Implementation of Control Strategies: Lessons of Experience
The following paragraphs provide a few concrete examples of interventions or policy changes that illustrate the actual implementation and effects of control strategies in developing societies (the examples are taken from Room and others 2002).
Tax Rate Reduction and the Resulting Disease Burden in Mauritius
Mauritius, an island nation in the Indian Ocean, has a population of about 1 million. These people are of Indian, African, European, and Chinese origin. By religious affiliation, 53 percent are Hindu, 29 percent are Christian, and 17 percent are Muslim. Tourism is the third-ranked industry in terms of hard currency earnings. In June 1994, the government drastically lowered customs duties on imported alcoholic beverages to 80 percent from rates that had ranged from 200 percent for wine to 600 percent for whisky and other spirits (Abdool 1998). The government made the change under pressure from the hotel industry, which claimed that tourists were not purchasing enough alcohol because of its high prices (Lee 2001). Other reasons given for the change were to reduce unofficial imports from abroad and to make better, more refined alcoholic beverages available to the local population. Despite little evidence to support the view, there were claims in the public discussion that better-quality alcohol would result in fewer health problems.
The effects of the change were felt mainly by Mauritians rather than tourists, as follows:
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Arrests for driving with blood alcohol over the legal limit made primarily in connection with traffic crashes increased by 23 percent between 1993 and 1997.
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Admissions of alcoholism cases to the island's psychiatric hospital shot up in 1994. The 1995 rate was more than twice the 1993 rate, and the rate rose again slightly in 1996 and 1997. Medical specialists in Mauritius agree that patients with alcohol problems account for an increasing portion of admissions in general medical wards and now represent between 40 and 50 percent of bed occupancy (Abdool 1998).
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Age-adjusted death rates per 100,000 population for chronic liver disease and cirrhosis rose from 32.8 for males and 4.0 for females in 1993 to 42.7 for males and 5.3 for females in 1996 (WHO 1999, 2000).
Even though available statistics are limited, the reduction in alcohol import taxes clearly had a substantial negative effect on the health of Mauritians. Thus, the government's 1997 call for control measures for alcohol—specifically, new permits for licensed premises, increased excise duties on alcohol, and limitations on bars' opening hours—was not surprising. Alcohol taxes were increased somewhat in the 1999/2000 budget (U.S. Department of State 1999). However, an analysis by World Bank staff that did not take health effects into account called for further reductions in maximum tariff rates, identifying Mauritius as having an antitrade bias on the basis of the structure of its alcohol and tobacco taxes (Hinkle and Herrou-Aragon 2001).
Wallace and Bird (2003) suggest the following general principles for setting and collecting alcohol taxes in the context of developing societies from the perspective of revenue generation rather than public health (see also Tax Policy Chief Directorate 2002):
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Countries around the world need revenues they can raise relatively efficiently, but this need is probably more critical in the case of developing nations. That said, alcohol taxes are probably a good bet for future revenues.
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Excise taxes on alcohol should be set by alcohol content, rather than as a percentage of the price.
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Tax rates should be logically defined so that alcoholic beverages with similar alcohol content are treated similarly, with stronger alcohol beverages taxed more heavily.
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Analyses of revenue-maximizing rates should be conducted to determine a range of tax rates that is likely to maximize government revenues.
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Tax systems should be designed to be as simple as possible to allow for the maximum efficiency of tax administration.
Reduced Access through Locational Prohibition in Brazil
The second example involves the institution of a new control on alcohol availability in an environment where it is likely to be combined with driving. Although we have modeled the effects of another, better studied availability control (namely, closing on a weekend day), a wide variety of possible measures is available to control the time and place of alcohol purchase or drinking (Babor and others 2003; Room and others 2002). Even though in this case the particular control was extremely limited in scope, it appears to have had measurable effects.
Traffic deaths are an important source of mortality in Brazil, amounting to 3.6 percent of overall mortality. The few available studies suggest that alcohol plays a significant role in traffic casualties. For instance, one study in Sao Paulo found positive blood alcohol levels in 72 percent of pedestrian deaths and 32 percent of driver and passenger deaths of persons age 13 and older (Carlini-Cotrim and Chasin 2000).
In 1985, motivated by concern about alcohol and impaired driving and about the lax enforcement of drinking and driving laws, a conservative party politician from the state of Sao Paulo introduced legislation to prohibit alcohol sales in commercial facilities that had access to state highways. Even though the bill passed in the legislature, its implementation was delayed by the state's alcohol producers and commercial and industrial federations, which claimed that the law would be a barrier to improved facilities for travelers, would encourage people to carry bottles in their cars, and would restrict individual freedoms. Discussion in the press was also generally unsympathetic. In August 1988, however, a new state governor from the same party implemented the law. At that time, the press was slightly more supportive. Since then, the law has been on the books, although site visits to restaurants and snack bars along a state highway in 1997 suggested a low level of compliance. In 1995, another legislator from the same party proposed repealing the law on the grounds that no studies proved that it lowered traffic accidents. The repeal passed the legislature without significant public debate, but the state governor vetoed it. Undaunted, the same legislator then proposed a law to criminalize buying as well as selling alcohol along state highways. That law passed but has not yet been implemented.
A study by Carlini-Cotrim, Pinsky, and Serrano Barbosa (1998) assesses the effects of the intervention. Finding data for a controlled study comparing traffic casualties on state highways with casualties on federal highways, which were unaffected by the law, proved impossible. The best data available were on crashes and crashes resulting in injuries per 10,000 vehicles traveling on three short highway systems administered by a private agency. Linear regressions on those data for 1983-93 showed that the law had made a significant difference in the number of accidents resulting in injuries on all three roads and a significant difference in all accidents on two of the roads. A separate analysis on estimated accidents and accidents with injuries per 10,000 vehicles in two geographic areas of the state did not show significant effects of the law. Overall, the analyses do provide some support for the law having a beneficial effect on the rate of traffic casualties.
Drunk-Driving Enforcement in South Africa
No published studies are available of the implementation of random breath testing in a developing country. However, some data are available on a campaign to increase drunk-driving enforcement in South Africa, a strategy that has often shown some effects, although weaker and less lasting than those of random breath testing.
The minister of finance launched a short-term campaign, ARRIVE ALIVE, for the period October 1997 to January 1998, in response to the high rate of traffic fatalities and injuries. The campaign's main aim was to mobilize all available traffic policing, control, and education resources to reduce traffic accidents on South African roads by at least 5 percent, especially in the Western Cape, Gauteng, and KwaZulu Natal provinces, because 75 percent of all accidents occurred in those provinces. The ARRIVE ALIVE campaign targeted, in turn, what were considered the three critical factors having the greatest impact on injuries: failing to wear seat belts, drinking and driving, and speeding. Unofficially, the campaign came to be called "belts, booze, and bats out of hell."
As many of the parties interested in road safety as possible were involved, with funding drawn from a variety of government and business sources. The campaign included a number of components particularly relevant to alcohol use. New equipment purchased by the provinces included alcohol screening devices, alcohol evidentiary units, and so-called booze buses (vehicles containing all the technology needed to check breath and blood alcohol levels). Sentences were increased to underline the point that traffic violations are serious offenses, with a three-month suspension of a driver's license and an increased maximum fine for a first conviction for drunk driving and with license suspension for one to five years for second offenders. Traffic supervisors underwent intensive training courses before the start of the campaign.
Because the aim of the campaign included educating road users, advertisements covering aspects of the campaign were run on the radio, on television, and in movie theaters throughout the country. Supplements were published in national and provincial newspapers. Private companies, such as a supermarket chain and an automobile manufacturer, also promoted the campaign. A national transportation center, established to collect and collate data from local and provincial authorities, operated for 12 hours every day throughout the campaign. Traffic authorities staffed an additional 80 roadside communications points, and at selected points on certain routes, road signs were erected and updated to display the percentage of speed limit and drinking-and-driving violations and the rate of seat belt use in that area.
A total of 776 enforcement points were set up on 195 strategic routes in the selected provinces. Posters, pamphlets, key rings, and license decals were produced for distribution and display at roadblocks in the three provinces. Between October 1, 1997, and January 17, 1998, 6,674 notices of prosecution were issued for alcohol-related traffic offenses, 83 percent of which were issued in the intervention provinces.
Comparison studies showed a decrease in the drinking rate of drivers in the three provinces, whereas the other six provinces, as a group, showed an increase. KwaZulu Natal had the lowest drinking rate of all drivers throughout the campaign (3 to 7 percent), and the Western Cape had the most dramatic decrease (from 12.0 to 9.3 percent in October). Except for in Gauteng, the drinking rates for pedestrians decreased from more than 15 percent to less than 7 percent. Overall, during the months targeted, drinking-and-driving rates decreased by 2 to 4 percent, as measured by breath testing. The total number of crashes decreased by 8 percent, and fatalities dropped by 9 percent. The ratio of benefits to costs for the intervention was estimated as 4 to 1, based on an investment in the campaign of R50 million, or about US$4.4 million at 2002 rates (ARRIVE ALIVE Campaign 2000).
Despite the potential inconvenience of roadblocks and other enforcement activities, the public generally perceived the campaign positively. The liquor retail and hospitality industries complained about decreased sales, and tow truck operators complained about reduced business.
Even though driver behavior improved during the focus months, violations often increased after the focus was changed, for example, from drunk driving to seat belt use. This finding emphasizes the need for sustained enforcement as opposed to ad hoc campaigns. (This example was summarized from ARRIVE ALIVE Campaign 2000 and Cerff and Pluddemann 1998.)
Implementation of Brief Interventions in Several Developing Countries
In the first phase of the WHO Collaborative Project on Identification and Management of Alcohol Related Problems (Saunders and Aasland 1987), a screening measure suitable for use in both developing and developed countries—the alcohol-use disorders identification test—was developed to identify people at risk for alcohol problems among those attending primary health care services. In the second phase, a multicenter clinical trial of brief intervention procedures designed to reduce the health risks associated with hazardous alcohol use was carried out in primary health care settings in Australia, Bulgaria, Costa Rica, Kenya, Mexico, Norway, the Soviet Union, the United Kingdom, the United States, and Zimbabwe (Babor and others 1994).
The project's aims were to study the influence of simple advice and brief counseling, to examine the moderating role of reduced consumption on the prevention of alcohol-related problems, and to evaluate the cross-national generalizability of brief intervention techniques. The project's hypothesis was that the amount of change in alcohol consumption over a nine-month period would be proportional to the intensity of the intervention provided by a trained primary health care professional. The results showed a significant effect of interventions on both consumption and intensity of drinking among males, but the intensity of the intervention was not related to the amount of change in drinking behavior; 5 minutes of simple advice turned out to be as effective as 20 minutes of brief counseling (Babor and Grant 1992). The female sample was too small for the results to attain significance, and the intervention did not significantly affect men's frequency of dependence symptoms, problems related to alcohol, or concern expressed by others (WHO Brief Intervention Study Group 1996).
The findings suggest that in a population of high-risk drinkers, behavior change is more a function of motivational factors and social influence than of the moderation skills and social learning techniques that behavioral self-control training packages typically use. Changes in drinking were not attributable solely to the small number of patients who achieved an abstinence goal, nor to the small number who gave up daily or almost daily drinking. Rather, changes seem to have been distributed across a broad spectrum of the drinkers who reduced their consumption by small, but clinically meaningful, amounts.
