MARK HUNTER: Where are the government rehabs?

We need to delve into the history of alcohol and drug rehabilitation in SA to explain why poor people who use mind-altering substances today are written off as “undeserving poor” and are mostly unable to access institutionalised support.

Beginning in the late 19th century the first interventions for white alcoholics were motivated by wider concerns about ‘poor whites’ — a group seen as deserved of support because they were an affront to “civilised” white rule. To this day almost all rehabs in SA are located in formerly white areas.

The history of black rehabilitation centres has been less documented. In 1969 MV Gumede became the founding medical officer and passionate advocate of the country’s first rehabilitation centre for those classified as African: Durban’s Kwasimama.

Combining social with medical approaches, Dr Gumede saw alcoholism as resulting not from an individual’s character flaw but in the context of the country’s racist history. “From a former ruler of this country,” he wrote, “he has been reduced to a hewer of wood and a drawer of water — a virtual non-personism”.

Kwasimama also signalled a change in the state’s attitude towards deserved recipients of treatment. For decades the government had held onto a deluded image of “tribal Africans” whose rightful home was ethnic reserves and whose rightful drink was sorghum beer. Those classified as coloureds were, in the state’s eyes, the most likely non-white alcoholics.

Signifying a shifting view, Durban city established Kwasimama in its new township of KwaMashu. Like other modern townships built at this time, KwaMashu was developed to supply booming industries with a stable and productive workforce.

Rehabilitation’s slow expansion was further bolstered by the disease model of alcoholism advanced by the SA National Council on Alcoholism (Sanca, later to also include “Drug Dependence”). If addiction was a disease, anyone could be affected. 

Established in 1956 and playing a key role in establishing Kwasimama, Sanca affiliates ran most of the country’s state-subsidised rehabilitation centres, which greatly outnumbered the state’s free facilities.

The arrival of drugs 

Drug treatment piggybacked late onto alcohol treatment in SA. Sixties counterculture created a moral panic in SA, as elsewhere, powered by sensational media depictions of drug-taking youth. Yet white hippies popping pep pills or smoking dagga did not fit the images of the poor idle whites for whom rehabilitation centres had been built.

Heroin and cocaine, major motivators for drug treatment in other countries, were barely accessible in SA. Propelled by an international “war on drugs”, punitive measures, not rehabilitation, remained the state’s key approach. A draconian 1971 drugs act imposed harsh minimum sentences and enabled detention without a trial.

Arresting black growers or dealers of dagga signalled the state’s commitment to curbing this “gateway” drug and restricting the subversive mixing of racial groups. In 1979 an astonishing 30,000 people, almost all black, were charged with cannabis offences.

Yet when it came to rehabilitation, dagga was largely sidestepped, being viewed as a “traditional” plant that, unlike alcohol, rarely undermined productivity.

Drugs and democracy 

At the dawn of democracy the country had about 50 rehabilitation facilities, with the most robust presence in Gauteng, an area with a historically large working-class white population, many Afrikaans-speaking.

Only 12 of those facilities were built for black South Africans. In the 1980s, Kwasimama had been absorbed into KwaZulu’s health system and lost its connection to rehabilitation.

After 1994 the new government turned its attention to building houses, roads and clinics in underserviced areas. But the geography of state rehabilitation remained largely frozen in the apartheid mould.

Today, KwaZulu-Natal province — despite seeing an astonishing rise in the use of heroin, crystal methamphetamine and cocaine — has only two government rehabilitation centres for its 11-million population.

It has been civil society that has led critical responses to drug use. In 2017 activists established the SA Network of People Who Use Drugs, part of an international movement to replace failed punitive with harm reduction approaches.

Harm reduction rightfully questions the conventional understanding of rehabilitation. Leaders have established several groundbreaking centres that offer potentially life-saving services such as providing sterile syringes and needles. These prioritise the safer use of substances, and the rights and humanity of people who use drugs. Yet despite an occasional nod towards harm reduction, the state’s approach has been weak. And rehabilitation is one of the few government areas not subject to service delivery protests.

Informed by an understanding of the past we can see three primary reasons for the relative inattention to rehabilitation and harm reduction.

The first is economics. Whereas in the 1970s Durban’s factories played a crucial role in referring workers to Kwasimama, today’s unemployment rate of over 40% diminish businesses’ need to sponsor rehabilitation. With workers queuing up outside gates for short-term contracts, employers can pick and choose who they employ.

Second is that the rehabilitation field, always heavily dependent on non-governmental institutions, has seen a boom in for-profit centres. Today, medical aids pay for addiction treatment for the 17% of the population covered by schemes — politicians included. 

The immodestly named luxuryrehabs.com website provides revealing insight into treatment inequalities. On it can be found 30 SA luxury rehabilitation centres that mix treatment with water sports, beach visits, safaris and countryside walks. Many are marketed to international clients, and all except two opened in the 2000s.

Yet the townships, hosting hundreds of thousands of people, remain without a single public rehabilitation centre. Here, mothers, grandmothers and occasionally faith-based centres are on the front line of support and care.

Third is the increased separation of alcohol from drugs. Reinventing itself in the dying days of apartheid, SA Breweries poured millions of rand into marketing alcohol as a harbinger of success and nonracial togetherness. In contrast, poor drug users have been cast as the enemy of postapartheid development — an undeserving poor.

People using heroin, who are almost all young men who dropped out of (or were pushed out of) poorlyresourced schools, can today be derided as amaphara. Heroin users are easy prey for cops with performance targets for arrests. Drug users can also be targeted by communities that are frustrated at the police’s inability to stem crime and officers’ sometimes close relationships with drug dealers.   

In 2018 I interviewed 20 people who use heroin/whoonga in Durban, almost all men in their 20s, most of whom wished to access a rehabilitation service. Five years on two had been killed by community groups after being accused of theft, and one had fallen sick and died. Only three had given up whoonga.

The division between who is deemed deserving or undeserving poor becomes more evident if we consider the workings of the department of social development, responsible for both drug and social welfare policy. Its inaction on drugs must be seen in light of the huge rise in social grant assistance for the “deserving poor”, the largest programme being the child support grant, which is overwhelmingly received by women.

Rehabilitation is not a magic bullet and the relationship between rehabilitation and harm reduction is a matter for another discussion. Yet what is indisputable is that institutions are desperately needed to promote care, support and humanity for people using drugs and alcohol.

The pioneering efforts of Dr Gumede and other rehabilitation leaders need to be resuscitated to address one of the country’s greatest social challenges.

• Prof Hunter is an academic at the University of Toronto.