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 alcohol-

related 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

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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; counter-

narratives 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 middle-

income 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

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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 post-

structuralism 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

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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

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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).

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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, ‘t he 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

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‘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 inter-

ministerial 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 alcohol-

related 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,

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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 alcohol-

related 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 non-natural

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 night-

time 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 Kwa-

Zulu 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 well-

intentioned 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 ‘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

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 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

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 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

20

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

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 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.

22

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

23

Root causes

residential segregation

racial segregation

income inequality

health inequality

gender inequality

educational inequality

absolute/ relative poverty

rising incomes/ growth of middle

class

worklessness

national liquor industry

Policy disaggregation

Dynamic pressuresrural-urban migration

in-migration growth in informal

settlements

unlicensed/ illicit trade

social/ethnic tensions

religious pressures

violent crime (reality and perception)

promotion of night time economy/

advertising

transactional sex

corruption

Unsafe conditions

normalisation of intoxication

normalisation of drink-driving

poor sanitation

HIV/AIDS & TB

chronic disease

poor road safety provision

inadaquate transportation

poor regulation and enforcement

violence and fear

blame, prejudice and stereotyping

short-term risk horizons

DISASTERInterpersonal

violence/ homocide/ abuse/

rapeco-usage of drugs

drink driving

intoxication

addiction and poor mental health

state and household burdenchronic and acute ilness (inc. foetal

alcohol syndrome)

Hazards

Addictive psycho-social properties

conviviality, tradition and

pleasure

affordability

ready availability

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