In the Gauteng province, one in 40 children who enter grade one have foetal alcohol syndrome. In the Western Cape, the rate is double. As we mark World Foetal Alcohol Syndrome Day, South Africa ashamedly still has the highest rate globally. Leslie London looks at what is needed to eradicate this scourge.
Although South Africa has the highest foetal alcohol syndrome rate in the world, government's efforts to address the problem have been inadequate. And the alcohol industry has evaded responsibility for tackling the root causes of the disease.
Foetal alcohol syndrome is a collection of birth defects involving physical and neurodevelopmental impairments. It results in low intelligence, behavioural disorders, poor social judgement and general difficulty in performing everyday tasks.
Local foetal alcohol syndrome figures are up to 100 times higher than other populations, such as indigenous nations of North America and Australasia, traditionally considered high risk.
In the Western and Northern Cape provinces, between 5% and 10% of children entering school have foetal alcohol syndrome. And there are areas in the Western Cape with clusters of higher foetal alcohol syndrome rates than those found in earlier studies.
In Gauteng, 2.5% of school-entering children – or one in 40 – have foetal alcohol syndrome, with some areas showing rates double this estimate.
In real terms, these figures amount to millions of young people affected by the syndrome, growing through to adulthood with the consequences impairing their development. This should be a cause for deep concern among South Africa's policymakers.
Understanding the disease
When women drink in pregnancy, alcohol is absorbed and circulates in the mother's bloodstream, increasing her risk of having a child born with foetal alcohol syndrome.
The physical deformities children are born with include atypical facial features such as a smooth ridge between nose and upper lip. A child with foetal alcohol syndrome will grow up stunted – shorter than they should be compared to normal children of their age group.
They will also be intellectually impaired and impulsive. They will have a low attention span, poor insight and impaired judgement of the world around them.
They are "difficult" children, who are disruptive in class and often turn to acts of violence to deal with their frustration. They fare poorly at school and eventually drop out. They are at increased risk of involvement in criminal activity.
A historical issue
Alcohol abuse in South Africa has very deep roots. The dop system – which involved paying workers with cheap alcohol, introduced by Dutch colonists as a way to control local labour – became institutionalised over centuries.
Although it is now illegal and practised only in the most obscure parts of the country's agricultural hinterland, alcohol dependence in rural areas of the Western Cape has become widespread.
The dop system has morphed into different forms of easy access to alcohol. This includes the purchase from a farmer's shop or local stores on credit through to mobile shebeens circulating alcohol from farm to farm or from the encouragement of livelihood retailing making alcohol all the more easy to access.
Various farm worker groups have sought reparations by suing the wine industry for its role in generating the problem.
Even though these efforts have not succeeded, attempts to hold industry accountable highlight how the foetal alcohol syndrome problem is a violation of the human rights of vulnerable populations.
The wine industry has never fully accounted for its role in the dop system and the habituation of workers and rural communities to alcohol.
Although it may be too complicated to quantify the financial compensation, the wine industry has made a lot of money using practices that demeaned the dignity and deprived rural populations of their capacity to be active citizens.
The need to tackle the problem
Addressing foetal alcohol syndrome is not straightforward.
The alcohol industry focuses on programmes educating women to drink less. However, there is evidence that educational interventions have low effectiveness in preventing harmful drinking. By focusing on pregnant women, industry avoids addressing the societal influences that encourage women to drink. These include industry's role in marketing their products.
Framing the problem as one of women knowing they should not drink in pregnancy makes it easy to blame the women for the conditions of their children.
But drinking among rural women is both the result of alcohol dependence and living conditions which give them few alternatives to the bottle.
Government programmes to address foetal alcohol syndrome remain limited. The National Department of Health has identified it as one of ten focal genetic conditions and the Western Cape government lists it as a priority in its Birth Defects service. But efforts to tackle the problem have been left largely to non-governmental organisations.
There is no surveillance, which means government has no handle on the extent of the problem. Attempts by government to organise a response across departments has not shown any substantial impact on reducing the burden.
The Health Department's attention to foetal alcohol syndrome is crowded out by infectious diseases such as TB or HIV and nutrition programmes for children.
A comprehensive programme that draws on community involvement is needed.
In North America and Australasia, local cultural frames have been used to successfully implement programmes.
In South Africa, these programmes should address pregnant women who drink, but also look at:
Tackling foetal alcohol syndrome requires a comprehensive response by all of society. Foetal alcohol syndrome is an enormous and not fully recognised as a drag on South Africa's human and economic potential. We need action based on evidence that tackles its root causes.
Written by Leslie London, Head of the Division of Public Health Medicine in the School of Public Health and Family Medicine at University of Cape Town.
Disclosure statement: Leslie London received funding from the South African Medical Research Council, the South African National Research Foundation, UNICEF and the Centre for Diseases Control (USA) for research into alcohol hazards and alcohol policy. The South African Wine Industries Trust gave Leslie London funding for supporting post-graduate students doing research into health and alcohol.
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