2024 UVA Global Health Case

The Center for Global Health Equity 2024 Global Health Case Competition Case Study: Health Impact of Excessive Alcohol Use in South African Youth Authors: Eliza Piché, Caroline Rich, Rola Suleiman, Alison Lim, Isabella Rutta, University of Virginia With guidance and contributions from: Champion Nyoni, PhD; Bonolo Makhalemele, MFS; Kelebogile Manjinja, MSN, University of the Free State; and, Scott Heysell, MD, MPH, University of Virginia

Photo: Detailed physical and road map of South Africa. Maps of all countries in one place | Vidiani.com. Accessed January 28, 2024. http://www.vidiani.com/detailed-physical-and-road-map-of-south-africa/.

Table of Contents: I. II. III.

Introduction

Overview of South Africa

Health, Health Systems, and Alcohol Use in South Africa IV.

South African Initiatives

V.

International Initiatives

VI.

Youth Alcohol Overuse

VII.

Summary and Your Task

I.

Introduction Tsepiso is an 18-year-old who lost her parents at the age of 10. She is at the primary

health care clinic, seeking assistance with her first pregnancy and is expected to complete routine blood investigations which includes HIV testing as the standard of care for all pregnant women attending antenatal care in South Africa. She is unaware if she is already living with HIV and learns she must attend a follow-up visit after a week to receive her results. Tsepiso is a bit frightened about the outcome of the test. Her aunt who lives with her encouraged her to have an alcoholic cider or two to calm her nerves and forget about the results. She further advised her to have one cider before going to the clinic.

Tsepiso comes from a small mining town in the Northern Cape Province in South Africa, where alcohol overuse and drug use are common, and poverty related violence is consequential.

In this area, most of the children do not complete their high school due to various challenges including the lack of money to pay fees. Tsepiso’s town and local economy support the mine and majority male mine workers, many of whom travel from their original communities to live for extended periods of time. Consequently, there are many bars and taverns catering to miners, including unlicensed shebeens, where access to alcohol is easy for young people like Tsepiso.

She dropped out of school two years ago and started working with her aunt who owns a shebeen.

Tsepiso is a waitress at the shebeen, and with time, she started drinking ciders originally to have a good time and relax after a long day, but later to cope with poverty. She felt comfortable drinking as that was what most of her friends did, her aunt encouraged her, and the alcohol was readily available at the shebeen. This occasional drinking eventually turned out to be daily drinking of more than six beers per night, tequila shots, and wine. Her aunt drinks in a similar pattern with her customers, among whom are her boyfriends who stay the night after a drinking session. These boyfriends have at times been violent with her, resulting in physical injuries. She has been admitted to the local hospital several times because of the fighting, leaving Tsepiso to manage the entire shebeen on her own.

The location of their home is in the Northern Cape Province of South Africa which experiences an above average rate of children born with Fetal Alcohol Syndrome (FAS), a condition related to excess maternal alcohol consumption during pregnancy, resulting in developmental delays in the child and long-lasting educational and social burdens. National strategies exist that aim to reduce alcohol consumption, but support for implementation and

monitoring of the strategies are lacking. In addition, there are no readily available services such as counseling or rehabilitation, which may only be available in major cities and out of reach for South Africans without high wealth. Furthermore, the culture within these mining communities may result in a person stigmatized for refusing to drink, reducing consumption, or attempting to remain sober.

Tsepiso explains that one of her aunt's boyfriends is the father of her child. She mentions that she had been engaging in unprotected sex usually after a couple of drinks with the customers of the shebeen. She had not been using contraceptives and was naive about her menstrual cycle.

Tsepiso only realized that she could be pregnant when she missed her periods for three consecutive months in addition to other physical changes. She knows that she needs to go to a hospital for services including registering her pregnancy, an HIV test, and an ultrasound scan related to the physical development of the fetus. Her aunt is confident that the boyfriend who impregnated Tsepiso has HIV but insists that Tsepiso stays with him since he has money and will continue to buy more alcohol which is good for her business.

At the clinic it is confirmed that Tsepiso is infected with HIV, and that her baby has FAS. She received this news with mixed emotional reaction, as she remains unsure what it all means.

The nurse explains that she needs to begin medicines for HIV: multiple pills to be taken daily for the rest of her life, especially during her pregnancy to limit the possible transmission of HIV to the fetus. She learns that she must come back to the clinic every month for a check-up and restock of her monthly distribution of HIV medicines. She is advised to stop all alcohol consumption. Her aunt explains that HIV is not a problem as many people in her community have the infection, and having a child with FAS will enable Tsepiso to access a disability grant from the government - which will increase their home income. Her aunt mentions that beer is good for pregnant women, and that her unborn child already has fetal alcohol syndrome, so what more harm can be done?

II.

Overview of South Africa

Demographics South Africa encompasses the southernmost part of the African continent, and is the second most populous country in the Southern Hemisphere.1 The Southern and Southeastern coasts are the most populated areas, with a majority of the South African population (about 16

million people) residing in the Gauteng province.2,3 Black Africans – including the Zulu, Xhosa, Sotho, and Tswana ethnic groups – account for about 75% of the 62 million people in the country.4 Other ethnic groups making up a minority in the population include White and Asian (particularly Indian) groups.

Historical Overview and Apartheid It is imperative to understand the history and impact of colonization and apartheid within South Africa to fully contextualize the modern systems and challenges of the nation. South African history dates back to 500 A.D. when Bantu speaking groups settled into the Northeast region of the modern nation. A few centuries later, the Dutch East India Company landed at the Cape of Good Hope (modern day Cape Town), setting the precedent of the colonial societies that would last for hundreds of years in the area.5 The settlers subjugated the indigenous peoples to new laws and possessed their resources such as the land, animals, and minerals through war and conquest. Subsequently, four White colony-states were formulated – two of these states being Afrikaner (Dutch descended) led and the other two being British led, subsequently sidelining the natives of South Africa.

The all-White National Party took power to lead South Africa’s government in 1948 and swiftly moved towards implementing apartheid.6 Apartheid was a legal system of political, economic, and social separation of people by the socially constructed definitions of race. It explicitly intended to maintain and extend political and economic control of South Africa for the minority of people designated as White. Citizens were categorized into one of four racial groups: Black/Native, Indian, Colored (Mixed-race), and White, with White people having the most privileges while the Black South Africans had limited economic, social and cultural privilege.7 The racial groups were forced to use separate public facilities based on their race. Black people were not allowed to vote, engage in politics, and were ultimately reduced to a mere labor force for the White minority. Later, the Afrikaners instated Afrikaans (a Dutch derivative) as the official language for work and education in South Africa. The education system was thus fragmented, with the Black children enrolling in the so-called “Bantu Education:” a skills based educational system aimed at creating a labor force.

During this time, Black South Africans were confined to overcrowded “homelands,” which were barren pieces of land, mostly remote and away from the city and separate from

White lands. Because of this division, each region had their own health system, including unequally funded individual departments of health. At that time, the ratio of physicians to White versus Black South Africans greatly contributed to healthcare disparities: compared to one doctor for every 308 White people, there was one doctor for every 22,000 to 30,000 Black people in the homelands. Furthermore, this geographic segregation led to lack of proper housing and the creation of overcrowded, unsanitary living spaces in the urban Black areas, which perpetuated health disparities.

After years of violent internal protest, international, economic, and cultural sanctions, and the end of the Cold War, apartheid ended. Two main political parties, the African National Congress and the Pan Africanist Congress, had led the primary resistance to apartheid, and in the early 1990s, former president F.W. de Klerk repealed apartheid legislation. On behalf of the National Party, President de Klerk agreed to democratic elections for the country, and in 1994, Nelson Mandela was elected as South Africa’s first Black president, ushering in a new era of constitutional democracy based on non-racialism.

The end of apartheid marked the beginning of a democratic South Africa. The nation’s political landscape transformed into a multiparty system with consistent elections. An inclusive constitution was adopted in 1996, focusing on principles of equality, human rights, and social justice. The South African government also sought to make investments into their social infrastructure

development following apartheid, including transportation, energy, and

telecommunications. The nation is currently listed as a high middle-income country and is not dependent on international financial aid. With comparatively successful trading policies, a strong domestic market, and urban infrastructure, South Africa is recognized as a key emerging market and boasts one of the largest and most developed economies in Africa.8 However, difficulties persist in the expanding and upkeep of both economic and social infrastructure, particularly in rural and semi-urban areas.9 Still today, the nation faces significant lingering social challenges from apartheid, including high levels of poverty, unemployment, income inequality and communities segregated by income or historical designations of race.

Culture South Africa is widely known as the ‘Rainbow Nation’ due to its modern-day plurality of cultures, and thus, there is great cultural preservation and mixing throughout the nation’s history

due to its ethnic diversity. South Africa has 11 official languages, with English being the main language of communication and commerce. IsiZulu is the most commonly spoken language – as 25.3% of the population are native speakers – followed by IsiXhosa (14.8%), and Afrikaans (12.2%). Christianity is reported as the dominant religion in South Africa with 85.3% of the population belonging to a denomination of Christianity. 8.7% of the population practice traditional African religions, and less than 3% of the population have no religious affiliation. As a society that values family unity, the dominant family structure in South Africa is the extended family, or multiple generations and relatives living in one household.10 South Africa’s geographic diversity lends itself to a variety of foods native to the country. However, due to persisting inequality within the society, the most accessible foods and ingredients are vegetables, meat and grain such as maize.

Social, historical, and religious factors in South Africa generate a culture of traditional healing practitioners (TCPs). Traditional healing emphasizes the use of herbs and natural ingredients to address medical concerns through a spiritual lens. Many traditional healers are located in rural areas and are influenced by South African history and customs in their practice.

There is a general rise in the number of faith-based healers, especially in the cities. In 2007, the South African Traditional Health Practitioners Act legislated that to practice as a TCP, one must be registered by the TCP Council. Around 80% of South Africans report consulting TCPs for health issues, and there are an estimated 200,000 traditional healers in the nation, a number that is over four times the 48,000 licensed medical practitioners.11,12 Educational Attainment In South Africa, education for children ages 7 to 15 became compulsory through the South African Schools Act of 1996. Approximately 98% of children in this age range are attending an educational institution.13 Approximately 46% of 15-19 year-olds are enrolled in general upper secondary education, 32% in lower secondary education, and 5% in tertiary education.14 Youth dropping out of school after grade nine is a common circumstance, with reasons including illness and disability, poor academic performance, lack of money for fees.15 In South Africa, basic education in public schools is free and subsidized by the government.

However, parents are still expected to pay a minimum amount of fees for their children which makes it difficult for many parents in this area to afford. While poverty remains a barrier to

education in South Africa, the attendance of no-fee schools has increased from 0.4% in 2002 to 70.2% in 2021. Along with poverty, gender inequality significantly impacts access to education.

Females are more likely to report leaving school due to family commitments than males (13.4% compared to 0.5%).

III.

Health, Health Systems, and Alcohol Use in South Africa Main Health Issues in South Africa According to the Centers for Disease Control and Prevention, the top ten causes of death

in South Africa include HIV/AIDS, ischemic heart disease, stroke, lower respiratory infections, diabetes, tuberculosis, road injuries, interpersonal violence, neonatal disorders, and diarrheal diseases.16 South Africa has the largest HIV/AIDS epidemic in the world; while people living with HIV make up only 0.7% of the world’s population, they account for 17% of the world's HIV infections.17 Ultimately, these health issues arise because there are extensive residual effects of apartheid which perpetuate numerous socioeconomic disparities and inequalities within the country. Many of South Africa’s communicable diseases can be traced back to the migration of South Africans from rural to urban areas, which led to overcrowding in congested cities.

Inadequate wastewater management helps the transmission of waterborne diseases that kill more than 3.4 million people a year, such as cholera and dysentery.18,19 The increase in heart disease and diabetes, however, can be accredited to the adoption of Western lifestyle and diet. Systemic studies suggest that cardiovascular risks that were almost unprecedented in non-Caucasian South Africans are now apparent in both rural and urban adult populations.20 Although the South African population continues to be adversely affected by diseases and faces challenges from the remnants of apartheid, the South African government has established many initiatives to reconcile the aftereffects of apartheid and mitigate injustices towards universal health coverage.

The South African Health System The South African public healthcare system is aligned with the Primary Health Care approach, which presents the public healthcare system as a four tier referral systems which integrates the community care level, the primary care level, the district hospital level, and the specialist or tertiary care level.21 The community level is often operationalized by Community Health Workers who are linked to clinics and function to provide both health prevention and

promotion services, such as encouraging mothers to send their children for vaccinations or to attend educational sessions. The over 2,000 primary healthcare clinics are scattered throughout local communities, and operate with a catchment of about 3-mile radius. Professional nurses lead the provision of basic healthcare services which often include treatment of minor ailments and healthcare for patients with stable chronic illnesses. Ideally, patients that cannot be managed at the primary care clinics, such as those who need minor surgeries, are referred to district hospitals who provide more comprehensive care through integrating various health professionals and being better resourced. Tertiary hospitals – which include academic or teaching hospitals, referral hospitals, and specialist hospitals – are the highest level of public care. Often these hospitals focus on the complicated cases that may require specialist attention.

In addition to the public health sector system, there are over 200 private hospitals across the country that offer various health services. Private hospitals are often well resourced, yet average to be about double the cost per day as private hospitals.22 While up to 80% of the population utilizes public hospitals for their health care, around 80% of physicians work in the private sector, causing the public system to be greatly under resourced.23 Long wait times, overcrowding, overworked and underpaid physicians, and out of date equipment all plague even the best (university-affiliated and urban) public hospitals in the nation. Oppositely, private hospitals boast modern facilities, premium physicians, and short wait times.

Public health services are subsidized by the government up to 40%.24 The health care system is primarily financed by the wealthiest 30% of South Africans, who contribute the greatest amount in taxes, out of pocket expenditures, and medical insurance. Thus, while the wealthiest third of South Africans’ need for health care is lower than the rest of the population, they benefit from health care services much more than the latter group. Because the lower ⅔ of the population is unable to contribute much financing in terms of taxes and insurance, they then mostly are able to gain access to services through out-of-pocket expenditures, which can be daunting amounts to those already lacking in funds.

Every South African citizen is guaranteed access to health services in both the public and private health sectors under the South African constitution.25 Federal health related governance is led by the National Department of Health (NDH), which provides strategic oversight for all health operations in the country. The NDH aims to improve the health status of South Africans through prevention of illness and diseases, the promotion of healthy lifestyles, and through

improving health care delivery systems by focusing on access, equity, efficiency, quality, and sustainability. They do this through developing national guidelines, policies, strategies and procedures for health and social care. There are also nine different provinces, who each have their own Provincial Department of Health (PDH). The PDHs are focused on operationalizing the strategic directives, guidelines and policies as formulated by the NDH at a more local level.

The intersection of privatized health care and racial segregation has contributed to enforcing barriers to healthcare for the Black population in South Africa. In 1889, medical plans were introduced to meet the healthcare demands of White mine workers, but these were exclusive to only them. Black South Africans were allowed to access this health coverage in the late 1970s, but were met with cost as a major barrier. Until 1970, over 120 medical plans excluded Black South Africans, and still today, they continue to cater primarily to the wealthier South African demographics. This is because medical plans vary by occupation and require members to pay co-payments. The lasting effects of apartheid are visible in this: 73% of White individuals have a medical plan, while 52% of Asians and only 10% of Black South Africans have one.

The majority of the South African public health system is funded by the National Revenue Fund, which is an accumulation of money from regional and the federal government.

However, the nation utilizes a decentralized distribution system for funding health services, causing local systems to be in charge of their own reserves. In 2014, Minister of Health Aaron Motsoaledi announced that the South African government has pledged to build a minimum of 213 new clinics across the country within the next five years. However, this never materialized.

Health System Challenges The major health system challenges in South Africa are the lack of quality and access to care in both public and private sectors, and the inequitable distribution of healthcare resources.

The high levels of poverty and unemployment, combined with the persistent inequality between the public and private sector healthcare has cultivated a system in which the public sector is large and poorly funded, while the private sector is smaller and better resourced.26 Additionally, large numbers of South Africans are unable to access public services, institutions, and facilities as consequences of the apartheid-era urban planning. The Groote Schuur Hospital in Cape Town serves as an example. It is a tertiary and quaternary (experimental medicine) care facility that is

government funded, but is a very far distance away for patients that do not live in Cape Town’s city center. Furthermore, transport into Cape Town’s city center is expensive, unreliable, and unsafe.

The COVID-19 pandemic exacerbated inequalities in South Africa. The government implemented a strict nationwide lockdown at the start of the pandemic, which lasted longer than other nations in the area, and which hurt vulnerable populations. Those with abnormal or precarious employment, or those who earned little income before COVID-19 were greatly affected by the income loss that the lockdown caused. Loss of jobs also led to loss of health care or health services, as well as a better health prevention measures, such as obtaining a nutritious diet.27 The economic impacts of the lockdown still affect the nation today. Economic recovery has been slower than many emerging markets, and the unemployment level has not returned to its pre-pandemic number.28 Overview of Alcohol Overuse and Its Impact Alcohol use disorder is a pattern of alcohol use that involves problems controlling drinking, being preoccupied with alcohol, or continuing to use alcohol even when it causes problems.29 Alcohol consumption leads to 3.3 million global deaths yearly, and excessive alcohol use and its associated health issues are a pressing public health issue in South Africa. 48% of men and 32% of women in South Africa binge-drink, causing the nation to have one of the highest levels of alcohol consumption in the world.30 In 2015, the total per capita alcohol consumption in South Africa was 11.5 L of pure alcohol, alcohol consumption per drinker averaged 27 L of pure alcohol, and approximately 62,300 adult deaths in South Africa were alcohol-related.31 Further analysis of these statistics elucidates a disparity in adverse health outcomes for men of low socioeconomic status in South Africa. The majority of adult alcohol-related deaths – 60% – were of people in lower socioeconomic status. Among this group, men aged 35 and older experienced more alcohol-related risk factors. However, it should also be noted that excessive alcohol use has also had an increasing impact on college aged youth.

Prevalence rates of those abusing alcohol have reached over 50% of the students at some universities, and most students started using substances after enrolling in the university. Not only can excessive drinking in adolescence cause an earlier onset of health implications associated with alcohol, but brain development may also be stunted as a result of premature alcohol abuse.

The negative health impacts of alcohol abuse are well known, and include liver disease, cardiovascular problems, mental health disorders, and an increased risk of accidents and injuries.

South Africa has one of the highest rates of Fetal Alcohol Syndrome (FAS), as 29 to 290 children per 1,000 live births are affected (numbers ranging due to regional disparities).32 In South Africa, alcohol use disorder is also correlated with high rates of mood disorders and sexually transmitted infections, including HIV/AIDS.33,34 The influence of alcohol is also closely linked to incidents of trauma and interpersonal violence in the nation.

There is a substantial impact of alcohol overuse on health systems in South Africa. The high rates of both alcohol-related motor vehicle crashes (60%) and hospitalizations (20-30%) cause considerable strains on healthcare and law enforcement resources. In urban and rural areas, there is insufficient access to substance use treatment for lower income communities, which primarily comprise Black African and colored individuals.35 In Cape Town, existing services can only treat approximately 3,500 persons annually.36 To address alcohol overuse as a public health issue, it is crucial to understand the social determinants and the history of the disease in South Africa. Industrialization in the 1890s gave rise to the mass manufacturing of goods – including alcohol – in Europe and eventually the colonies in the Union of South Africa.37 The presence of an alcohol industry grew significantly in South Africa following the end of apartheid, which ushered in informal alcohol outlets (shebeens) that operate outside the regulated business sector in primarily rural areas.38 In the city, alcohol is sold in licensed taverns and conventional liquor outlets. Additionally, high rates of poverty and social inequality in the country contribute to heavy drinking. Alcohol is cheaply priced and readily available, and alcohol trading and marketing is largely unregulated, especially in residential areas. As a result of high alcohol consumption, the rates of sexual violence and crimes are very high.39 Liquor outlets are the third most likely place to be murdered in South Africa, and approximately ⅛ of all reported rape and sexual assault cases are related to alcohol and drugs.40 While there is stigma around the concept of alcohol addiction or “alcoholism,” the act of heavy drinking is culturally accepted in South Africa, most likely as a result of its accessibility.

IV.

South African Initiatives Excessive alcohol use in South Africa is a persistent challenge, with research indicating a

significant surge in alcohol consumption due to the pandemic and national lockdowns.41 Tackling this complex issue requires a collaborative effort from both nonprofit and governmental organizations. The South African Department of Health takes a lead role in formulating and implementing policies to regulate alcohol consumption, with objectives spanning public education and healthcare provision. The department actively engages in community outreach programs, providing educational resources on responsible alcohol consumption and hosting healthcare clinics for those affected by alcohol abuse.42 However, despite its effectiveness in policy implementation, consistent enforcement across diverse communities remains challenging.

The Department of Social Development complements these efforts by focusing on support and treatment services for individuals and families affected by alcohol abuse. Their work includes providing counseling services, rehabilitation programs, and community-based support networks to address the social impact of alcohol addiction.43 Meanwhile, the National Liquor Authority (NLA) is pivotal in regulating the liquor industry, overseeing licensing, and mitigating negative societal impacts. The NLA collaborates with law enforcement agencies to conduct regular inspections, ensuring compliance with regulations and deterring illicit activities within the alcohol industry.44 Nonprofit organizations like the South African National Council on Alcoholism and Drug Dependency (SANCA) and the Matrix Treatment Center, actively contribute through prevention, education, and treatment programs, albeit facing challenges such as limited funding and resource constraints.45 South Africa has implemented various policies to manage alcohol consumption, especially during the COVID-19 pandemic. Temporary bans on alcohol sales, curfews, and limited trading hours were imposed to curb the spread of the virus and manage healthcare resources.46 Stringent regulations govern the alcohol industry, overseen by the government to prevent abuse and addiction. Regulatory efforts involve monitoring marketing practices, ensuring responsible advertising, and conducting regular inspections of liquor outlets. Despite these efforts, persistent challenges exist, including the existence of a black market for alcohol, which raises concerns about the quality and safety of illicit beverages. Policing becomes crucial to ensuring compliance with regulations and combating illicit activities within the industry.

Despite

significant

efforts,

challenges

persist

in

addressing

alcohol

abuse

comprehensively. Accessibility to treatment remains a major hurdle, especially for marginalized populations with limited resources. The Matrix Treatment Center, in its efforts to combat alcohol addiction, provides comprehensive treatment programs involving rehabilitation, counseling, and relapse prevention. Additionally, societal stigma associated with alcohol addiction further complicates intervention and support efforts, hindering affected individuals from seeking help.

SANCA's community-based programs actively work to reduce this stigma through awareness campaigns that emphasize empathy and understanding. The informal sector and illicit trade pose significant challenges to regulatory bodies, contributing to health and safety risks.47 Although organizations like SANCA and the Matrix Treatment Center have been effective in raising awareness and providing support, limited funding and resource constraints hinder their ability to expand reach and impact.

Looking ahead, addressing alcohol overuse in South Africa demands ongoing strategies and collaboration. Continued dedication to increasing accessibility to treatment and dismantling societal stigmas associated with alcohol addiction is essential. Challenges posed by the informal sector and illicit trade necessitate innovative solutions and effective policing. Achieving a fully integrated approach requires sustained collaboration between governmental bodies, non-profit organizations, and regulatory authorities. Despite resource constraints, there is an imperative to explore sustainable funding models and maximize the impact of available resources. Future success hinges on a multifaceted, collaborative approach that is adaptable and responsive to the evolving nature of the challenge.

V.

International Initiatives Along with South African initiatives, there are many international organizations assisting

South Africa with decreasing the prevalence and effects of alcoholism. The International Society of Substance Use Professionals (ISSUP) acts globally to create a collaborative and knowledgeable network of professionals who handle substance use prevention, treatment, and recovery through evidence-based methods.48 ISSUP facilities webinars, workshops, newsletters, and awards to serve as informative, professional development opportunities. A specific South African chapter allows the country’s professionals to connect, collaborate, and educate each other. Similarly, the Global Alcohol Policy Alliance (GAPA) aims to produce an international

network that advances policies which are aligned with science-backed research instead of commercial interests.49 GAPA has been involved in the formation of the World Health Organization’s plans regarding alcohol usage and often provide criticism on the organization’s collaboration with the alcohol industry and their lobbyists.50 In October 2023, GAPA hosted The Global Alcohol Policy Conference in Cape Town in collaboration with the South Africa Medical Research Council, Southern African Alcohol Policy Alliance, and the South Africa Department of Social Development. The conference focused on taxation, reducing industry influence, regulating digital alcohol marketing, denormalizing alcohol usage in everyday events, and finding ways to promote helpful policies. South African leaders felt the conference was highly applicable to their country’s current state due to strong industry influence in South Africa and lack of movement of alcohol-related policies through the South African government.51 While the organizations related to alcohol regulation and consumption are increasing collaboration amongst actors promoting safer alcohol usage, their work has yet to make lasting policy changes in South Africa or provide direct education to South African citizens.

VI.

Youth Alcohol Overuse The case study of Tsepiso represents an amalgamation of the many alcohol-related health

issues currently facing youth in South Africa. The need for school fees results in some students dropping out of high school to engage in jobs such as working in gardens, farms, spaza shop (Mini-Market) or at the mines to earn additional income for their families. In some cases, younger girls may be engaged in prostitution and other activities for money and survival. Poverty creates stresses on children, and common practice increases access to alcohol. As seen in the introduction, alcohol overuse has many adverse health effects on rural, low-income youth and their potential offspring.

However, as noted earlier, excessive alcohol use also greatly impacts youth who continue with their studies into higher education. As similarly seen in the United States, universities can create an environment conducive to risky behaviors involving alcohol. In both nations, those between 18-25 have the highest rates of alcohol use of any age group, and have extremely high rates of excessive drinking.52,53 Universities are also high-risk locations for the spread of HIV/AIDS, as students engage in riskier behaviors, such as having multiple sexual partners,

having unprotected sex, and engaging in substance abuse before sex.54 However, despite being an academic environment, college students have a relatively low amount of knowledge about the HIV and its transmission and prevention. Thus, there is a prevalent need to address the problem of excessive alcohol use in South African youth between the ages of 15 and 25, both in poorer, rural communities, and for those in urban university environments.

VII.

Summary and Your Task The goal of mitigating alcohol abuse in South African youth will require engaging

diverse stakeholders and reflecting on the unique needs of its various populations . Through your planning, you should reflect on how to engage with community-based stakeholders (ie: the public, patients, health centers, and clinicians) as well as the government at various levels. Be sure to address cultural, social, economic factors when creating your plan. These include (but are not limited to): stigma surrounding alcohol overuse, familial norms and cultural practices which increase access to alcohol and decrease the urgency for aid, affordability barriers, limited awareness about where to seek help, geographic access barriers, and flawed and fragmented service delivery. Your task is to incorporate a program that: ● Finds a solution for decreasing alcohol overuse of the South African youth (15-25) in either rural and impoverished communities, urban university settings, or both populations ● Works to deliver a comprehensive initiative with an emphasis on equality of access to health educational resources and inequality reduction ● Mobilizes the community to work towards sustainable empowerment while working to reduce misconceptions or educational gaps ● Strengthens community involvement with key stakeholders such as the community and healthcare providers and locations In addition, there are several central questions to take into consideration: (1) How will your program properly decrease alcohol overuse in the population despite the difficulties associated with treating those in underserved populations or areas? (2) How do we assure accessibility and active engagement between communities, individuals, and stakeholders? (3) How would you consider long-term impacts such as the surge caused by COVID-19 in conjunction with the remaining challenges? (4) What funding sources have you incorporated into your proposed solution, and how much will it ultimately cost? If there are stages to your solution,

be sure to consider each stage individually as well as the total cost. Provide also a budget and rationale for your proposal that makes sense to achieve your desired goals. Your team may choose to focus on one aspect of ensuring a comprehensive program or take on multiple projects.

Good luck!

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