In South Africa, substance use is rife, resulting in a health system overburdened with substance-related trauma and chronic disease, and communities plagued by substance-related crime. The World Health Organisation has ranked the country as one of those with the riskiest patterns of alcohol use in the world, 30% of South Africans smoke, and illicit drug use is on the rise, but a local organisation in the Garden Route is spearheading an approach to change that.

The Smoking and Alcohol Harms Alleviation and Rehabilitation Association (SAHA℞A) is an organisation based in George that supports people who use substances problematically in the local community. It uses a game-changing combination of free medical treatment and support groups to help people to reduce or stop alcohol, tobacco or drug use.

“We’ve found, through international research and our own experience, that medication is a vital part of the treatment strategy,” says Dr Hermann Reuter, founder of SAHA℞A. He shares the statistics: after adding medicines such as varenicline and naltrexone to their programme, successful six-month smoking cessation jumped from 0% to 33%, and the successful treatment of alcohol use disorder doubled.

“The availability of medication makes people more confident to seek help and start the SAHA℞A intervention,” he explains. Enrolment in the programme has trebled when medications have been made available.

The official South African Smoking Cessation Guidelines recommend varenicline, bupropion, and nicotine replacement therapy to assist with smoking cessation; however, at present, SAHA℞A is only able to offer nicotine replacement therapy. Reuter says that although these medications are approved and available in South Africa in the private sector, the Department of Health has yet to add them to its Essential Medicines List, which means that no public hospital can acquire and dispense them. This, as well as widespread misinformation and stigmatisation of substance use disorders, does little to alleviate South Africa’s burgeoning epidemic of substance use.

Smoking is a deadly habit — up to a third of deaths among South African males older than 35 have been attributed to tobacco use. The cost of smoking-related disease to the straining South African economy is estimated to be R59-billion. Research has repeatedly demonstrated the cost-effectiveness and safety of medical therapy for smoking cessation — without medication, success rates are dismal. However, the government maintains that supplying these medications in the public service is too expensive. (Also read www.ncbi.nlm.nih.gov/pubmed and analysis-of-varenicline-for-smoking-cessation)

With the current lack of government action, it remains up to organisations such as SAHA℞A to supply this life-saving treatment, and to advocate for national change.

The Department of Health recently turned down an attempt by the Garden Route Pharmaceutical and Therapeutics Committee to make smoking cessation medication available at public clinics, citing the expense. 

Reuter is lobbying the Department of Health to set a threshold price at which it deems it feasible to include these medicines on the Essential Medicines List. This would allow for possible negotiations with drug companies to lower the price of these medicines. The Treatment Action Campaign set the precedent for this in 2000 when it challenged Pfizer to lower the price of fluconazole, a then unaffordable drug used to treat the complications of HIV. In the end, Pfizer made fluconazole available to South Africa, free.

Among alcohol consumers in South Africa, nearly one in two men and two in five women engage in binge drinking, a pattern of consumption which leads to particularly high rates of alcohol-related harms such as interpersonal violence, road traffic injuries, and chronic health problems. In areas such as Thembalethu in George, dangerous alcohol use is widespread and is leading to rising crime and violence. SAHA℞A emphasises a harm-reduction approach, using medicines such as naltrexone in combination with counselling and group work to aid people to reduce or quit their alcohol consumption or to change to less harmful drinking patterns. Its treatment approach does not require complete alcohol cessation, but encourages a move towards responsible and safe alcohol consumption. The programme uses the Sinclair method, a validated system which has been shown to be particularly effective in poorly resourced areas.

SAHA℞A is active at clinics in the Thembalethu, Pacaltsdorp, and George East areas, serving a total population of about 150,000 people. Every week, Reuter attends the clinics with a cooler box of medicines and helps patients start the life-changing therapy. The medical intervention generally lasts for three months. 

SAHA℞A’s weekly support groups and community-based clinics run on an outpatient basis, which means that after attending the clinic, its patients can go home, and do not have to stay in a rehab centre or hospital, isolated from their families or missing work. Due to rising demand for its services, SAHA℞A is expanding its area of coverage to more clinics in the surrounding areas. It is also branching out to provide more holistic community support.

A pioneering new branch of the project is Planet Youth, which is working with the Western Cape government to provide the local youth with recreational activities. Drawing on the success of a well-known programme first rolled out in Iceland, it aims to curb substance use among the younger generation by offering a yearly science-based questionnaire at schools and a variety of after-school activities, as well as psychosocial support and community education.

Much of the local substance use problem can be traced back to the many taverns operating in residential areas in George, often with inadequate regulation and licensing. SAHA℞A has been involved in investigating and mobilising the community to fight against unregulated liquor outlets in their neighbourhoods, resulting in the recent closure of one of the most damaging of these establishments. Community members have voiced the sentiment that SAHA℞A has taken over the role of a failing municipality in dealing with substance use prevention and care.

Watch Daniel Steyn’s documentary on the SAHA℞A project in George:

Having been involved in the Treatment Action Campaign in the early 2000s, Reuter is no stranger to advocacy for medicines availability. In the face of ever-weakening government excuses, SAHA℞A will continue to fight for the availability of life-changing substance use medication at local clinics around South Africa, free of charge. Its approach of prevention, treatment, advocacy and education is set to bring about a revolution in the way patients with substance use disorders are treated in South Africa. MC