Invest in South Africa’s potential - PowerPoint Presentation

Slide1

Invest in South Africa’s potential

The legacy of Douglas and Eleanor Murray

Dr David

Harrison

Chief Executive Officer19 August 2020

Five urgent strategies to reduce the harm of excessive alcohol consumption in South Africa

Together with

Ms

Sinazo Nkwelo (DGMT), Dr Charles Parry (SAMRC) and Dr Richard Matzopoulos (SAMRC/ UCT School of Public Health)

Slide2

Economic benefits of alcohol industry, South Africa in 2009/10

* 2009/10 chosen for comparability between National Treasury Tax Review and analysis of costs published in South African Medical Journal (both based on 2009 statistics)

Source: National Treasury (2014). A review of the taxation of alcoholic beverages in South Africa: A Discussion Document.

ECONOMIC BENEFIT

TAX REVENUE

41.7 bn

Direct

34.7 bn

Indirect

7.0 bn

EMPLOYMENT

Direct

21,300

Indirect

501,000

CONTRIBUTION TO GDP

Gross amount

68

bn

Gross percentage

2.90%

Slide3

Economic benefits and costs of alcohol industry, South Africa in 2009/10

* 2009/10 chosen for comparability between National Treasury Tax Review and analysis of costs published in South African Medical Journal (both based on 2009 statistics)

Source: 1. National Treasury (2014). A review of the taxation of alcoholic beverages in South Africa: A Discussion Document.

2. Matzopoulos R, Truen S, Bowman B and Corrigall J (2014). The cost of harmful alcohol use in South Africa. South African Medical Journal Vol 104 (2): 127-132

ECONOMIC BENEFIT1

TANGIBLE COSTS

37.9

bn

Health care

11.7

Social and welfare

0.4

Crime prevention & response

18

Road traffic accidents (motor vehicle damage)

7.9

INTANGIBLE COSTS208 - 242 bnPremature death and disease (loss of earnings)8.2 - 9.8Premature death and disease (value of life)183 - 216Absenteeism141 -148Other welfare costs16.1TOTAL COSTS245 - 280 bnDirect financial loss to fiscus1.60%Cost to GDP (direct and indirect)10-12%

ECONOMIC COSTS2

TAX REVENUE41.7 bn Direct34.7 bnIndirect7.0 bn EMPLOYMENTDirect21,300Indirect501,000CONTRIBUTION TO GDPGross amount68 bnGross percentage2.90%

Slide4

Associations between alcohol excesses and societal harm in South Africa

Caused by alcohol

Associated with alcohol

MORTALITY BURDEN

62,000

deaths per

year*

 

Probst, C., Parry, C.D.H.,

Wittchen

, H-U, &

Rehm

, J. (2018). The socioeconomic profile of alcohol attributable mortality in South Africa. BMC Medicine, 16. Doi.org/10.1186/s12916-018-1080-0.

GENDER-BASED VIOLENCE

 

 

Rape 40% (of men)Jewkes R, Sikweyiya Y, Morrell R, Dunkle K. (2011) Gender inequitable masculinity and sexual entitlement in rape perpetration South Africa: findings of a cross-sectional study PLoS One 6(12): e29590. doi:10.1371/journal.pone.0029590Femicide 61% (women)Mathews S, Abrahams N, Jewkes R, Martin LJ, Lombard C Alcohol use and its role in female homicides in the Western Cape, South Africa. Journal of Studies on Alcohol and Drugs 2009; 70(3): 321-327HOMICIDE AND VIOLENCE 54%SAMRC-UNISA (2009) A Profile of Fatal Injuries in South Africa.TRAFFIC ACCIDENTS 56%FOETAL ALCOHOL SPECTRUM DISORDER (FASD)Up to 18-26% in some high risk rural communities  May, PA de Vries, et al (2016). The continuum of fetal alcohol spectrum disorders in four rural communities in South Africa: Prevalence and characteristics. Drug & Alcohol Dependence, 159, 207-218.* 95% Confidence intervals for mortality burden 27,000 – 103,000

Slide5

Weighing up the benefits and costs of the alcohol industry

Tax revenue

Direct cost to fiscus

+ 3.1bn

Sources:

National

Treasury (2014). A review of the taxation of alcoholic beverages in South Africa: A Discussion Document.

Matzopoulos

R,

Truen

S, Bowman B and

Corrigall

J (2014). The cost of harmful alcohol use in South Africa. South African Medical Journal

104 (2

): 127-132

Note that another 2009 study found that direct costs to national and provincial departments exceeded tax revenue by R1 billion:

Budlender D (2010). Money down the drain: The direct cost to government of alcohol abuse. South African Crime Quarterly. DOI: https://doi.org/10.17159/2413-3108/2010/v0i31a889

Slide6

Weighing up the benefits and costs of the alcohol industry

Tax revenue

Direct cost to fiscus

Employment, tourism and other spinoffs

Individual loss of earnings & related welfare costs

+ 5bn

Sources:

National

Treasury (2014). A review of the taxation of alcoholic beverages in South Africa: A Discussion Document.

Matzopoulos R,

Truen

S, Bowman B and

Corrigall

J (2014). The cost of harmful alcohol use in South Africa. South African Medical Journal 104 (2): 127-132

Slide7

Weighing up the benefits and costs of the alcohol industry

Tax revenue

Direct cost to fiscus

Employment, tourism and other spinoffs

Individual loss of earnings & related welfare costs

Productivity losses from absenteeism

- R100

bn

*

Sources:

National

Treasury (2014). A review of the taxation of alcoholic beverages in South Africa: A Discussion Document.

Matzopoulos R,

Truen

S, Bowman B and

Corrigall

J (2014). The cost of harmful alcohol use in South Africa. South African Medical Journal 104 (2): 127-132

Slide8

Weighing up the economic benefits and costs of the alcohol industry

Tax revenue

Direct cost to fiscus

Employment, tourism and other spinoffs

Individual loss of earnings & related welfare costs

Productivity losses from absenteeism

Value of loss of life and health

- R210

bn

*

Sources:

National

Treasury (2014). A review of the taxation of alcoholic beverages in South Africa: A Discussion Document.

Matzopoulos R,

Truen

S, Bowman B and

Corrigall J (2014). The cost of harmful alcohol use in South Africa. South African Medical Journal 104 (2): 127-132

Slide9

Weighing up the social benefits and costs of the alcohol industry

Personal enjoyment

Gender-based violence

Socialisation

&

comraderie

Lack of fulfilment of potential through Foetal Alcohol Syndrome

Family misery through bereavement, domestic violence

Community stress

?

Sources:

National

Treasury (2014). A review of the taxation of alcoholic beverages in South Africa: A Discussion Document.

Matzopoulos R,

Truen

S, Bowman B and

Corrigall J (2014). The cost of harmful alcohol use in South Africa. South African Medical Journal 104 (2): 127-132

Slide10

A ‘culture’ of heavy drinking in South Africa

WHO 2018

1

% current drinkers

Adult per capita consumption per drinker in grams pure alcohol per dayHeavy episodic drinking among drinkers (≥5 drinks: 60g) in single occasion past 30 days - (%) of drinkersWorld

43.032.850.2

Africa

32.2

40.0

39.5

South Africa

Males

Females

31.0

43.2

19.4

64.659.070.833.7Sources: World Health Organisation (2018). Global Status Report on alcohol and health. https://apps.who.int/iris/bitstream/handle/10665/274603/9789241565639-eng.pdf?ua=1National Department of Health (NDoH), Statistics South Africa (Stats SA), South African Medical Research Council (SAMRC) & ICF. (2017). South African Demographic and Health Survey 2016: Key indicators report. Pretoria, South Africa, and Rockville, Maryland, USASADHS 20162MENAge% drank in last 12 mo.% of those who report 5 or more drinks at least once in past month15-1916.671.120-243782.425-3443.483.235-4440.279.145-5436.775.755-6445.157.065+39.552.9

SADHS

20162WOMENAge% drank in last 12 mo.% of those who report 5 or more drinks at least once in past month15-1916.39.820-2425.633.625-3422.627.035-441735.345-5415.528.455-641623.165+13.115.3

Slide11

Apartheid origins of the ‘culture’ of heavy drinking in South Africa

1928

1962

Abolition of slavery desire for cheap, pliant labour

‘dop system’

Liquor Act – beer as an instrument of control and complianceSeizure of sorghum beer industry from Black women

Government monopoly on its production

Creation of municipal beerhalls for working men

Permit system for educated Black men to access ‘European beer’

‘Liquor

freedom’

intended to

take the sharp edge off political oppression

and ensure that blacks fund apartheid structures

SA

leaves

Commonwealth loss of preferential trade status Desire to dampen opposition to repressive legislationWhites don’t want to fund black areasLiquor Amendment Act Blacks permitted to buy ‘European’ liquor at beerhall outlets (& non-European off-sales)Profits go to Bantu Areas Admin Boards (BAABs) to fund township upgradesGrowth of illegal shebeens, supplied by SAB & liquor industryBreweries linked to men’s hostels1834Late ’60’s to ’70’sSources: London, L (1999). The `dop' system, alcohol abuse and social control amongst farm workers in South Africa: a public health challenge. Social Science & Medicine, 48(10), 1407-1414Mager, A. (1999). The First Decade of 'European Beer' in Apartheid South Africa: The State, the Brewers and the Drinking Public, 1962-72. The Journal of African History, 40(3), 367-388. Retrieved August 15, 2020, from www.jstor.org/stable/183619BAAB’s neglect urban upgrades to fund bantustans

Slide12

Socio-economic gradients of binge drinking in South Africa

Source:

National

Department of Health (

NDoH), Statistics South Africa (Stats SA), South African Medical Research Council (SAMRC) & ICF. (2017). South African Demographic and Health Survey 2016: Key indicators report. Pretoria, South Africa, and Rockville, Maryland, USA.

Slide13

The vicious cycle of social and economic marginalisation

Alcohol (27.8%) and smoking (7.4%) together account for a third of measured inequalities in health*

*

Source

: Mukong A, Van Walbeek C, Ross H (2018). The Role of Alcohol and Tobacco Consumption on Income-related Inequality inHealth in South Africa. Economic Research Southern Africa. https://

econrsa.org/publications/policy-briefs/role-alcohol-and-tobacco-consumption-income-related-inequality-health, Accessed 15 August 2020

Slide14

Burden of alcohol related mortality falls on poorer people

Source:

Probst C, Parry C, Wittchen

H-U, Rehm J (2018) The socio-economic profile of alcohol attributable mortality: A modelling study. BMC Medicine 16:97 https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1080-0

HighMiddleLow

High

Middle

Low

SES

Men

Women

Slide15

National priorities that are unattainable without curbing heavy drinking

1. Major reductions in mortality

Covid-19

30-40,000

62,000

[

95% CI 27,000 – 102,000]

Alcohol- related

1

2020

Excess deaths of black people compared to white mortality

2

~200,000

2. Major reductions in gender-based violence

Rape perpetrators had been drinking

3

61%Femicide victims had been drinking4Sources:1. Probst C, Parry C, Wittchen H-U, Rehm J (2018) The socio-economic profile of alcohol attributable mortality: A modelling study. BMC Medicine 16:97 https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1080-02. Pillay-van Wyk V, et al (2016). Mortality trends and differentials in South Africa from 1997-2012: second National Burden of Disease. Lancet 4: e-642-6533. Jewkes R, Sikweyiya Y, Morrell R, Dunkle K. (2011) Gender inequitable masculinity and sexual entitlement in rape perpetration South Africa: findings of a cross-sectional study PLoS One 6(12): e29590. doi:10.1371/journal.pone.00295904. Mathews S, Abrahams N, Jewkes R, Martin LJ, Lombard C Alcohol use and its role in female homicides in the Western Cape, South Africa. Journal of Studies on Alcohol and Drugs 2009; 70(3): 321-32740%3. Progressive social developmentSocial cohesion and safe communitiesEducation, skills and healthVicious cycle of marginalization and heavy drinkingMarginalisation drives heavy drinkingHeavy drinking drives marginalisation

Slide16

How government needs to respond

“

Is

not alcohol that rapes or kills a woman or a child. Rather, it is the actions of violent men. But if alcohol intoxication is contributing to these crimes, then it must be addressed with urgency

”. President Cyril Ramaphosa 17 June 2020

A virtuous cycle for social development:

Mutually reinforcing strategies to reduce heavy drinking

Sources:

World

Health Organisation (2018). WHO launches SAFER alcohol control initiative to prevent and reduce alcohol-related death and disability. https://www.who.int/substance_abuse/safer/launch/en/

Chisholm

D, Moro D, Bertram M, Pretorius C,

Gmal

G, Shield K,

Rehm

J (2018). Are the “best buys” for alcohol control still valid? An update of the comparative cost effectiveness of alcohol control strategies at the global level. Journal of Studies on Alcohol and Drugs 514-522

“[W]e will also need to look at further, more drastic measures to curb the abuse of alcohol”. President Cyril Ramaphosa 17 June 2020‘Drastic’ not needed now. We can implement policies that are highly cost-effective, feasible and implementable at low cost, with compounding benefits

Slide17

1. The case for a comprehensive

ban on alcohol advertising

Sources:

Chisholm D, Moro D, Bertram M, Pretorius C, Gmal G, Shield K, Rehm J (2018). Are the “best buys” for alcohol control still valid? An update of the comparative cost effectiveness of alcohol control strategies at the global level. Journal of Studies on Alcohol and Drugs 514-522

Saffer, H. Tobacco Advertising and Promotion. In: Jha P, Chaploupka F, editors. Tobacco Control in Developing Countries. New York: Oxford University Press, Inc.; 2000. p. 215-236. Available from: http://www1.worldbank.org/tobacco/tcdc.asp. Morojele N, Lombard C, et al (2018). Alcohol marketing and adolescent alcohol consumption: Results from the International Alcohol Control Study (South Africa). South African Medical Journal 108 (9):

782-788World Health Organisation (2013). Successful tobacco legislation in South Africa. Intersectoral case study. https

://

atca-africa.org/images/pdf/19-Dec-2013_Successful-Tobacco-Legislation-in-South-Africa.pdf

INTERNATIONAL

LOCAL

A ban on

advertising

of alcohol

(

except on the site of sale, where it should not be visible to those under 18 years).

Adolescents: More exposure to alcohol advertising, more likely to drink. 13 % more likely to drink when exposed to each additional advertising platform.316 country study shows 1.2% reduction in prevalence of harmful drinking through comprehensive bans.1 Learning from tobacco advertising bans: Review of 102 countries founds that comprehensive advertising bans can reduce consumption but partial bans have little or no effect.2Tobacco advertising bans: Decrease in smoking from 32.6% to 20.9% from 1993 – 2010. Highest declines among younger people and lower incomes.4

Slide18

2. The case for raising the price of alcohol: Technical terms

Price elasticity of demand (Ep

d

)The percentage change in consumption as a result of a specified change in price e.g.

↑ price by 10% leads to ↑ in demand of 6% = Epd of +0.6↑ price by 10% leads to ↓ in demand of 6% = Epd of -0.6[We want a high negative price elasticity of demand for alcohol i.e. > -0.5]

CONSUMER BEHAVIOUR

PRICING STRATEGIES

Excise taxes

Tax levied on any manufactured goods, especially high volume daily consumables and luxury items.

Paid by manufacturer or importer to SARS.

Minimum unit pricing (MUP)*

A minimum price below which a unit of alcohol cannot be sold.

Paid

by the consumer to the seller

* In SA, a unit is defined as 15ml of 12g of pure alcohol

Slide19

2. The case for raising the price of alcohol

Sources:Chisholm D, Moro D, Bertram M, Pretorius C,

Gmal G, Shield K, Rehm J (2018). Are the “best buys” for alcohol control still valid? An update of the comparative cost effectiveness of alcohol control strategies at the global level. Journal of Studies on Alcohol and Drugs 514-522

O’Donnell, A., Anderson, P., Jané-Llopis, E., Manthey, J., Kaner, E. and Rehm, J., 2019. Immediate impact of minimum unit pricing on alcohol purchases in Scotland: controlled interrupted time series analysis for 2015-18. bmj, 366, p.l5274. Van Walbeek, CP and Chelwa, G (2019). Using Price-Based Interventions To Reduce Abusive Drinking In The Western Cape Province; https://www.news.uct.ac.za/article/-2019-04-23-a-minimum-unit-price-on-alcohol-could-limit-heavy-drinking

INTERNATIONAL

LOCAL

Differential pricing strategies target heavy drinkers

: Heavy drinkers in SA pay at least 5 times less per standard drink than moderate drinkers.

3

16 country study shows price elasticity of demand range from -0.3 for beer to -0.79 for wine and spirits.

1

i.e. 10% increase in price reduces beer & wine consumption by 3% and 7.9% respectively

Introduction of an MUP in Scotland (2018) led to a 4-5% reduction in consumption, with greatest effect in heavy drinkers.2In Russia, the introduction of an MUP resulted in a -1.2 per 100 000 people reduction in mortality rates.3MUP will have greatest effect on heavy and binge-drinkers: e.g. based on price elasticities of demand for SA drinkers, a R6 MUP could decrease consumption by 6.2% among binge-drinkers, 15.5% among other heavy drinkers and 4.6% among moderate drinkers .3Increase the price of alcohol, both through excise taxes and by introducing a minimum price per unit of pure alcohol in liquor productsCalculated by Dr Charles Parry, SAMRCCARLING BLACK LABELVol. per containerPrice / std unit330mlR8.54750mlR4.821000mlR5.52

Slide20

3. The case for lowering the legal drink-drive limit

Sources:

1. Chisholm D, Moro D, Bertram M, Pretorius C, Gmal G, Shield K,

Rehm J (2018). Are the “best buys” for alcohol control still valid? An update of the comparative cost effectiveness of alcohol control strategies at the global level. Journal of Studies on Alcohol and Drugs 514-5222. Fell J,

Voas R (2006). The effectiveness of reducing illegal blood alcohol concentration (BAC) limits for driving: Evidence for lowering the limit to 0.05 BAC. Journal of Safety Research 37: 233-2433. Road Traffic Management Corporation, Medical Research Council , UNISA (2018). Alcohol and its implications for road traffic crashes in South Africa: Phase A – review. http://www.rtmc.co.za/images/rtmc/docs/research_dev_rep/Alcohol%20and%20its%20implications%20for%20RTCs%20in%20South%20Africa%20Phase%20A%20March%202019.pdf

INTERNATIONAL

LOCAL

Alcohol is a factor in over half of all traffic-related deaths in South Africa.

3

16 country study shows 15-20% reduction in road traffic deaths (when properly enforced).

1

Risk of death in a single vehicle accident at 0.02% is double that of 0.00%; by 0.05% risk is 7-10 times greater.

2

Reduce the legal limit for drinking and driving to a blood alcohol content of 0.02% or below.

Slide21

4. The case for reducing ease of access to alcohol

Sources:

1. Chisholm D, Moro D, Bertram M, Pretorius C, Gmal G, Shield K, Rehm J (2018). Are the “best buys” for alcohol control still valid? An update of the comparative cost effectiveness of alcohol control strategies at the global level. Journal of Studies on Alcohol and Drugs 514-522

2. Livingston, M., Chikritzhs, T., Room, R., 2007. Changing the density of alcohol outlets

to reduce alcohol-related problems. Drug Alcohol Rev. 26, 557–566. https://doi.org/10.1080/095952307014991913. Matzopoulos R, Bloch K, Bowman B, Lloyd S, Berens C, Myers J, Thompson ML. 2020. Urban upgrading and levels of interpersonal violence in Cape Town, South Africa: the Violence Prevention through Urban Upgrading Programme. Social Science & Medicine 255: 112978. https://doi.org/10.1016/j.socscimed.2020.112978 4. Trangenstein

, P. J., Morojele, N. K., Lombard, C., Jernigan, D. H., & Parry, C. (2018). Heavy drinking and contextual risk factors among adults in South Africa: findings from the International Alcohol Control study. Substance abuse treatment, prevention, and policy, 13(1), 43. https://doi.org/10.1186/s13011-018-0182-1

INTERNATIONAL

LOCAL

Restricting outlet density

: Urban upgrading strategies (together with social programmes) can reduce rates of interpersonal violence.

3

16 country study shows that reducing physical availability of alcohol leads to 1.8-2.1% reduction in prevalence of heavy drinking in men and 4% in women.

1

Restricting outlet density: Higher density of alcohol outlets in communities is associated with higher rates of interpersonal violence.2Reduce the availability of alcohol, especially in residential areas (by limiting the density of liquor outlets, shorter trading hours, and ending the sale of alcohol in larger containers like 1 litre bottles of beer and 5 litre wine boxes).Limiting container size: People who drink from above average containers are 7.9 times more likely to drink heavily than those drinking from average sized containers.4Limiting trading hours: Consumption outside of the home is associated by greater odds of heavy drinking (Odds Ratios: shebeen 1.85, sports club 15.8).

Slide22

5. The case for greater access to counselling and treatment

Sources:

1. Chisholm D, Moro D, Bertram M, Pretorius C,

Gmal G, Shield K, Rehm J (2018). Are the “best buys” for alcohol control still valid? An update of the comparative cost effectiveness of alcohol control strategies at the global level. Journal of Studies on Alcohol and Drugs 514-522

2. Morojele N, Ramsoomar L (2016). Addressing adolescent alcohol use in South Africa. S Afr Med J 2016;106(6):551-553. DOI:10.7196/SAMJ.2016.v106i6.109443. Marais D, Jordaan E, Viljoen D, Olivier L, de Waal J &

Poole C (2011) The effect of brief interventions on the drinking behaviour of pregnant women in a high‐risk rural South African community: a cluster randomised trial, Early Child Development and Care, 181:4, 463-474, DOI: 10.1080/030044309034503924. Petersen Williams P, Petersen Z, Sorsdahl

K, Mathews C, Everett-Murphy K, Parry CD. Screening and Brief Interventions for Alcohol and Other Drug Use Among Pregnant Women Attending Midwife Obstetric Units in Cape Town, South Africa: A Qualitative Study of the Views of Health Care Professionals. J Midwifery Womens Health. 2015;60(4):401-409. doi:10.1111/jmwh.12328

INTERNATIONAL

LOCAL

Breaking intergenerational cycles:

11-19% of patients treated for alcohol use/ dependence are < 20 years of age.

2

16 country study shows that that brief psychosocial interventions can reduce prevalence of harmful drinking in men (15-59

yrs

) by 13-21% and older women (>60yrs) by 11-17%).1 Intensify the availability of counselling and medically assisted treatment for persons struggling with dependencePrevention of Foetal Alcohol Spectrum Disorder: Brief interventions for pregnant mothers can reduce the risk of alcohol harm substantially.3 Health workers recognise substantial need for screening and brief interventions in maternal and obstetric care.4

Slide23

What needs to be done now?

1. Concerted inter-governmental and inter-departmental strategy to achieve mutually reinforcing effects

 

NATIONAL

PROVINCIAL

LOCAL

 

 

 

Regulation of liquor trade in all respects other than liquor licensing

Liquor licensing

Zoning, drinking & outlet by-laws

1

Comprehensive ban on alcohol advertising

 

 

  2Pricing policiesTaxation↑ excise tax  

 

 Minimum unit pricing If framed as liquor trade regulation (not licensing)If framed as condition of licence 3Reduce legal limit for drinking and driving     4Reduce availability of alcohol Restrict size of packaging

 

 

 

 

Reduce outlet density/location

 

 

 

 

 

Limit trading hours

 

 

 

5

Increase counselling and treatment

 

 

 

 

ENFORCEMENT

Slide24

What needs to be done now?

Finalise existing legislation urgently

Source: Bertscher A, London L,

Orgil M (2018) . Unpacking policy formulation and industry influence: the case of the draft control

of marketing of alcoholic beverages bill in South Africa. Health Policy and Planning 33: 786-800 * A 0.00% BAC may not be advisable given medicinal use, and may lead to unnecessary challenges

Relevant provisions

Control of Marketing of Alcoholic Beverages Bill 2013

Restrictions on alcohol advertising - bill not issued for public comment

Liquor Products Amendment Bill 2017

Limit advertising in all forms of media

 

Increase legal drinking age from 18

yrs

to 21

yrs

*

 Prohibit liquor outlets within 500 metres of schools, places of worship, rehab centres, residential areas and parksRoad Traffic Amendment Bill 2015 (revised March 2020)Total prohibition for use and consumption of alcohol by all motor vehicle operators

Slide25

Making some good come from Covid-19:Acting on a ‘natural experiment’ that showed up the harms of alcohol

WHAT WON’T WORK

Total bans on alcohol cannot be sustained – illegal industries will mushroomAppeals for ‘responsible drinking’ – socio-economic circumstances shape life choices

Industry self-regulation – its business model relies on heavy drinkersWHAT

COULD WORKImplementing the five strategies can begin to reduce mortality, gender-based violence and social fragmentation Change will take time – but we can create a virtuous cycle of positive compounding returns.

Changed individual incentives

Changed markets

Changed

spaces

Changed systems of support

Changed culture of drinking

There is a window of opportunity.

We must act now.

SA’s heavy drinking culture has its roots in the structural violence of apartheid – and requires structural

intervention