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Jake McKinstry, MS

At the time the editorial was written, the author was a Master of Science candidate in Urban Planning at Columbia University’s School of Architecture, Planning, and Preservation, New York, NY.

Correspondence: Requests for reprints should be sent to Jake McKinstry, 2514 34th Avenue South, Seattle, WA 98144 (e-mail: jsm2106{at}columbia.edu).

	INTRODUCTION

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While the AIDS epidemic in South Africa has been well publicized and documented in recent years, a lesser-known health crisis with profound socioeconomic implications has been developing for hundreds of years. The Western Cape Province of South Africa has the highest rates of fetal alcohol syndrome (FAS) in the world. FAS is caused by maternal alcohol use during pregnancy and is one of the leading causes of preventable mental and physical retardation among infants worldwide.¹ Infants suffering from FAS often have low birthweights; physical dysmorphology, most notably in the face and head; and developmental difficulties. The most recent statistics on FAS rates in the Western Cape Province, reported by the National Institute of Alcoholism and Alcohol Abuse, show that 40.5 to 46.4 per 1000 children are found by screening to have FAS.¹ Compare this rate with a FAS frequency of 0.5 to 2.0 per 1000 children in the United States or the average rate of 0.97 per 1000 children in the developed world,² and the difference is staggering.

In the population-based study "Maternal Risk Factors for Fetal Alcohol Syndrome in the Western Cape Province of South Africa,"³ a control group and a case group of mothers of varying socioeconomic status were used to examine the factors that are associated with mothers’ having children with FAS. Two of the most telling findings of the study were that mothers of lower socioeconomic status were at higher risk for having children with FAS and that the study community as a whole had very limited knowledge or understanding of FAS and the implications of consuming alcohol during pregnancy. In addition, this study corroborates current research that is finding an increase in FAS in the Western Cape Province and in the rest of South Africa. The study accurately summarizes contemporary drinking patterns as a product of the Western Cape Province "dop" system and concludes that prevention is needed to combat the FAS epidemic. For prevention to be effective, however, it is essential to understand the legacy of the dop system in the Western Cape Province and to examine why FAS rates are so astonishingly high in such a small geographic area.

	HISTORICAL CONTEXT AND THE DOP SYSTEM

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In the 1700s European colonialists capitalized on the fertile land and climate of South Africa to create an agricultural economy. In the Western Cape Province, this meant grape and wine production.⁴ To pay the farm-workers, the colonial farmers developed what is now known as the dop system.

Payment under the dop system initially consisted of bread, tobacco, and wine.⁵ While this method of payment was not particularly unusual in farming communities, the dop system became unique to the Western Cape as farmers "institutionalized alcohol as a condition of service."^6(p60) One incentive for using the system was that it provided an ingenious way for farmers to dispose of excess wine that was deemed unfit to drink. As one study noted, it was "reject wine unsuited for the open market"^6(p61) and was sold back to the farmers for next to nothing.

The dop system continues today, despite being recently made illegal, and after 300 years of implementation in the Western Cape Province, the world is only now beginning to see its devastating repercussions. The system has become so ritualized that "it is still apparent today that alcohol is a favored, valued and expected commodity among many of the local population workers, who receive low pay and who live in very humble circumstances."^7(p7) To counteract this mentality, the health care sector in the Western Cape Province has formed the Dop-stop Association to educate the community and inform farm-workers of their legal rights.⁵ The dop system promoted and sustained a culture of alcohol intake that not only ensured that local communities stayed impoverished, but also had negative biological, psychological, and social consequences for the population. Nowhere is this more evident than in the effect the system has had on the mothers and children of the Western Cape Province.

	MOTHERS AND FAS

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To fully understand why the FAS rates of the Western Cape Province are the highest in the world, it is crucial to examine the social conditions in which the women of the province live. Women constitute roughly 30% of the commercial agriculture workforce and are 2 to 3 times more likely than men to be hired as casual laborers.⁶ More than two thirds of farmworker families live in waged poverty, with a household income of less than $100 per month.⁶ Women in the Western Cape Province face a difficult challenge as both mothers and workers dealing with waged poverty. Not surprisingly, many of the women surveyed in the region reported struggling with feelings of depression and low self-esteem and with alcohol abuse.⁷ With alcoholism so entrenched in the culture, both at work and at home, it is likely difficult for mothers attempting to maintain sobriety to get support.

Almost 50% of pregnant mothers in the Western Cape Province drink alcohol, compared with 34% of pregnant mothers in the metropolitan areas of South Africa.⁷ It has been found that mothers of FAS children in the region come from families with a history of generations of alcohol abuse and heavy drinking.⁷ Mothers of children with FAS reported having 12.6 drinks per week, compared with 2.4 drinks for control subjects, and 50% of mothers of FAS children reported drinking more heavily while pregnant.⁸ While the use of alcohol as a coping mechanism for dealing with stress is clearly documented, the future repercussions of this social habit remain uncertain.

	LONG-TERM IMPLICATIONS IN THE WESTERN CAPE PROVINCE

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FAS is now an epidemic in the Western Cape Province.⁸ In a community dependent on a low-wage economy that is slowly undergoing modernization, FAS has dangerous implications.⁵ There is strong evidence that farm children in the region, who are often malnourished or suffering from FAS, grow up to be low-skilled, malnourished adult farmworkers.⁶ It is a difficult cycle to break, and FAS children born into impoverished conditions will be hard pressed not to perpetuate the cycle.

In addition to labor rights, the physical and mental health of the community must be attended to through structured educational interventions. There are limited resources in the Western Cape Province for pregnant women and for children with FAS. Primary intervention methods should focus on the education of mothers and the community at large on the direct correlation between alcohol consumption during pregnancy and FAS. As a secondary intervention, it is crucial that FAS continue to be monitored and tested for at the earliest possible age. Timely data collection documenting current FAS trends among children in the region is critical to implementing effective methods of intervention and awareness programs.¹

An important research project that could serve to refine intervention methods would be to study the social habits of mothers in the Western Cape Province who do not produce offspring with FAS. Mothers of FAS children in the province reported drinking heavily to cope with a stressful relationship with an alcohol-abusing man.⁷ Furthermore, mothers of FAS children were found to consume 97% of their alcohol intake on weekends, which is when they spend a significant amount of time with their partners.⁷ This could suggest that women who are not producing FAS children have stronger, healthier support networks, reducing their reliance on alcohol. Researchers are also looking into the possibility of biological and genetic mutations caused by generations of alcohol use in the region, making children more susceptible to FAS.⁴

FAS has profound socioeconomic implications for the future health of the Western Cape Province. The combination of high FAS rates and high HIV infection rates poses a serious threat to the family structure and core work-force in the region. South African public health authorities must address the past inequities of the dop system and restructure health care systems and strategies to address the epidemic of FAS in the Western Cape Province.⁵ Children with FAS are the ones who will suffer the consequences of an outmoded farming system predicated upon the abuse of human rights for profit. The highest rates of FAS in the world are caused by a multitude of contributing factors, and a holistic, comprehensive approach will be necessary to begin reversing a trend that has been developing for 300 years.

Accepted for publication October 8, 2004.

	References

TOP INTRODUCTION HISTORICAL CONTEXT AND THE... MOTHERS AND FAS LONG-TERM IMPLICATIONS IN THE... References

 
1. Control Centers for Disease and Prevention. Fetal alcohol syndrome—South Africa, 2001. MMWR Morb Mortal Wkly Rep. 2003;28(52):660–664.

2. May PA, Gossage JP. Estimating the prevalence of fetal alcohol syndrome. A summary. Alcohol Res Health. 2001;25:159–167.[ISI][Medline]

3. May PA, Gossage JP, Brooke LE, et al. Maternal risk factors for fetal alcohol syndrome in the Western Cape Province of South Africa: a population-based study. Am J Public Health. 2005;95: 1190–1199.[Abstract/Free Full Text]

4. Viljoen D, Carr LG, Foroud TM, Brooke L, Ramsay M, Li TK. Alcohol dehydrogenase-2*2 allele is associated with decreased prevalence of fetal alcohol syndrome in the mixed-ancestry population of the Western Cape Province, South Africa. Alcohol Clin Exp Res. 2001;25:1719–1722.[CrossRef][ISI][Medline]

5. London L. Alcohol consumption amongst South African farm workers: a challenge for post-apartheid health sector transformation. Drug and Alcohol Dependence. 2000;59(2):199–206.[CrossRef][ISI][Medline]

6. London L. Human rights, environmental justice, and the health of farm workers in South Africa. Int J Occup Environ Health. 2003;9:59–68.[Medline]

7. Viljoen D, Croxford J, Gossage JP, Kodituwakku PW, May PA. Characteristics of mothers of children with fetal alcohol syndrome in the Western Cape Province of South Africa: a case control study. J Stud Alcohol. 2002;63: 6–17.[ISI][Medline]

8. May PA, Brooke L, Gossage JP, et al. Epidemiology of fetal alcohol syndrome in a South African Community in the Western Cape Province. Am J Public Health. 2000;90:1905–1912.[Abstract/Free Full Text]

This Article Extract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by McKinstry, J. Search for Related Content PubMed PubMed Citation Articles by McKinstry, J. Related Collections Family Health Social Science Birth Outcomes Health Education Alcohol Women's Health