[Commentary] COMMENTS ON SURVEYING ALCOHOL IN AFRICA

Clausen et al.[1] use data collected by the World Health Organization to examine drinking patterns in 20 African countries. The analysis is based on 77 165 face-to-face interviews, conducted mainly in countries with little or no previous survey research infrastructure. The paper concludes that African drinking patterns are diverse. Life-time abstinence is predominant and several countries have an ‘all-or-nothing’ pattern (high abstinence combined with high abuse among those who do drink) although, not surprisingly for such a diverse continent, there is no universal African drinking pattern. In parts of rural subSaharan Africa, for kinship and religious celebrations and collective labor parties, women once made traditional ‘beers’—thick, nutritious and low in alcohol—that were more like liquid breads or porridges. For decades, however, there has been a trend towards commercial alcoholic beers consumed, not from gourds in rural rituals, but from bottles and cans in urban African bars. This change was well captured in Elizabeth Colson's Zambian monograph, For Prayer and Profit[2]. In some parts of Africa, including Arab countries north of the Sahara, the same process has happened with palm wine. The transition from traditional to commercial alcohol undoubtedly relates to increases in problem drinking and attendant social disruptions. Alcohol is estimated to account for 4% of the global burden of disease. In the developing world, however, in spite of lower overall levels of consumption, alcohol is estimated to account for an even greater proportion of mortality and morbidity than in developed countries—sometimes as high as 10% [3]. Attention needs to be directed to the best types of prevention, intervention and treatment, especially for Africa, where some of the poorest countries of the world are located. The authors suggest that subSaharan countries may have a greater need for proactive policy interventions, such as taxation and limiting availability of alcohol, relative to ‘some Northern African and Muslim dominated countries’. This may be true, but even the Arab and Muslim countries have serious problems. For example, of the 20 countries in the survey Tunisia has the highest level of heavy drinking among current drinkers (76.6%), and an abstention rate that is lower than five of the subSaharan countries. Tunisian alcohol sales doubled between the mid-1990s and the mid-2000s [4] and drunkenness is currently a factor in about a fifth of the daily newspaper court reports—a trend that has been tracked for the past 2 years by the authors of this commentary. Thus alcohol seems to be an increasingly serious public health problem in Tunisia, which has no prevention policy, research or treatment infrastructure. As the authors demonstrate, the belief that alcohol is not a problem in Muslim countries is a dangerous one that could lead to letting a silent spread of hazardous drinking go unchecked. There are a few methodological issues relating to the surveys. With surveys based on self-report, there is always the question of to what extent the respondents answer honestly about their drinking practices. This is especially true in this case, as nine of the 20 countries surveyed are predominantly Muslim, and the authors acknowledge that in these Muslim countries there may have been higher under-reporting of drinking. As part of an earlier paper we discussed the problem of Muslim under-reporting of drinking [5]. Because even moderate drinking is forbidden for Muslims, survey questions about alcohol can elicit ‘culturally desired responses’[6]. An example is a survey in Malaysia (which has about 60% Muslims); many Muslim Malays drink, but only one of over 300 would admit to it [7]. The degree of stigma associated with drinking undoubtedly varies and exists to some extent for many non-Muslims too. Mauritius, an island nation counted as part of Africa, has more in common with Asia in some ways because more than half its population comprises Hindus of Indian origin, who also have prohibitions against alcohol. The World Health Organization (WHO) study does not mention if the Muslim respondents were interviewed by Muslims; if so, this probably increased under-reporting. Dotinga has conducted useful research, cited in the WHO paper, on the effects of data collection mode and ethnicity of the interviewer on drinking survey responses among Muslims in the Netherlands [8]. While it is recognized that the World Health Survey needed to cover a huge amount of material on all types of medical conditions, it is unfortunate that so few questions were included about alcohol (one to distinguish ever-drinkers from abstainers and another on amount of consumption on each of the last 7 days). The 1-week time-frame helps to minimize recall bias but has been found to be less effective in identifying the most hazardous drinkers, perhaps by as much as half [9]. Drinking in low-income countries can be sporadic, often linked to paydays and/or festivals. Future surveys might consider adding quantity/frequency questions or graduated frequencies to improve measurement. Overall, this survey is a major achievement in data collection; this paper and the individual country reports (available freely on the WHO website) richly merit the attention of alcohol scholars and policy makers interested in Africa. None.