The Political Ecology of Alcohol as “Disaster” in South Africa’s Western Cape
Abstract
While attention to the socio-ecological and political economic influences on health grows,
there remains a paucity of political ecological analyses of health (King, 2010). At the same
time, the growing burden of non-communicable diseases (NCDs) in the Global South
demands new conceptual and pragmatic engagements with their modifiable risk factors.
Drawing on the example of South Africa, this paper argues that alcohol consumption might
usefully be theorised in political ecological lexicon as a “disaster”. To do so, it draws attention
to the upstream causes of vulnerability, rather than just the downstream effects of risky
drinking. This reorientation is needed for sustainable, publicly acceptable alcohol policies. To
realise this, it draws on Blaikie et al’s (1994; 2003) political ecological approach to risk,
vulnerability and coping and, more specifically, applies their Pressure and Release model to
explore liquor as a situated “disaster” in South Africa’s Western Cape province. In so doing, it
aims to mark out an under-explored research agenda that considers alcohol as a pervasive
governance dilemma. In addition, it also reflects on the model's utility as a means of
communicating findings that might reorient policy discussions on alcohol control in both South
Africa and countries of the Global South.
Introduction
This paper emerges from two points at different ends of the research process. The first concerns
how best to theorise and conceptualise the intersections between alcohol, poverty, development
and urban space. The second involves the question of how best to convey the complexity of these
interrelationships to a series of disparate “end users”. The importance of generating impact from
research is undoubtedly clear, especially where research concerns risk behaviours that result in
disproportionately high mortality and morbidity rates and that undermine progress towards
developmental objectives. Yet, despite this burgeoning of demand for impact (Pain, Kesby et al.
2011; Williams 2012) from the UK’s Research Excellence Framework (REF), research grant criteria,
and government Higher Education and research policy, trying to effect impact may necessitate
reframing how the research problem itself is viewed. For example, the UK’s Department for
International Development (DfID) asks that the primary area of impact be poverty alleviation. The
challenge is therefore clear: how to translate social science research in ways that hold the
potential to alleviate poverty and generate ‘useful, legible and relevant’ research findings (Wilton
and Moreno 2012, 107). In the case of the research project explored in this paper which concerns
behaviours and practices that both stem from and aggravate poverty, this task is all the more
important, but no less demanding. This paper therefore ruminates on the theoretical and
empirical problem of how best to translate findings of complexity into messages that can be
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communicated simply and which, ultimately, could have the intended outcome of alleviating the
vulnerabilities that drive and exacerbate poverty. In so doing, it draws on the example of the risks
associated with alcohol (production, retailing and consumption) in the Western Cape Province of
South Africa (SA) to consider two impact objectives: (1) Shifting governmental agendas from
treating effects to identifying, acknowledging and addressing the causes of hazardous
drinking
and
its
(intended
and
unintended)
consequences,
and
(2)
injecting
development aspirations into alcohol control policy and, no less importantly, alcohol control into
development policy.
To do so, it argues for the value of adopting a political ecological approach to alcohol as an
emergent and serious challenge to development, an area of research that is largely absent from
the study of alcohol within Geography with the exception of Lawhon’s recent work (2012). The
disproportionately high rates of alcohol-related harm in low and middle-income countries (Parry
2000; Room, Jernigan et al. 2002) represent the kind of “disaster” for which the social
(pre)conditions ‘arise out of “normal” life’ (Blaikie, Cannon et al. 1994, 49). However, in spite of
the political attention now being devoted to alcohol harm reduction; these conditions of normal
life court less interest. This doubtlessly undermines the efficiency of efforts to reduce alcoholrelated harms as the prevailing risks associated with ‘normal life’ remain unaltered and
vulnerabilities persist. If risky drinking practices and their effects are to be mitigated to achieve
‘conditions that improve the health and wellbeing of all people, and equity in the distribution of
these conditions between people’ (Labonte, Polanyi et al. 2005, 10), then it is fundamental to
reframe discussions on alcohol to consider the causes of risky drinking. Doing so also responds to
Blaikie’s recent interjection over the ‘use’ of political ecology (Blaikie 2012) by reflecting on the
approach’s application to alcohol framed, somewhat controversially, as “disaster” (Blaikie,
Cannon et al. 1994). In contrast to hyperbolic accounts of “epidemics” or even “pandemics” of
disease or risk behaviours now common in media and academic accounts alike, theorising and
communicating alcohol as “disaster” serves a valuable analytical purpose. In this case, the notion
of disaster presents an opportunity to theoretically engage with the intersections of alcohol
production, retailing and consumption practices with macro and micro-scale social, economic, and
political processes and materialities that shape and reinforce vulnerabilities. Thus, adopting a
political ecological approach to alcohol-as-disaster augments nascent work on the political
ecologies of health and disease within geography (Turshen 1977; Mayer 1996; King 2010), adds a
new perspective to the emergent field of critical geographies of alcohol (Wilton and Moreno
2012) and also enables an engagement with contemporary behavioural risks and their political
2
economic drivers in the study of development.
In Cape Town, capital of the Western Cape, the high prevalence of alcohol-related harms is
layered over abject poverty and profligate wealth. The province and city have long struggled with
the need to develop an effective alcohol control strategy and, only in April 2012 was the
provincial liquor bill made law, after a decade of contestation, debate and delay (see Lawhon and
Herrick, 2012). Against an urban backdrop of endemic risky drinking practices, this paper asks how
theorising drinking in Cape Town as “disaster” might, somewhat counter-intuitively, deflect
tendencies to hyperbole to instead engage with the multi-scalar processes driving risk and
vulnerability that underpin socio-ecological models of health. To do so, the paper is structured in
three sections. First, it explores how political ecologies might be fruitfully applied to alcohol as an
instance where ‘the activities of daily life comprise a set of points in space and time where
physical hazards, social relations and individual choice converge’ (Blaikie, Cannon et al. 1994, 13).
Second, it argues that Blaikie et al’s under-utilised Pressure and Release (PAR) Model offers a
powerful tool to interrogate the ‘social production of vulnerability’ (1994, 21) which, in turn,
creates the conditions for disaster when they intersect with hazardous substances and
behaviours. The search for appropriate frameworks to organise ‘work from analysis to action’
(WHO, 2010: 8) prioritises structuralist interpretations of vulnerability and, consequently,
interventions. Socio-ecological models of health also draw attention to the contexts in which
health is produced or reproduced and must also, this paper argues, inculcate post-structural
interpretations of the progressions of vulnerability if they are to be effective. The PAR model is
explored in four sections that examine: (1) the root causes; (2) dynamic pressures; and (3) unsafe
conditions that produce (4) hazards and disaster. Third, it discusses the implications of these
theoretical engagements for alcohol policy in SA, before offering a brief conclusion.
Disasters, alcohol and political ecologies of health
Non-communicable diseases (NCDs) and their manifold risk factors (e.g. drinking, smoking,
inactivity, poor diets) are frequently cast unproblematically as “epidemics” or even “pandemics”
within the public health literature, by international organisations (see for example World Health
Organisation 2000; World Health Organisation 2011) and the media. Notwithstanding the fact
that in strictly epidemiological terms, an epidemic or pandemic is of infectious origin; counternarratives from within critical social science approaches to health and illness have recently started
to challenge the justificatory bases for such semantic choices. For example, many within the
emergent field of ‘critical obesity studies’ have deconstructed and challenged the hegemony of
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obesity’s purported “epidemic” status (Astrup, Larsen et al. 2004; Gard and Wright 2005; Flegal
2006; Oliver 2006; Mitchell and McTigue 2007; Saguy and Almeling 2008; Chiolero and Paccaud
2009), and, in the process, highlighted the consequences of such a framing for both policy and the
obese. However, those studying alcohol use and abuse have not yet thought through the
consequences of similar metaphorical usage. This paper asserts that alcohol, especially in
countries of the Global South (GS) where alcohol control policies are often nascent and poorly
enforced, is a disaster on a number of levels and scales. However, rather than applying this label
unreflectively and uncritically, it is appended purposefully in order to actively explore how such
“long-wave” (Barnett and Blaikie 1992; Adger 2006) disasters are constituted and unfold. Unlike
an “epidemic”, disaster is not merely a statement of magnitude or of mode of transmission, but
rather represents a systematic starting point for an analysis of the upstream causes and
constructions of risk and vulnerability. For, as Parry et al have asserted, ‘attention must now be
directed towards addressing the drivers of alcohol use, especially of heavy use, and particularly
those drivers operating at the social and environmental level’ (2011, 1722).
The increasing urgency with which alcohol is being viewed by some countries of the GS mirrors
bold shifts in the burden of disease from infectious to NCDs such as coronary heart disease,
diabetes and cancers, for which lifestyle is a primary risk factor (Beaglehole and Yach 2003;
Boutayeb 2006). As such, public health paradigms and policies are being fundamentally
challenged by the changing burden of disease and, even more so in countries like SA, where
infectious (especially HIV and TB) and chronic diseases coexist (World Health Organisation 2010;
UN Secretary General 2011). The report of a recently convened high-level meeting of the UN
General Assembly NCDs highlighted that 80% of deaths from NCDs occur in the GS and the burden
is by far the highest in middle-income countries (Beaglehole, Bonita et al. 2011). Both the UN and
WHO are now calling for greater global attention to the burden of NCDs and, as a result, the
causal role played by alcohol as one of four modifiable risk factors which also include: tobacco;
physical inactivity and unhealthy diets. Given that alcohol consumption among drinkers in middleincome countries is fast approaching that in high-income countries, the interrelated focus on
alcohol and NCDs is a laudable, especially since both have been shown to have serious and
complex relationships to poverty. In 2012, the WHO set voluntary targets for countries to reduce
per capita adult alcohol consumption by 10% by 2025 (World Health Organisation 2011). It is
notable that SA has gone one step further than this, setting a target of a 20% reduction in per
capita adult consumption by 2020 (Payne 2012).
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In SA, ‘poverty, gender inequalities, crime and violence play a major role in exacerbating the
health problems of the South African population’ and, as a result, ‘efforts to improve health will
have to extend to the very core of [...] society and cultures, with refurbishment of [the] social
fabric and comprehensive strategies to reduce poverty’ (Bradshaw, Groenewald et al. 2003, 687).
With these aspirations in mind, political ecological approaches to the study of alcohol are of
extensive value given their concern with:
…the need to set a problem or phenomenon into its broader social and economic context, and the
need to relate both the phenomenon and its socioeconomic context to a variety of scales ranging
from the local to the global (Mayer, 1996: 447)
Such thinking mirrors recent thinking at the WHO on addresses the social determinants of health
inequities, building on the work of Michael Marmot (2005; 2010). Given this, it is still curious that
while political ecologies have grown in scale and scope (see Bryant 1998; Robbins 2004; Muldavin
2008 for reviews), their application to health remains limited despite concerted calls for greater
engagement (Turshen 1977). Political ecologies of health remain scarce even within the
burgeoning field of health geography (King 2010) and its concern with the complex relations
between health (outcomes, practices and understandings), place, meaning and experience
(Kearns 1993; Kearns 1997; Rosenberg 1998; Kearns and Moon 2002; Parr 2004). While mounting
concern with so-called ‘diseases of comfort’ that stem from physical inactivity and/or obesity
(Choi, Hunter et al. 2005) have again reframed how we should best conceptualise vulnerability in
relation to health (Yach, Leeder et al. 2005; Daar, Singer et al. 2007; Robert, David et al. 2010), the
notion that behaviours are driven by certain attributes of place mean that they require critical
attention to the ecological. By extension, if we agree that ‘the major determinants of health are
social, [then] so must be the remedies’ (Marmot 2005, 1103), then critical reflection on the
political is of equal importance.
Over the past thirty years, ecological approaches to public health have increased in importance
and application as the environmental contexts of behaviour have come under renewed scrutiny
when designing intervention strategies. At root, ecological approaches aim to identify and
produce environments or ‘social contexts’ (Blankenship, Bray et al. 2000) that enable healthy
lifestyles (Sallis, Owen et al. 2008) with ‘ecology’ here representing a human/non-human
ecosystem within which human behaviour is shaped (Kickbush 1989). Ecological approaches to
health have been prolific in relation to physical activity (Bauman 2005; Blanchard, McGannon et
al. 2005; Sallis, Cervero et al. 2006) and obesity (Egger and Swinburn 1997; Reidpath, Burns et al.
2002; Pepin, McMahan et al. 2004; Lang and Rayner 2007), however they have not yet been
explicitly applied to drinking despite a burgeoning of geographical engagements with alcohol (see
5
for example Jayne, Valentine et al. 2008a; Jayne, Valentine et al. 2008b; DeVerteuil and Wilton
2009; Wilton and Moreno 2012). This is notable given that the factors producing risky drinking
practices exist at multiple levels of influence (e.g. individual, community, regional and national
policy, global political economic systems) and require multi-level interventions to change
individual behaviour and its environmental determinants (e.g. location of drinking places,
licensing, availability etc). Moreover, as models prioritise the role of external drivers, they
consequently problematise the politicised notions of individual responsibility and choice that
most frequently characterise debates on alcohol policies in the Global North (Sallis, Owen et al.
2008). As Blakenship et al (2000, S16) have argued ‘structural interventions operate to promote
public health without necessarily altering individual behaviour’. Thus, such an approach may
inspire productive engagements with vulnerabilities and their mitigation, rather than deferring to
the tendency to castigate and blame “irresponsible” drinkers in the GS. Thus, the paper responds
to Wilton and Moreno’s assertion that geographers should ‘problematize taken for-granted
assumptions about the nature of, and motivations for, [...] alcohol use, and direct attention to
both the intended and unintended consequences of regulation’ (2012, 106).
While ecological models of health remain primarily structuralist, political ecology itself has
embraced post-structuralism (Forsyth 2008). The limited application of political ecology to
contemporary health challenges (King 2010) thus seems curious given the clear uptake of poststructuralism to explore the production of health (Lupton 1995; Petersen and Lupton 1996).
Furthermore, calls for an explicitly urban political ecology (Bryant 1998; Keil 2003; Swyngedouw
and Heynen 2003; Keil 2005), mindful of the ways in which meanings of health and illness are
constituted in and by social processes situated in city spaces, make the need for political ecologies
of health all the more valid. This is particularly the case in relation to those health concerns
located in cities where rapid urbanisation and shifting livelihood patterns can quickly enhance
vulnerabilities and undermine coping strategies. Obesity may have been earmarked as a ‘growth
area’ in urban political ecology (see for example Guthman and DuPuis 2006; Heynen 2006; Marvin
and Medd 2006), but this growth has not yet spilled over into the study of liquor (Lawhon 2012).
Questions consequently still need to be asked of how alcohol, as practice and product, is best
conceptualised within a political ecological framework and, in turn, how such frameworks might
be usefully deployed. Spelt out another way, what kind of punitive ecologies might alcohol reveal
and in what ways can political ecology’s concern with ‘political economy and power’ (King 2010,
42) add to our understandings of alcohol-related harm in SA? To begin to approach these
questions, Blaikie et al’s PAR model is used as a starting point and framework through which to
critically interrogate alcohol-as-disaster in SA and, in so doing, both strengthen the case for
6
political ecologies of alcohol and provide a clear point of communication that gives necessary
weight to the importance of causal influences on drinking-as-disaster.
South Africa and the Alcohol Pressure and Release Model.
With a population of 49.3 million and GDP per capita of $5,786 in 2009, SA is Africa’s most
powerful economy. Since 2000, GDP per capita has risen by $2,736 or 90% (World Bank 2010).
However, with “official” unemployment in excess of 25%, average life expectancy of 51.5 (which
represents a decline of 4.5 years since 2000) and average HIV prevalence of 18% (Ibid), the
country faces clear barriers to achieving equity in health. Added to this, SA’s high rates of alcohol
consumption are layered over a post-apartheid ‘protracted and polarised health transition’
characterised by the ‘persistence of infectious diseases, high maternal and child mortality and the
rise of non-communicable diseases’ (Chopra, Lawn et al. 2009, 1). SA may be an exception in the
region for its reasonably and relatively well-developed alcohol regulations and a vocal public
health lobby (Parry 2010); but its fine line between ‘sociable and unsociable drinking’ (Mager
2010, 3) presents clear policy challenges. Moreover, the vulnerabilities to the multiple effects of
alcohol consumption are not limited to the country’s drinkers, but rather endured by the majority
of the population. Furthermore, the co-existence of regulated (i.e. licensed and legal) and
unregulated (i.e. unlicensed and illegal) drinking spaces present clear governance challenges. This
is due to the extent to which the delineation between public and private drinking (mirrored in
legislative terms by the on/off trade distinction) that guides the political logic of alcohol control
interventions (i.e. public order v. public health) in the Global North becomes even more of a “grey
zone” of “ambiguity” (Blum 2011) when transposed to contexts in the Global South. Indeed,
where prevailing policy thinking has been to tightly regulate alcohol supply to reduce average
drinking rates among the whole population (Kneale and French 2008), the dominance of the
informal unlicensed sector in alcohol retailing and consumption (and, increasingly production)
raises important questions about the broader effects of supply-side interventions on either risk or
vulnerabilities. For this reason, the paper suggests a need to reorient thinking from addressing
effects to mitigating the causes of consumption.
The development rationale for this is evident: In 2010, SA ranked towards the lower end of the
“medium” development category (110/169) in the Human Development Index. The persistence of
poor health indicators (e.g. under-nourishment, the mortality rate of under fives and life
expectancy) means that this ranking has not demonstrably improved since the measure’s
inception in 1990 (UNDP 2010a). The importance of health outcomes is further revealed by the
7
country’s progress towards meeting the MDGs. The ‘MDG Monitor’ suggests that SA is “on track”
to eradicate extreme poverty and hunger, but looks less likely to satisfy the criteria needed to
combat HIV/AIDS, malaria and other diseases, reduce child mortality and maternal health (UNDP
2010b), largely because of the rising burden of NCDs. It should be noted that the MDGs have
been subject to intense criticism for their ‘performance measurement’ logic which is ‘poorly and
arbitrarily designed to measure progress against poverty and deprivation’ (Easterly 2009, 26). This
logic, Sen (2009, 229) argues, tends ‘to focus specifically on the enhancement of inanimate
objects of convenience’, at the expense of enhancing opportunities for people to improve their
wellbeing. Moreover, the downstream thinking encouraged by the target-driven logic of the
MDGs risks losing sight of the upstream focus of rights and capabilities-based approaches to
development (Sen 1999; Sen 2009). For this reason, political ecological approaches and the PAR
model serve as valuable tools for identifying those upstream causes of vulnerability that so often
actually make drinking a rational response to a seemingly irrational or hazardous environment.
The PAR model therefore serves as an ‘explanatory or organisational device’ (Blaikie, Cannon et
al. 1994, 59) within which different theoretical constructs can be emplaced. At root, it
systematises how “disaster” emerges when ‘a significant number of vulnerable people experience
a hazard and suffer damage/ disruption of their livelihood system’ (Blaikie, Cannon et al. 1994,
21). Recovery is compromised because hazards impinge upon household resources, resilience and
capacities. Vulnerability is thus the culmination of three stages: root causes (e.g. the unequal
economic, demographic and political processes that influence resource distribution); dynamic
pressures (e.g. processes that translate root causes into unsafe conditions); and unsafe conditions
(e.g. the specific expression of vulnerability in space and time). The PAR model highlights those
upstream causes of vulnerability that are often deeply unpalatable to policy makers because ‘any
fundamental solutions involve potential change, radical reform of the international economic
system, and the development of public policy to protect rather than exploit people and nature’
(Blaikie, Cannon et al. 1994, 233). However, such reform may be necessary if the ‘catastrophic
expenditure’ associated with alcohol-related harm and poor health are to avoid becoming ‘a
substantial drain on society’s economic potential by adversely affecting the four main factors of
economic growth – i.e. labour supply, productivity, investment, and education’ (Beaglehole,
Bonita et al. 2011, 450-451). Yet, despite the model’s clear potential for exploring the risks and
vulnerabilities associated with alcohol, its application has thus far been limited to HIV/AIDS (Tsasis
and Nirupama 2008).
8
In contrast to most European counties where drinking is the norm, ‘many Africans abstain from
alcohol...[but] those who do drink, drink a lot’ (Jernigan and Obot 2006, 58). South African
drinking is characterised by high rates of heavy episodic drinking at weekends, underage drinking
and alcohol dependence among men (World Health Organisation 2004). While 55% of men and
83% of women do not drink, this does not make them any less vulnerable to the effects of unsafe
sex, interpersonal violence, accidents and injury precipitated by others drinking. In SA, therefore,
alcohol might be viewed as a disaster that ‘affect[s] people in varying ways and differing
intensities’ (Blaikie, Cannon et al. 1994, 5), with distinct spatial manifestations. SA is notable in
this respect as apartheid-era urban planning has carved cities such as Cape Town into distinct
pockets of privilege and privation (Parnell and Mabin 1995; Parnell 1997; Lemanski 2004;
Lemanski 2007; Tucker 2008), which often map directly both onto the unsafe conditions that
generate vulnerability and the normative social relations to drinking that both legitimate and
castigate risky behaviours. Thus, place – understood as having distinct materialities and produced
through ‘particular sets of social relations, networks and experiences’ (King 2010, 42) – is
inextricable from the constitution of unsafe conditions.
Blaikie et al (1994) originally applied the PAR model to famines, biological hazards (i.e. the Irish
Potato Famine), floods, coastal storms and earthquakes. However, they offered little
methodological guidance as to how to apply the model to alternative contexts. Thus, for the
research project explored in this paper, the model represents the research team’s collective
analysis of both secondary (i.e. literature review and health survey data) and primary data sources
(i.e. focus groups, stakeholder interviews, ethnographic fieldwork) according to the categories in
Blaikie et al’s original model (1994, 23). This is shown in figure 1. Building from this, figure 2
details the PAR model as applied to the political ecology of liquor in the Western Cape. The model
thus represents the systematisation of the research participants’ assertions of the most significant
causes of risky drinking practices and their consequences by the research team, bringing together
the broad findings of a multi-method research project in a way that enables further, in-depth
exploration of each category. Each stage of the model will be explored in turn below before
turning to a broader discussion of the policy significance of such an approach.
-
FIGURE 1 HERE-
-
FIGURE 2 HERE -
i. Root causes
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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
10
‘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 interministerial 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 alcoholrelated 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,
11
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
1
The SADHS classifies ‘responsible’ drinking among men as less than 4 drinks on one occasion, ‘hazardous’ drinking as
4-6 drinks and ‘harmful’ drinking as more than 6 drinks. For women, the thresholds are less than 2 drinks, 2-4 drinks and
more than 4 respectively. It should be noted that units are not widely used in South Africa. Instead a ‘standard drink’ is
12g of pure alcohol (n.b in the UK this is 8g and in the US 14g). Weekly guidelines in South Africa are to not exceed 252g
for men and 168g for women (n.b. in the UK this is 168g/112g and in the US 196g/98g). These figures demonstrate, if
anything, the ‘impure science’ (Epstein, 1998) of risk calculations with respect to alcohol consumption.
12
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 alcoholrelated harms (e.g. domestic violence), may leave root causes untouched.
ii. Dynamic pressures
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 nonnatural 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
13
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 nighttime 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.
14
iii. Unsafe conditions
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
15
or resonance. Simply put, when you are statistically unlikely to live past 52 (or 43 for men in KwaZulu 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
16
renders fatalism a logical response to danger, and risk a logical outcome of such fatalistic
purviews. And, sadly, alcohol strategies rarely deal with fatalism.
iv.
Hazards and disaster
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 wellintentioned 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
17
(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?
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 ‘undertheorise’ 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 humanenvironment 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
18
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 15 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
19
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 microand 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
20
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
21
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 multidimensionality 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.
22
Figure 1 - Original PAR model (Blaikie, Cannon et al, 1994, 23)
Root causes
residential
segregation
racial segregation
Dynamic
pressures
rural-urban
migration
in-migration
growth in informal
settlements
Unsafe
conditions
normalisation of
intoxication
normalisation of
drink-driving
DISASTER
Interpersonal
violence/
homocide/ abuse/
rape
co-usage of drugs
Hazards
Addictive psychosocial properties
conviviality,
tradition and
pleasure
income inequality
unlicensed/ illicit
trade
poor sanitation
drink driving
affordability
health inequality
social/ethnic
tensions
HIV/AIDS & TB
intoxication
ready availability
gender inequality
religious pressures
chronic disease
addiction and poor
mental health
educational
inequality
absolute/ relative
poverty
rising incomes/
growth of middle
class
worklessness
violent crime
(reality and
perception)
promotion of night
time economy/
advertising
poor road safety
provision
inadaquate
transportation
transactional sex
poor regulation
and enforcement
corruption
violence and fear
national liquor
industry
blame, prejudice
and stereotyping
Policy
disaggregation
short-term risk
horizons
state and
household burden
chronic and acute
ilness (inc. foetal
alcohol syndrome)
Figure 2 - PAR model as applied to alcohol as “disaster” in Cape Town, South Africa
23
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