensions between departmental goals and
remits (ie health v dept for trade and industry)

23. WCLB:
• Formalisation or closure of shebeens
• Land use zoning
• Restricted opening hours
• Limits on licenses in residential areas
• Community involvement in licensing
applications
• enforcement at metro scale - complaints and
tip offs - but conflict with SAPS.
• No education component.

24. • Policy driven by: violence, rape, injury, RTAs
and drunk driving, crime, absenteeism, drugs.
• NCDs have been absent from calls to curb
alcohol consumption and abuse, despite
burden of CVD, hypertension, T2 diabetes,
cancers etc.
• SA WHO target = 20% reduction in alcohol
consumption by 2020
• Policy focuses on restricting access to deal
with acute effects, not chronic consequences.
• 'the poor also have a right to choose'

25. 4. Concluding thoughts

26. • Linking NCDs and alcohol necessitates thinking
about risk behaviours and behaviour change
in a more nuanced way, rather than trying to
engineer risk out of environment (eg shebeens
in Freedom Park), we need to better
understand and acknowledge complexity of
demand
• Need to understand dynamics of consumption
and points of intervention/ settings for this
• Expanding role of CSR/ CSI

27. • Need to communicate risks of drinking to
change temporality of risk horizons
• How to make data more accurate and
representative. Success of interventions (i.e.
shebeen closures measured through crime
numbers not volume of liquor consumed -
little effect on NCDs)
• Funding priorities shaping knowledge
• Prevention must be prioritised, not treatment
- but is evidence-based always best?