Prevention of and Treatment for Substance Abuse Bill [B12-2008]: public hearings

Meeting report

Middle-Village Community Representative Council (CRC) submission.
Mr Michael Kotsokoane, President, Middle Village Community Representative Council (CRC) presented a submission. He advised that the Bill could be implemented by forming strong working relationships between the Department of Social Development (DSD), the Department of Health (DOH), the Department of Safety and Security (DSS) and Community Based Organisations. He cautioned that responsibility should not rest with Local Government Municipal Ward Councillors in order to avoid political influence. Community Based Organisations should monitor and assess treatment centres and halfway houses.

Discussion
Mr L Nzimande (ANC) emphasised the importance of the infrastructure that the municipalities provided and the capabilities of local authorities.

Mr B Mkongi (ANC) expressed doubt as to the exclusion of local government in relation to the proposed involvement of community organisations. He asked for details about intervention services and who would be given these responsibilities, as human resource capacity was lacking. He also asked what the community services mentioned were.

Ms J Semple (DA) asked which Cluster was being referring to in the submission.

Mr Kotsokoane responded that the local ward councillors should not be responsible as drivers, because the problem at local level was that some of their councillors were not fair. When a ward councillor was involved in a project, he or she tended not to have an inclusive approach because of the political situation. He added that by Cluster he had meant Social Development, Health and other relevant departments working together.

Ms Semple asked if by combatting substance abuse only certain people would be helped and others not.

Mr Mkongi asked if the presenters felt that political interference could be avoided by involvement of local councilors, as he was of the opinion that communities should be strengthened to assist in avoiding this problem.

Mr Kotsokoane stated that powers should be given to local ward councillors as participants, but not as drivers.

Mr Pusoletso Lesolo, Chief Director: Legal Services, DSD, noted that the arrangement for managing substance abuse could not exclude local government.

Mr David Bayever, Director, Central Drug Authority, argued that the vision of a functioning local government was to assist in combatting substance abuse to make an impact and facilitate buy-in from all local drug authorities. He added that co-ordination required responsibility at a local level by local government.

Mr Mogotsi Kalaeamodimo, Director Substance Abuse, DSD, outlined the vision of the Department which was to decentralise power from national to provincial level.

Mr B Solo (ANC) expressed the need to capacitate local government.

The Chairperson stated that other line functions had to include both National and Provincial levels and a balance should be found to approach this problem.

Aids and Rights Alliance for Southern Africa (ARASA) submission
Ms Paula Akugizibiwe, representative for ARASA, emphasised the need for an evidence-based scientific approach to the prevention and treatment of substance abuse, and a critical need for harm reduction programmes. The Bill did not adequately recognise substance abuse as a chronic medical condition that required primarily a medical intervention. Ms Akugizebiwe submitted that a focus on values perceptions, expectations and beliefs encouraged a moralistic approach to prevention programmes, which had proved less effective than an evidence-based scientific approach, the priority of which was to reduce the personal, medical, public health, and social harms associated with substance abuse. There was a need for holistic programmes and policies that did not approach drug users as individual agents who applied for  treatment for a preventable medical condition.

Treatment Action Campaign submission
Ms Lesley Odendal, representative, Treatment Action Campaign (TAC) presented on the specific harm reduction activities that the TAC  were proposing. She said that the Bill failed to recognise the links between substance use and infectious diseases such as HIV and Aids. There was an absence in the Bill of key interventions to prevent and treat substance abuse and associated harms. Interventions would ideally include examples such as syringe exchange programmes and substitution therapy. Syringe exchange programmes were critical in addressing problems in  South Africa. According to international organisations like the World Health Organisation (WHO) and the United Nations (UN), syringe exchange programmes were found to discourage substance abuse and related diseases. Substitution therapy encouraged and facilitated ongoing engagement with health care providers and substance users, which was a vital requirement for rehabilitation. She strongly recommended the need for education, training and information sharing programmes.

Discussion
The Chairperson asked whether the submission could be seen as encouraging drug abuse and who should bear the costs. He asked further if an addiction could be eliminated by a reliance on scientific treatment.

Mr L Nzimande (ANC) said he needed clarity in terms of Clause 7 and that he was expecting  proposals on a health approach to detoxification. His preference was that the legislation aspire to the total eradication of substance abuse as opposed to harm reduction.

Ms H Bogopane-Zulu (ANC) wanted to know if, when the submission was written, it had noted the progress that the country had made in terms of intravenous drug users, as it seemed to suggest that little or nothing was being done. She felt that there was a need for further engagement and work and the issue of syringe exchanges could not just be put into the legislation without assessing what it would mean. She stated that the issue of drugs was a social issue from a human rights perspective. She stated further that the recommendations for Chapter 5 of the Bill were confusing.

Mr Bayever said that one needed to be sure about whether the issues being addressed were issues of health, social or bio-psycho. He felt that what was being dealt with was a bio-psycho and social issue and had to be seen in this context, while it was correct in questions of morality and harm reduction.

Mr Loselo noted that the Bill did acknowledge a link between HIV and substance abuse, as a provision in Clause 8.

Mr Greg Gonsalves, representative for ARASA,  responded to the issue of morality by stating that approaches to drug use internationally on prevention and treatment did recognise drug use as a psycho-social issue. He added further that substitution therapy had reduced the harms associated with drug use such as overdose; and promoted the entrance of drug users to treatment and did not increase drug use.

The Chairperson stated that in the context of South Africa, the social reality could not be divorced from the moral character of society.

Ms Fatima Hassan, Aids Law Project, responded that the Alliance was not promoting the use of illegal drugs, but argued that the evidence showed that certain harm reduction programmes, like needle exchange programmes and substitution therapy actually did not foster the increase in drug use. She stated further that there was a constitutional obligation to have programmes that reduced drug use, and Section 27 of the Constitution provided the required legislative framework.

Ms Semple stated that syringe exchange was more of a health issue than a social development issue.

Ms Bogopane-Zulu stated that the South African country report to the UN should be reviewed, including what the Strategic Plan said about vulnerable groups. There was a need to deal at a policy and programmatic level as it was not possible to legislate at this level.

Mr Bayever stated that this was a curable disease, on the condition that abstinence was the ultimate goal to strive for.

Mr Kalaeamodimo said that the approach of the Bill was more developmental than medical, and it was looking to address the causal factors of substance abuse by way of that developmental approach.

Ms Akugizibiwe responded that the approach of ARASA was endorsed by the World Health Organisation and the UN and was based on evidence from countries that had practised syringe exchange and substitution therapy. She added that in regard to the cost, government should be obliged to provide all these facilities for drug users. ARASA would send the cost programme to the Committee. This would show that for the recovery cost of harm reduction programmes, one-third would be the cost to government.

Ms Akugizibiwe stated further that the preoccuppation with the rights of drug users at ARASA was based on their role as a rights based organisation. Their proposals were for the broader society and also provided a platform for all. She said that simply moralising about these ills would never provide a forum for engagement for all users.

Ms Akugizibiwe said that ARASA was proposing that Clause 7 should be removed from the Bill, because there were dangers to adopting a moralistic approach as the primary factor in prevention programmes.

Ms Bogopane-Zulu stated that the values of the communities where one wanted to implement these programmes should be recognised and respected, especially if they were traditionally based communities.

Drug Free Africa (DFA) submission
Ms Christine Gordon, Executive Director, Drug Free Africa, presented the submission, which promoted primarily abstinence programmes for recovering addicts. Their concern was the lack of an accreditation body to accredit substance abuse and training programmes in schools, business and communities; and also to accredit treatment, research and community development programmes in the  province. This was necessary to put a stop to the lack of researched, mixed-messaging and unscientific approaches currently prevalent in society. Ms Gordon felt that this challenge could be taken up by engaging each of the provincial substance abuse forums, and for them to take the reigns on these programmes. Bearing in mind that each province had its own unique dynamics, accreditation should be localised, with each portfolio assisting on accreditation. This meant that each province’s substance abuse forum would advise and assist in the process of accreditation in co-operation with the Department of Health and Local Government. The forum should remain a-political.

Ms Gordon stated that because of their intrinsic grassroots level of involvement, local drug action committees should be able to make recommendations to the accreditation committee at the local district office level of the DSD. Accreditation should belong to the CDA so as to ensure that standards were met. A best practice model should be created by experts in the field. who had the service excellence and were without a personal agenda. Best practices should emanate from pro-active central drug authorities or substance abuse provincial forums on substance abuse. There should be mandatory evaluation and monitoring of all programmes delivered, including early prevention and treatment programmes. In these programmes there should be a heavy emphasis on criminal and addictive thinking. Local drug action committees should have executive powers.

Ms Gordon concluded by stating that rehabilitation programmes should be encouraged and only accredited drug prevention and rehabilitation programmes should be delivered to the people of South Africa.

Discussion
The Chairperson asked how it was proposed that these programmes should be implemented.

Ms Gordon said that currently Drug Free Africa ran rehabilitation programmes at schools for drug users and dealers. Students were not expelled, but were brought before the governing body with their parents. Adequate parenting programmes were also provided and children were put through an intensive twelve week programme This had been found to influence children positively.

Mr Mkongi asked what the success rate was of the programme; what the rationale was for the structures that were being proposed; who were the experts mentioned in the submission and what powers were planned for the local drug action committees. He asked finally what challenges could be foreseen in terms of the powers mentioned.

Ms Gordon responded that the success rate was about 74%. DFA were putting people through a rehabilitation and treatment programme according to international standards, which assured a success rate of about 33%.

With regard to powers and structure, Ms Gordon stated that regarding the Local Drug Action Committee, the network sometimes felt they should be able to engage by having to do things and engage others to come on board. There were circumstances stopping them from having a better footing in the community. The Bill did not give the Local Drug Action Committee powers of accreditation, only the co-ordinating structure. Programmes were not happening formally, but were run only at certain schools as pilot projects.

The Chairperson asked who should do accreditation.

Mr Loselo responded that as stated in Clause 3, and Chapters 3 and 4 of the Bill, the Minister would be responsible for accreditation.

The Chairperson expressed concern regarding the content of programmes.

Mr Pierre Viviers, Deputy Director: Substance Abuse, DSD stated that the Bill referred to ‘the registration of treatment centres and out-patient programmes ‘ only. These were purely a government function and the DSD dealt with this. Clarification was needed on the concept first, as Ms Gordon was using the word “accreditation”, but not referring to “registration”. What she was in fact referring to was something additional to registration, and this did not really have much relevance or reference to this particular Bill.

Mr Loselo said that the Minister  accredited training and programmes; and also had to develop the framework for programmes on substance abuse.

The Chairperson asked who actually implemented the programme

Ms Gordon responded that the infrastructure did lend itself to doing something about the situation, but was concerned about the CDA, as it had to be part of accreditation because so many programmes were unscientific. The community needed the assurance of quality.

Ms Bogopane-Zulu noted that programme providers must be accredited first, and then the actual programmes, and the Department must set norms and standards for operation. This must then be registered by the DSD. Drug committees could not have accreditative powers.

Mr Viviers stated that there were a number of programmes for which the Act did not legislate, like out-patients and prevention programmes, but that the new Bill had the intention to regulate these services. However, he agreed that better legislation was required for programmes as Ms Gordon was talking about better control.

Eastern Cape Youth Development Board (ECYDB) submission
Mr Viwe Sadali, representative for ECYDB,  presented the submission expressing concern about the high levels of substance abuse amongst young people. If the objective of the Bill was to make provision for the prevention of and treatment of substance abuse, then it was suggested that preventative measures should not be minimally applied, as was the case at present. The ECYDB had recently lobbied for partnership with the Eastern Cape Liquor Board to ensure the reduction in the use of alcohol. Mr Sadali stated that the Departments of Social Development, Health, Education, Safety and Security and Correctional Services should ensure that they were playing a vital role in the establishment of ‘Ward Moral Regeneration Forums’ to work with ward committees, street committees and NGOs to fight substance abuse.

Discussion
Ms S Rajbally (MF) said her concern was that the Liquor Board needed to be made aware of the problem as illegal things were happening in communities.

Mr Mkongi welcomed the submission, and asked if the organisation was proposing a new structure and an interventionist approach in local municipalities to run parallel with current structures.  He asked further if they had a proposal for an age limit for selling alcohol and tobacco to young people.

Ms Semple asked where funding came from and if the ECYDB specifically addressed substance abuse and prevention programmes.

Mr Bayever stated that alcohol was the primary drug of abuse in this country. It should be recognised as a gateway drug and was a priority area to be targeted. The mandate of CDA was to advise and make recommendations.

The Chairperson expressed concern about whether the Bill would provide for a major intervention strategy to deal with this matter.

Mr Nzimande stated that in the informal briefing held last week the Department had been tasked with bringing forward a schedule of supply-side legislation.

Mr Kalaeamodimo noted that ECYDB had recommended the need for a national conference.  The Department did host a bi-annual summit and needed the contact details of ECYDB to invite them to the conference.

Mr Sadali responded that it would not be desirable for government to operate parallel structures and requested that moral regeneration take place within the Director-General’s office to ensure that programmes reached their proper targets sooner, and had a more direct route to targets. With regard to shebeens, Mr Sadali believed that shebeens should be closed on Sundays.

Substance Misuse Advocacy Research Training (SMART) submission.
Ms Sarah Fischer, representative of SMART, presented the submission, raising the need for a common language amongst workers in the field of substance abuse. Ms Fischer believed that the Bill would provide an improved quality of service for users, making them more visible, understandable and easy to be monitored. She stated that the Bill however failed to acknowledge research showing that substance-use disorders were preventable and were treatable; and failed to sufficiently define in-patient treatment centres, halfway houses, out-patient and community-based programmes managing these patients.

Discussion
The Chairperson stated that the Minister was being loaded with establishing various forums with a lesser focus on performance. Key concepts needed to be prioritised in this Bill, including co-ordination, as it was being raised again as an important issue.

Mr Nzimande welcomed the presentation as it gave food for thought, especially in matters such as consistency in the language. He asked for examples regarding the language being proposed.

Ms Lana Peterson, Parliamentary Liaison Officer, DSD, asked for more information regarding references to government organisations funding unregistered organisations, as it would be useful if there was evidence provided about these organisations.

The Chairperson responded that treatment centres came in various guises, but as long as the purview of the legislation was clear it would be possible to avoid problems.

Mr Loselo stated that the Department was not able to accommodate everyone’s definitions.

Mr Nzimande stated that mention was made of alcohol in relation to substance abuse and asked if it was proposed that society should become teetotal. He asked that some understanding of misuse and abuse of alcohol be provided.

Ms Fischer responded that definitions were the same throughout the world and that a better understanding could be developed through using a common language. She explained the meaning of ‘use’ and ‘misuse’  and the circumstances in which ‘misuse’ and ‘abuse’ were legislated against. There were individual cases where money had been given to unregistered organisations and this arose because there was insufficient regulation about who should be getting money. This information would be forwarded to the Department.

Embalini Child and Youth Centre (Embalini) submission
Ms Buyiswa Qodi, who ran Embalini,  presented the submission and gave the history of the organisation. She outlined the core activities of the organisation as being home based child-care, health-care, health education and counseling, and referrals to appropriate health-care advisors, substance abuse awareness and family reunification. Embalini also provided support to young adults around substance abuse. She recommended early intervention to avoid later disasters for young children and youth who were abusing substances; government-run centres; the counselling of victims and families and the need for clinics and hospitals to offer proper medication for withdrawal and treatment. Ms Qodi added that Government should fund treatment and prevention programmes in co-operation with the Departments of Education, Health and Social Development by equipping child-care workers with tools for the social relief of stress. She concluded by stating that properly trained workers and community-based organisations should be assisted in establishing programmes for aftercare and early intervention programmes.

Discussion
Mr B Solo (ANC) asked if the presenter had read Chapter 4 of the Bill, and if she thought this was sufficient to strengthen awareness.

Ms Semple asked if Buffalo City had access to rehabilitation programmes.

Ms C Dudley (ACDP) wanted to know about prevention programmes and asked to what degree the use of drugs and alcohol was prevalent, and also where the loopholes were in providing treatment.

The Chairperson stated that an important question was whether the Department had adequately engaged the professional sector as there was a host of concepts and systems that was not reflected in the communication. He ruled that there was no need to answer the question around the centers of programmes as the Committee would meet to discuss this matter.

Ms Qodi raised a concern about people who did not have medical aid, but urgently required treatment for substance abuse.

The Chairperson asked again if Ms Qodi felt that Chapter 4 adequately addressed the concerns of the organisation.

Ms Qodi responded that there should be an entry point where assistance would be provided for community-based treatment. She added that in her experience this had produced positive results.

South African National Council on Alcohol and Drug Dependence (SANCA) submission
Mr Johan Barnard, representative, SANCA, and Dr David Fourie, Regional Director, SANCA, presented the submission of the Council, which drew attention to inclusion of behavioural addiction and the need for a more integrated approach. The lack of adequate partnerships between departments had hampered effective service delivery. The presenters suggested that there should be consistency throughout the Bill in regard to references and terminology.  They also suggested that the requirements for monitoring and evaluation of private and public treatment centres should be the same. The presenters also called for a clear definition of detoxification. Proposals were put forward regarding re-wording, additions and changes to the Bill.

Discussion
Ms Semple asked for more specifics regarding classification in terms of in-patients and out-patients.

The Chairperson requested clarity about public and private institutions and differentiation in the regulations.

Ms Bogapane-Zulu asked why there was specific reference to compliance with the Constitution.

Dr Fourie responded that it was not the behaviour but the addiction itself that required treatment, and there was a great need to admit people with other addictions to current programmes. He also felt that this should be included in the Bill.

Dr Fourie added that he could only speak from a Western Cape perspective when referring to health facilities, but there was not sufficient medical assistance for substance abuse, and it was difficult to access hospitals.

With regard to public and private institutions he referred to both having the same norms and standards and therefore the regulations need not differ.

Dr Fourie stated that the Constitution was often not seen to work in practice, hence he felt that an emphasis should be placed on Constitutional obligations, especially with regard to human rights issues, and accessibility to treatment, to overcome the barriers that often excluded people.

The Chairperson stated that the prevention of substance abuse was fundamentally a supply-side function, and even though detoxification was a small part of the treatment process, it was necessary to recognize that there was a behavioural problem. The problem lay in trying to reinforce the human psyche to abstain because abstinence equalled cure.

Dr Fourie agreed that looking at the current National Drug Master Plan, it was not possible to include other behaviour. He added that the impact of pornography should not be underestimated and the whole spectrum of addictions should be looked at from a regulatory point of view.

Mr Kalaeamodimo stated that when dealing with the issue of substance abuse there were other side issues also involved, such as crime and family violence, but here the emphasis was on substance abuse.

Mr Loselo stated that the Department had not applied its mind to all the issues mentioned here. He would take all the legal matters back to the Department for discussion.

The meeting was adjourned. A further meeting would be held on 14 May.