Addiction in South and East Africa: Interdisciplinary Approaches [1st ed.] 978-3-030-13592-8;978-3-030-13593-5

Table of contents :
Front Matter ....Pages i-xxi
Introduction: Making a Case for Addiction in Africa (Yamikani Ndasauka, Grivas Muchineripi Kayange)....Pages 1-6
Front Matter ....Pages 7-7
Addiction in the Light of African Values: Undermining Vitality and Community (Thaddeus Metz)....Pages 9-31
Cannabis Use and Addiction in African Communities; a Value or a Vice? (Grivas Muchineripi Kayange)....Pages 33-48
The Moral Question of Addiction: An African Philosophical Perspective (Wilfred Lajul)....Pages 49-69
An Ubuntu Approach to Addiction-Response Framework in Malawian Schools (Chikumbutso Herbert Manthalu)....Pages 71-90
Front Matter ....Pages 91-91
Oral Traditions: A Tool for Understanding Alcohol and Drug Addiction in Swaziland (Telamisile Phumlile Mkhatshwa, Gloria Baby Malambe)....Pages 93-104
Sex Addiction in Contemporary African Fiction: An Analysis of Selected Works of Short Fiction (Beaton Galafa)....Pages 105-124
Popular Culture and Representations of Addiction: Understanding Malawi Urban Music in the Narratives of Drugs and Sex (Dave Mankhokwe Namusanya)....Pages 125-141
Semiotic Creativity and Innovation: Offshoots of Social Media Addiction (Hambaba Jimaima, Gabriel Simungala)....Pages 143-156
Macho Rhetoric in Alcohol Addiction: The Narratives of Masculinities among Malawian Youths (Anthony Mavuto Gunde)....Pages 157-172
Front Matter ....Pages 173-173
Neurochemistry and Pharmacology of Addictions: An African Perspective (Andrew G. Mtewa, Serawit Deyno, Emmanuel L. Peter, Annu Amanjot, Lucrèce Y. Ahovegbe, Duncan C. Sesaazi)....Pages 175-192
Neurobiology of Substance of Abuse (Drugs) and Behavioural Addiction in Africa (Godfrey S. Bbosa)....Pages 193-212
Front Matter ....Pages 213-213
Prevalence of Alcohol Addiction in Africa (Edith B. Milanzi, Yamikani Ndasauka)....Pages 215-228
Drug Use and Addiction Amongst Women with Disabilities Who Are Commercial Sex Workers in Zimbabwe (Tafadzwa Rugoho)....Pages 229-239
Drug Addiction among Youths in Zimbabwe: Social Work Perspective (Tatenda Nhapi)....Pages 241-259
Internet Addiction and Mental Health among College Students in Malawi (Tiwonge D. Manda, Edister S. Jamu, Elias P. Mwakilama, Limbika Maliwichi-Senganimalunje)....Pages 261-280
Curbing Tobacco Addiction in Kenya: Ethical and Legal Challenges Arising (Smith Ouma, Jane Wathuta)....Pages 281-305
Conclusion: Defining the Future of Addiction Research in South and East Africa (Yamikani Ndasauka, Grivas Muchineripi Kayange)....Pages 307-309
Back Matter ....Pages 311-312

Citation preview

Addiction in South and East Africa Interdisciplinary Approaches Edited by Yamikani Ndasauka Grivas Muchineripi Kayange

Addiction in South and East Africa

Yamikani Ndasauka Grivas Muchineripi Kayange Editors

Addiction in South and East Africa Interdisciplinary Approaches

Editors Yamikani Ndasauka Chancellor College University of Malawi Zomba, Malawi

Grivas Muchineripi Kayange Chancellor College University of Malawi Zomba, Malawi

ISBN 978-3-030-13592-8    ISBN 978-3-030-13593-5 (eBook) https://doi.org/10.1007/978-3-030-13593-5 © The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the ­publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and ­institutional affiliations. Cover illustration: Marina Lohrbach_shutterstock.com This Palgrave Macmillan imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

This work is an interdisciplinary volume that investigates addiction in Africa, particularly in South and East Africa. The contributors of this volume are experts in different fields including psychology, chemistry, biology, African philosophy, ethics, literature, anthropology and cultural studies. The chapters are mainly dependent on original research given that there is not much that has been written on the subject of addiction in Africa. The book has therefore responded to the gap of knowledge on addiction in Africa. Apart from the provision of knowledge, the book has discussed and attempted to provide solutions to specific issues regarding drug abuse and addiction, alcohol abuse and addiction, and sex addiction. Drug and alcohol abuse have been on the rise in Africa and have proved to be hazardous for the African continent. Among the different causes of deaths in Africa, abuse and addiction have led to premature deaths, mainly among the youths. Similarly, sex addiction has negatively affected development in Africa, due to its role in increasing sexually transmitted diseases, such as HIV/AIDS and related diseases. The information in this edited volume is suitable for a broad category of readers, including both academics and non-academics. The book will be a good source of reference for different university students (undergraduate and post-graduate) across disciplines, researchers in various fields (in research centres), organisations working with the youth (such as World Health Organisation and UNESCO), psychologists, philosophers, linguists, cultural critiques, public health practitioners and legal practitioners. v

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PREFACE

It is with great pleasure that we consider this work as providing a ­ enuine background for any further research on addiction in the south, g east and other parts of Africa. It is further opening a possible dialogue with the studies of addiction that were and are currently being done in different parts of the world. Zomba, Malawi 

Yamikani Ndasauka Grivas Muchineripi Kayange

Acknowledgements

We thank all contributors for making this work possible. We also thank Professor Richard Tambulasi, the principal of Chancellor College, and Dr. Japhet Bakuwa, the dean of Faculty of Humanities, for allowing us some days off to put together the chapters of the book. Finally, a huge thanks should go to members of Philosophy Department at Chancellor College for encouraging us as we undertook this project.

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Contents

1 Introduction: Making a Case for Addiction in Africa  1 Yamikani Ndasauka and Grivas Muchineripi Kayange References  6 Part I Conceptualization of Addiction   7 2 Addiction in the Light of African Values: Undermining Vitality and Community  9 Thaddeus Metz 2.1 Introduction  9 2.2 Addiction, Immorality, and Western Ethics 11 2.3 Addiction as Incompatible with Vitality 17 2.4 Addiction as Incompatible with Community 21 2.5 Concluding Remarks on Responding to Addiction 26 References 28 3 Cannabis Use and Addiction in African Communities; a Value or a Vice? 33 Grivas Muchineripi Kayange 3.1 Introduction 33 3.2 Cannabis Use and Addiction in Africa 35 3.3 Cannabis as a Value in African Communities 39

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CONTENTS

3.4 Cannabis as a Vice and Illegal in African Communities  43 3.5 Conclusion  46 References 46 4 The Moral Question of Addiction: An African Philosophical Perspective 49 Wilfred Lajul 4.1 Introduction  49 4.2 Literature and Theory  52 4.3 Discussion  58 4.4 Implications  62 4.5 Conclusion  65 References 66 5 An Ubuntu Approach to Addiction-Response Framework in Malawian Schools 71 Chikumbutso Herbert Manthalu 5.1 Introduction  71 5.2 Autonomy, Neoliberalism, the School, and Addiction  76 5.3 Ubuntu-Responsive Frameworks to Addiction  81 5.4 Conclusion  87 References 88 Part II Addiction in Literature and Popular Culture  91 6 Oral Traditions: A Tool for Understanding Alcohol and Drug Addiction in Swaziland 93 Telamisile Phumlile Mkhatshwa and Gloria Baby Malambe 6.1 Introduction  93 6.2 Songs and Addiction  96 6.3 Proverbs and Traditional Terms and Addiction 100 6.4 Conclusion 102 References 103 7 Sex Addiction in Contemporary African Fiction: An Analysis of Selected Works of Short Fiction105 Beaton Galafa 7.1 Introduction 105 7.2 Understanding Sexual Addiction 107

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7.3 The Concept of Sexual Addiction in Selected Works 109 7.4 Gender Representation 115 7.5 Age and Addiction to Sex 118 7.6 Morality and Addiction to Sex 120 7.7 Conclusion 121 References122 8 Popular Culture and Representations of Addiction: Understanding Malawi Urban Music in the Narratives of Drugs and Sex125 Dave Mankhokwe Namusanya 8.1 Introduction 125 8.2 Understanding Urban Music in Malawi 127 8.3 Understanding Addiction 129 8.4 Representations of Addiction in Popular Culture 130 8.5 Conclusion 138 References139 9 Semiotic Creativity and Innovation: Offshoots of Social Media Addiction143 Hambaba Jimaima and Gabriel Simungala 9.1 Introduction: The Internet and Social Media 143 9.2 Internet and Social Media in Zambia: Perspectives on Addiction 144 9.3 Theoretical and Methodological Appraisal 146 9.4 Conceptualizing Social Media 147 9.5 Semiotic Creativity and Innovation 148 9.6 Globalization and the Production of Locality 153 9.7 Conclusion 154 References155 10 Macho Rhetoric in Alcohol Addiction: The Narratives of Masculinities among Malawian Youths157 Anthony Mavuto Gunde 10.1 Introduction 157 10.2 Research Design and Methodology 163 10.3 Findings and Discussion 165 10.4 Conclusion 169 References170

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CONTENTS

Part III Neurobiology and Neurochemistry of Addiction 173 11 Neurochemistry and Pharmacology of Addictions: An African Perspective175 Andrew G. Mtewa, Serawit Deyno, Emmanuel L. Peter, Annu Amanjot, Lucrèce Y. Ahovegbe, and Duncan C. Sesaazi 11.1 Introduction 175 11.2 Neurochemistry in Africa, a Brief Historical Perspective 176 11.3 Addiction amongst People of the African Descent 177 11.4 Chemical and Pharmacological Descriptions of Addiction Episodes in Neurosciences 179 11.5 Withdrawal Symptoms in Drug Addiction 184 11.6 Treatment Approaches to Addictions 184 11.7 Neuroscience Research and Training in Modern-­Day Africa 186 11.8 Conclusion 187 References188 12 Neurobiology of Substance of Abuse (Drugs) and Behavioural Addiction in Africa193 Godfrey S. Bbosa 12.1 Introduction 193 12.2 Types of Addiction 195 12.3 Neurobiology of Addiction 198 12.4 Neurotransmitters Involved in Addiction 201 12.5 Addictive Drug Targets and Their Main Mechanisms of Action in the Reward System201 12.6 Behavioural Addiction Targets and Their Main Mechanisms of Action in the Reward System 204 12.7 Conclusion 207 References208 Part IV Substance and Non-substance Addiction 213 13 Prevalence of Alcohol Addiction in Africa215 Edith B. Milanzi and Yamikani Ndasauka 13.1 Introduction 215 13.2 Methods 218

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13.3 Results 219 13.4 Discussion 224 13.5 Conclusion 226 References227 14 Drug Use and Addiction Amongst Women with Disabilities Who Are Commercial Sex Workers in Zimbabwe229 Tafadzwa Rugoho 14.1 Introduction 229 14.2 Literature Review 231 14.3 Factors Driving Disabled Women Entrance into Sex Work and Drug Abuse 233 14.4 Drug Addiction and Sex Work 236 14.5 Conclusion 237 References238 15 Drug Addiction among Youths in Zimbabwe: Social Work Perspective241 Tatenda Nhapi 15.1 Introduction 241 15.2 Types of Addictive Substances 245 15.3 Conceptual Framework 246 15.4 Socio-economic Context249 15.5 Key Drivers of Substance Abuse 250 15.6 Addiction Mitigation Strategies 252 15.7 Conclusion 256 References257 16 Internet Addiction and Mental Health among College Students in Malawi261 Tiwonge D. Manda, Edister S. Jamu, Elias P. Mwakilama, and Limbika Maliwichi-Senganimalunje 16.1 Introduction 261 16.2 Literature Review 263 16.3 Methodology 267 16.4 Results and Discussion 271 16.5 Conclusion 278 References279

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CONTENTS

17 Curbing Tobacco Addiction in Kenya: Ethical and Legal Challenges Arising281 Smith Ouma and Jane Wathuta 17.1 Introduction 281 17.2 Stakeholders in Tobacco Production and Control in Kenya 282 17.3 Marketing and Sale Approaches in Favour of Tobacco Companies 283 17.4 Prevalence of Tobacco Use and Addiction in Kenya 285 17.5 Public Health Implications of Tobacco Addiction 286 17.6 Legal and Policy Interventions on Tobacco Addiction in Kenya 288 17.7 Ethical Consideration 293 17.8 Conclusion 300 References300 18 Conclusion: Defining the Future of Addiction Research in South and East Africa307 Yamikani Ndasauka and Grivas Muchineripi Kayange Index311

Notes on Contributors

Lucrèce Y. Ahovegbe  is a research fellow in the Department of Pharmacy and Pharmacology at the Mbarara University of Science and Technology, Uganda. Annu Amanjot  is a doctoral student in the Department of Pharmacy and Pharmacology at the Mbarara University of Science and Technology, Uganda. Godfrey  S.  Bbosa is Lecturer in Pharmacology & Therapeutics at Makerere University, Uganda. Serawit  Deyno  is Assistant Professor of Pharmacology at the Mbarara University of Science and Technology in Uganda. Beaton Galafa  is an MA student in Comparative Education at Zhejiang Normal University in China. Anthony Mavuto Gunde  is a research fellow at the Journalism Department, Stellenbosch University. He is also Senior Lecturer in Media, Communication and Cultural Studies in the Language and Communication Skills department, Chancellor College, University of Malawi. Gunde holds a PhD in Journalism Studies from Stellenbosch University and a Master of Arts degree in Communications from Missouri State University. He has published works in a number of peer-reviewed journals and books. Gunde has overarching interests in the political economy of mass communications, communicating masculinities and the intersection of religion, media and culture.

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NOTES ON CONTRIBUTORS

Edister S. Jamu  is Lecturer in Psychology at the University of Malawi, Chancellor College in Malawi. Hambaba Jimaima  is a lecturer and department head of Literature and Languages at the University of Zambia in Zambia. Grivas  Muchineripi  Kayange  is Senior Lecturer in Philosophy at the University of Malawi, Chancellor College in Malawi. Wilfred Lajul  is Associate Professor of Philosophy at Makerere University in Uganda. Gloria  Baby  Malambe is Senior Lecturer in African Languages and Literature at the University of Swaziland in Swaziland. Limbika  Maliwichi-Senganimalunje  is Senior Lecturer in Psychology at the University of Malawi, Chancellor College in Malawi. Tiwonge  D.  Manda is Senior Lecturer in Computer Science at the University of Malawi, Chancellor College in Malawi. Chikumbutso Herbert Manthalu  is Lecturer in Philosophy of Education at the University of Malawi, Chancellor College in Malawi. Thaddeus Metz  is Distinguished Professor of Philosophy at the University of Johannesburg, South Africa. Edith B. Milanzi  is a doctoral student at the Institute for Risk Assessment Sciences (IRAS) at Utrecht University in the Netherlands. Telamisile Phumlile Mkhatshwa  is Lecturer in African Languages and Literature at the University of Swaziland in Swaziland. Andrew G. Mtewa  is a doctoral student in Pharmacy and Pharmacology at the Mbarara University of Science and Technology in Uganda. Elias  P.  Mwakilama is Lecturer in Mathematical Sciences at the University of Malawi, Chancellor College in Malawi. Dave  Mankhokwe  Namusanya is a researcher at Malawi-Liverpool-­ Wellcome Trust in Malawi. Yamikani Ndasauka  is Senior Lecturer in Philosophy at the University of Malawi, Chancellor College in Malawi.

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Tatenda  Nhapi  is a social worker at West Kent Integrated Children in Care Service in Kent, UK. Smith Ouma  is a doctoral researcher in the School of Law and Politics at the University of Cardiff in Cardiff, Wales. Emmanuel  L.  Peter  is a research fellow at the National Institute for Medical Research (NIMR) in Tanzania. Tafadzwa Rugoho  is a PhD student at the University of Kwa Zulu Natal in South Africa. Duncan  C.  Sesaazi  is the head of Pharmaceutical Sciences at Mbarara University of Science and Technology in Uganda. Gabriel  Simungala  is a staff development fellow at the University of Zambia in Zambia. Jane Wathuta  is a lecturer at the Institute for Family Studies & Ethics at Strathmore University in Kenya.

List of Figures

Fig. 13.1 Fig. 13.2 Fig. 13.3 Fig. 13.4 Fig. 16.1 Fig. 16.2 Fig. 16.3 Fig. 16.4 Fig. 16.5 Fig. 16.6 Fig. 16.7 Fig. 16.8

Selected demographic characteristics of the study population by country 220 Overall alcohol prevalence by country 221 Overall alcohol prevalence by country, separately by men and women221 Prevalence of addiction by country 223 Distribution of IAT total scores 271 Proportions of reported IAT score ranges for study participants272 Description of IAT scores by level of study 273 Proportions of IAT scores by age group 274 Distribution of IAT score ranges by year of study in college 275 Description of probable common mental disorder students 276 Scatter plot of IAT and SRQ total performances 277 Distribution of existence or non-existence of common mental disorder within each IAT category 278

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List of Tables

Table 3.1 Table 3.2 Table 9.1 Table 9.2 Table 9.3 Table 12.1 Table 13.1 Table 16.1 Table 16.2 Table 16.3 Table 16.4 Table 16.5

Cannabis value in African culture 40 Cannabis seizures in Africa 45 Semiotic nature of the codes 150 WhatsApp and Facebook abbreviations 152 WhatsApp and Facebook abbreviations and language 154 Main classes of drugs of abuse, their main molecular targets, and some of the mechanism(s) by which they increase DA in NAc202 Average number of days spent drinking alcohol within a specified period 222 Socio-demographic characteristics of study participants by gender268 Description of IAT total score ranges 270 Proportions of IAT score ranges by age group 272 Measure of association between IAT scores and sociodemographic variables 273 Proportions of probable CMD symptom existence by gender 276

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CHAPTER 1

Introduction: Making a Case for Addiction in Africa Yamikani Ndasauka and Grivas Muchineripi Kayange

This book focuses on two issues that have characterized modern studies on addiction, mainly the understanding of the concept of addiction and the problem of the prevalence of addiction in various cultures, with a special focus on South and East Africa. Pertaining to the general understanding of the concept of addiction, academics have offered different explanations. The two common ways of conceptualizing addiction are the Disease Model and the Will Power Model (Ndasauka et al. 2017). In the Disease Model, addiction is conceptualized as a malfunction of a brain process that causes the individual to engage in a particular activity repetitively and excessively. In the Will Power Model, it is contended that addiction is a consequence of weakness of the will, which may be considered as part of a negative disposition brought about by bio-psycho-socio-cultural factors (Ndasauka et al. 2017). Although studies in other parts of the world have been divided between the Disease Model and the Will Power Model, there is no clear academic development of this concept in the African context, as far as the literature shows. Apparently, most of the studies have adopted the Western view Y. Ndasauka (*) • G. M. Kayange Chancellor College, University of Malawi, Zomba, Malawi e-mail: [email protected]; [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_1

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and have attempted either to treat addicts as sick (e.g. Liranso and Yosph 2017) or correct their will power by attempting to make them ethical. The connection with ethics comes from the understanding that the Will Power Model is reflective of or is a source of unethical behaviours. Further complications in conceptualizing addiction in the African context come from the fact that in most of the studies there is no clear demarcation between the concept of addiction and abuse. In fact, in most of the studies these terms are used interchangeably (Liranso and Yosph 2017). However, Mark Griffiths (2005) shows that these concepts are different. For Griffiths, addiction requires satisfaction of the following components: salience, mood modification, tolerance, withdrawal, conflict and relapse. Salience refers to the situation when a given activity becomes a fundamental activity in one’s life and dominates one’s way of thinking, feeling and behaving. Mood modification refers to what an individual reports after engaging in a particular activity. For example, one may report about feeling high after an activity. Tolerance regards increasing involvement in a particular activity in order to repeat the experience that one previously had. For example, an individual may want to smoke more cannabis in order to repeat the past experience. Withdrawal symptoms refers to the unpleasant feelings that are experienced when one reduces or discontinues a particular activity, for example when one stops exercising and starts feeling uncomfortable, such as being irritated. Conflict refers to a situation where the addicted individual enters into conflict with those around him. For example, one addicted to the internet will enter into conflict with those around him/her as this will make the individual compromise other activities. Relapse refers to the tendency of an individual to go back to the addiction status. For example, after stopping masturbation for a month, one goes back to it. While the concept of ‘addiction’ requires the fulfilment of all six elements, ‘abuse’ will only refer to some of the indicated aspect. Nevertheless, most of the studies (as far as the literature shows) have focused on the concept of abuse. In line with the emphasis put on the concept of ‘abuse’, studies in the African context have mainly focused on substance abuse and some behavioural addiction (Moodley et al. 2012; Tshitangano and Tosin 2016). In an attempt to build an African conceptualization of addiction and its prevalence, this work is divided into five parts. Part I focuses on the ‘Conceptualization of Addiction’ in the African context. In Chap. 2, Thaddeus Metz focuses on the African conceptualization of addiction in the context of morality. He specifically addresses the

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question of what makes addiction morally problematic, and seeks to answer it by drawing on values salient in the sub-Saharan African philosophical tradition. He argues that both African vitalism and communalism merit consideration as rivals to accounts that Western ethicists would typically make, according to which addiction is immoral insofar as it degrades rationality or autonomy, as per Kantianism, or causes pain or dissatisfaction, as per utilitarianism. In Chap. 3, Grivas Muchineripi Kayange investigates the concept of addiction by focusing on cannabis use and addiction in a traditional African setting. He argues that cannabis addiction is conceptualized in African traditional culture as having an instrumental value and not as a disease that requires treatment or as immoral. Cannabis is used in different contexts for different purposes such as medicine, military use, increasing energy during farming and sex, and for religious purposes. It is further argued that the current African conception of cannabis as a vice/illegal has generally been pushed by governments due to international pressure and the understanding that the use of this plant for purposes other than medicinal is increasing. In Chap. 4, Wilfred Lajul investigates the African conceptualization of addiction relative to African morality. He argues that, because addiction takes place in the context of societies, then the ontological constitution of an individual, the communal context and the choices made by the individual are responsible for the prevalence of addiction in society. In Chap. 5, Chikumbutso Herbert Manthalu explores Ubuntu considerations in the conceptualization and implementation of addiction-response frameworks in Malawian schools. He highlights the prevalent individual-centric and neo-liberal models of education on developing an autonomous individual and equipping her with the knowledge and skills for job market competition as the modern, ultimate and exclusive aims of school practices and education. The chapter proposes that meaningful approaches to addiction should include Ubuntu’s relational rationality and not only the prevalent agent-centric one. Part II focuses on conceptualization of addiction in African languages, music and culture. In Chap. 6, Telamisile Phumlile Mkhatshwa and Gloria Baby Malambe discuss how Swazi people conceptualize addiction, specifically alcoholism and drug addiction. They argue that Swazi oral traditions function as a tool that provides insight on how Swazis view addiction. They analyse Swazi oral traditions–songs, proverbs and traditional terms–in order to understand how Swazi people perceive addiction. Basing the research on sociological criticism, they hypothesize that the current modern problem of

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substance and alcohol abuse in Swaziland stems from deep-seated Swazi oral traditions. In Chap. 7, Beaton Galafa explores the concept of addiction in the African literary world through a study of sex addiction. The author studies different stories and indicates that there are multiple viewpoints of addiction, and puritanism is one of the views that shapes the authors’ narratives in the works under review. The works in the anthologies are marked by a complexity of themes ranging from sexuality through racism to social injustice, with addiction coming out subtly in some more than it does in others. In Chap. 8, Dave Mankhokwe Namusanya discusses how urban music fits in the narratives of drug addiction and sex addiction, especially as it relates to young people. The chapter specifically discusses such narratives in the music of Mafo, who is a ‘celebrated’ producer of urban music especially among young people. In Chap. 9, Hambaba Jimaima and Gabriel Simungala engage and interrogate social media addiction as it relates and extends to the emergence of creative and innovative codes of communication and representation amenable in the online semiotic landscapes. Taking as its point of departure insights from Young’s Internet Addiction Test, Blommaert’s Supervernaculars, and Kress’s Multimodality the chapter locates Zambia’s online narratives on Facebook and WhatsApp as bearing socio-linguistic resources that transcend the classical and normative attributes of language for communication. Thus, the chapter leans on Blommaert’s Supervernaculars as well as Kress’s Multimodality as it uncovers intricacies of this addictive, creative and innovative way of communicating to learn its potentialities, constraints and permeation across spaces. With superdiversity at play, the chapter establishes whether these creative and innovative codes reflect trends that inform transformation or distortions. The chapter concludes with a sketch detailing the normative processes in local socio-linguistic spaces in the absence of the pedagogic spaces. In Chap. 10, Anthony Mavuto Gunde examines traditional sources of masculine rhetoric employed by Malawian youth to glorify alcohol addiction, their implications for social and behavioural change, and how the sources and the implications in turn are represented by the local media. The aim is to provide an overview of how macho rhetoric has been employed by Malawian youth throughout history and its implications for social and behavioural change with regard to addiction from an African point of view. Part III focuses on neurobiology and neurochemistry of addiction relative to Africa. In Chap. 11, Andrew G. Mtewa, Serawit Deyno, Emmanuel L.  Peter, Annu Amanjot, Lucrèce Y.  Ahovegbe and Duncan C.  Sesaazi outline the general chemical and pharmacological mechanisms involved in

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addiction, African participation in neuroscience research and studies, and challenges and opportunities on the continent. They argue that research and training in the area of neurochemistry and pharmacology in addiction in Africa still remain limited due to inadequacy and lack of interest by professionals specializing in the area and study facilities. Appropriate systematic investment in the field of neurochemistry is required across the continent, which will enhance the understanding that currently Africa has a multifaceted disciplinary approach, and be able to devise sound interventions against addictions with no significant side effects. In Chap. 12, Godfrey S. Bbosa investigates the neurobiology of addiction in Africa. He seeks to interrogate African literature and compare the neurobiology of psychoactive drugs and behavioural addiction. Part IV examines substance and non-substance abuse in Africa. In Chap. 13, Edith B. Milanzi and Yamikani Ndasauka study the prevalence of addiction in Africa using 2015/2016 Demographic Health Survey (DHS) data. After examining the previous trends and prevalence of alcohol use in different countries, they discuss results on prevalence of alcohol use calculated from the most recent DHS for each country separately. Then they attempt to harmonize the data to calculate a pooled prevalence. They then determine differences in alcohol consumption between males and females. In their conclusion, with reference to the data analysed,  they make a case for alcohol addiction in Africa. In Chap. 14, Tafadzwa Rugoho discusses the experiences of sex workers with disabilities who are using drugs. They buy drugs from the streets and these drugs can be hazardous to their health. The author laments that the government of Zimbabwe and non-governmental organizations are doing very little to combat the illicit sale of drugs on the streets. In Chap. 15, Tatenda Nhapi uses a Merton critique to explore youths’ addiction to drugs in Zimbabwe’s current socio-economic discourse. The author further analyses domains of youths’ drugs addiction and resultant impacts. Finally, using a social work lens, this chapter offers pathways for continued robust drug addiction mitigation among Zimbabwean youths. In Chap. 16, Tiwonge D. Manda, Edister S. Jamu, Elias P. Mwakilama and Limbika Maliwichi-Senganimalunje explore the phenomenon of addictive internet use among college students in Malawi and how this relates to probable cases of common mental disorders. The chapter applies a combination of the Internet Addiction Test and the Self-Report Questionnaire. The authors argue that despite growing acknowledgement of the negative aspects of excessive internet use, there is still a dearth of studies on the subject, especially in sub-Saharan Africa.

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In Chap. 17, Smith Ouma and Jane Wathuta reflect on the prevalence of tobacco use and addiction in Kenya. They further reiterate the continued relevance of the Framework Convention on Tobacco Control (FCTC) and subsequent national legislation to aid the Kenyan government in promoting and protecting public health, while urging the tobacco industry to maintain high ethical standards in the conduct of their business.

References Griffiths, M.D. 2005. A “Components” Model of Addiction Within a Biopsychosocial Framework. Journal of Substance Use 10: 191–197. Liranso, G.S., and D.M.  Yosph. 2017. Drug Addiction and Mental Illness Treatment in Sub Saharan Africa. Journal of Substance Abuse and Alcohol 5 (3): 1064. Moodley, S.V., M.J. Matjila, and M.Y.H. Moosa. 2012. Epidemiology of Substance Use Among Secondary School Learners in Atteridgeville, Gauteng. South African Journal of Psychiatry 18 (1): 2–7. Ndasauka, Y., et al. 2017. Received View of Addiction, Relapse and Treatment. In Substance and Non-Substance Addiction, ed. X.  Zhang, J.  Shi, and R.  Toa. Singapore: Springer Nature. Tshitangano, T.G., and O.H.  Tosin. 2016. Substance Use Amongst Secondary School Students in a Rural Setting in South Africa: Prevalence and Possible Contributing Factors. African Journal of Primary Health Care & Family Medicine 8 (2): a934. https://doi.org/10.4102/phcfm.v8i2.934.

PART I

Conceptualization of Addiction

CHAPTER 2

Addiction in the Light of African Values: Undermining Vitality and Community Thaddeus Metz

2.1   Introduction Virtually no one believes that addiction is a good thing, with nearly all finding it imprudent, and many deeming it also to be immoral. Where there is normative controversy, it is about why, if at all, one should think that addiction is unethical, and about whether agents such as the state ought to punish or otherwise blame addicts. In this chapter, I set aside the latter issues, which concern how to respond properly to those who are addicted,1 and focus strictly on the former ones, about their potential

Reprinted by permission from Springer Nature: Springer Link, Monash Bioethics Review. Addiction in the Light of African Values: Undermining Vitality and Community, Metz Thaddeus, © Monash University 2018, 2018. 1  For discussion of whether and, if so, how to treat addicts as responsible for their condition, or for the harmful effects that have come in the wake of it, see Morse (2000); Husak (2004); the papers in Poland and Graham (2011a); Frank and Nagel (2017); and Pickard (2017).

T. Metz (*) University of Johannesburg, Johannesburg, South Africa e-mail: [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_2

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immorality. Precisely why should one think that it is immoral to become an addict or to do what is likely to cause others to become addicted? Which sorts of addiction are particularly unethical, and by virtue of what? I critically explore answers to these questions by appealing to values salient in the sub-Saharan African philosophical tradition. Specifically, I draw on two major ways that African philosophers (writing in English in the post-independence era) have understood foundational ethics, and show how they each account for the immorality of addiction. According to one characteristically African approach, a person’s basic aim as a moral agent should be to promote life-force at least in herself and perhaps also in others, and, according to the other, at bottom one morally should prize communal (or harmonious) relationships with other people. I work to tease out from the values of vitality and community explanations of when, why, and to what extent various kinds of addiction are immoral. I do not seek in this chapter to defend either vitality or community as the best explanation of the immorality of addiction, instead arguing that each of these characteristically African values2 grounds an independent and plausible account of that. In addition, note that I am not really aiming to demonstrate that addiction is in fact immoral, something beyond a mere medical condition such as a broken leg. I am, in contrast, supposing for the sake of argument that there is something morally problematic about addiction and seeking attractive explanations of what that might be. I conclude that both vitalism and communalism merit consideration as rivals to explanations that Western ethicists would typically make, according to which addiction is immoral insofar as it degrades rationality or autonomy, as per Kantianism, or causes pain or dissatisfaction, à la utilitarianism. In the following I begin by indicating what I mean by the word “addiction” and sketching the ways that dominant Western moral philosophies would construe it as unethical (Sect. 2.2). I also take care to distinguish my enquiry, into why one might sensibly think that at least salient instances of addiction are immoral, from what is sometimes called the “moral model” of addiction, which includes a “moralized” response to it. Next, I expound the concept of life-force as a basic value in the African tradition of philosophy, 2  By “African,” “Western,” and similar geographical labels, I mean features that have been salient over a large part of a territory and for a long time that differentiate it from many other territories (on which see Metz 2015a). Hence, there is no “essentialist” suggestion here that these features are exhaustive of, exclusive to, or invariably present in a given region.

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and draw out its implications for the immorality of ­addiction (Sect. 2.3), after which I do the same for the concept of communal relationship (Sect. 2.4), in both cases contending that their accounts are revealing. I conclude by raising important questions about addiction that have not been addressed here, in particular those pertaining to the right ways to respond to those forms of addiction that are plausibly deemed immoral (Sect. 2.5). I suggest that the African values are also promising with respect to these issues, which deserve to be considered elsewhere in depth.

2.2   Addiction, Immorality, and Western Ethics In this section I provide some background to the debate about the immorality of addiction. Key aims here are to: define what is characteristically involved in a state of addiction; make it clear that this chapter is about addiction’s immorality, where that is distinct from other debates about addiction prominent in the literature; and articulate the standard views in Western philosophy and culture more generally about why addiction is morally objectionable. I address African alternatives only in the following sections. As with many other psychological disorders, debates about whether there is an essence to addiction and what it might be continue in earnest. There is as yet no clear consensus about how to distinguish the causes of addiction, or even its effects, from what constitutes it (as has been pointed out by Morse 2000, pp. 11–12 and Poland and Graham 2011b, pp. 2–3; for some of these debates, see the papers by Levy 2013; Shelby 2016; and the papers by Pickard and Ahmed 2018). I therefore define what I mean by “addiction” by appealing to examples of it that nearly all those party to those debates would accept, and by making some plausible, even if not outright uncontentious, assumptions about it. Paradigms of addiction on the part of human beings presumably include the following: smoking a pack or two of cigarettes a day despite the high risks of cancer, respiratory ailments, heart disease, and early death; having taken cocaine on a daily basis for an extended period and being willing to spend lots of money to continue the habit because of not wanting to suffer from withdrawal; consistently engaging in unprotected and promiscuous sexual behaviour to avoid painful feelings, despite knowing the chances of acquiring HIV and other sexually transmitted diseases; being unable to engage with others socially and to complete one’s work because one has a powerful desire to play games on the internet; needing to place bets on horse races to the point of stealing from

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one’s employer and family members. I also suppose that those engaging in such behaviours would sincerely report that they “could not help themselves,” “could not stop if they tried,” and the like. These are what Anglo-American metaphysicians would tend to call the “surface properties” (Putnam 1975) or “appearances” (Kripke 1980) of human addiction, that is, what just about everyone familiar with the property would ascribe to it, where philosophers, psychologists, and neurologists debate about what (if any) “deep structure” (Putnam 1975) or “essence” (Kripke 1980), perhaps a particular operation of the brain or of the will, might best account for all of them. Rather than posit a specific, core mechanism with which one might identify human addiction, I note some characteristic features of it, ones that are commonly, even if not invariably, associated with the examples above. First, there is typically a craving, an overwhelming urge, for a substance such as a drug or a process such as gambling, where the craving is habitually satisfied. Second, there would often be psychological or physical pain upon not satisfying the craving and “kicking the habit,” of which the person is fearful and more generally strongly averse. Third, the craving and the interest in avoiding pain have reduced a person’s self-control, that is, her ability to recognize good judgement and to act in accordance with it. These three are the most widely discussed contributory properties of addiction, with the following ones being more contested. Some would say that a fourth recurrent feature of addiction is denial, the failure to apprehend one’s own motivations, to appreciate risks, or to recognize harm one is bringing on others (Ainslie 2013; Pickard 2016). Others would add a fifth, that often addiction is a way of coping with or “self-medicating” a psychological wound or stressor, such as self-hatred or abuse (Khantzian 1997; Pickard and Pearce 2013; Shelby 2016). Still others would suggest a sixth, that addiction, properly speaking, involves at least the risk of substantial harm to the addict or those close to her (see especially Pickard and Sinnott-Armstrong 2013). My claim is not that any particular set of these properties is necessary and sufficient for something to count as “addiction,” but rather that addicted people typically exemplify some cluster of them, and that such a construal of addiction is enough for us to make ethical headway, which is the aim of this chapter. This approach means that sometimes I will need to hedge my phrasing, for example, when it is unclear whether the moral problem is with addiction as such or with a particular form of it. However, such hedging will not interfere with the ability to point to specific ways of behaving that are ethically objectionable.

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With much of the field now, I suppose in the rest of this chapter that human persons who are addicted are neither utterly compelled to satisfy their cravings nor utterly free to decide whether or not to do so. These days it is routinely pointed out (for just one example, see Uusitalo et al. 2017) that, on the one hand, addicted human persons characteristically have some control over their behaviour, for example, in being responsive to the price of the object sought out and often enough eventually being able to quit it, but that, on the other, knowledge of the reward systems of their brains indicates that their cognitive, motivational, and volitional responses differ from those of non-addicted persons (at least in respect of the object to which they are addicted). A common (even if not utterly uncontroversial) view is that addicts suffer from an impaired, but nonetheless existent, ability to recognize good reasons and to act in the light of them, which I accept below when morally evaluating addiction. The project of appraising addiction from a moral perspective must be differentiated from ones with which it is likely to be conflated. First off, I have already implicitly rejected part of what is sometimes called the “moral model” of addiction (which is discussed in [but not accepted by] Levy 2011, p. 95; Morse 2011, p. 163; and Pickard 2017). One facet of this approach is the claim that decisions undertaken by an addicted person in respect of a craved object do not qualitatively differ from the everyday decisions made by a non-addict. Addicts are considered to have the substantially free choice to decide whether to take the drug or place the bet. However, I suppose here that decisions made by addicts, at least in respect of a craved object, are less voluntary than, say, the decisions of nonaddicts in respect of which tie to wear. Addicts characteristically have some self-control, but it is less than non-addicts when it comes to their addiction. Addiction is more than merely a habit, and is instead a habit that is to some degree out of control, unable to be easily regulated by good judgement. There is a second aspect of the “moral model” of addiction that I also reject, or at least am not committed to simply by virtue of morally evaluating it. This is moralization, which involves blaming, stigmatizing, and perhaps even punishing addicts, as well as downplaying the biological, psychological, and social causes of addiction. Douglas Husak remarks that he suspects “that an inquiry into the moral dimension of addiction is unlikely to be undertaken solely for its intrinsic interest. The judgement that addiction is morally important will probably be used in attempts to defend given responses to addicts” (2004, p. 400), where he is especially concerned to refute the suggestion that addiction merits punishment.

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However, in this chapter I am indeed focused squarely on the questions of when and why there is something immoral about addiction, and I set aside, apart from a few concluding remarks (in Sect. 2.5), the issue of whether, and, if so, which negative responses towards it are justified. There is no logical inconsistency in holding that, although some instances of addiction are immoral, they do not warrant blame or stigma, let alone punishment or something like a “war on drugs.” If positive (rewarding) or neutral (changing the social context) responses were to reduce addiction much more than negative ones, it would be coherent to prescribe the former in lieu of the latter. Everything depends on having a further, distinct account of how to respond to wrongdoing, and retributivism, which would best justify the moral model, is far from the obviously correct one. The reader might have noticed that, up to now, my talk of addiction being “immoral” or “unethical” has been vague. In particular, I have glossed over a normally important distinction between vice and wrongness. For many ethicists, a bad person can sometimes do the right thing, while a good person can sometimes do the wrong thing. Or, at the very least, there are plausibly two dimensions of moral appraisal, concerning a person’s attitudes and his decisions (even if one believes that the wrongness of the latter is a function of the vice of the former, or vice versa). In this chapter I do not focus on only one of these dimensions of moral appraisal, and instead readily consider both. It is pertinent to ask questions about not only the sort of person who would let himself become addicted or has remained so, but also the way an addicted person is treating others or himself. In the modern Western tradition of philosophy, rationality, autonomy, project-pursuit, and related properties are familiar ground for morally appraising addiction. By this sort of approach, addiction is bad or wrong largely because of the recurrent (if not inherent) feature of weakened self-­ control. Even Husak, who is at pains to protect addicts from moralized responses, believes: The value of freedom and the capacity for voluntary choice are beyond controversy…. Anything that undermines freedom and our capacity for voluntary choice is likely to be bad.…Arguably, the truly excellent being has no addictions; his choices are never compulsive, but are always completely free and voluntary. The status or condition of being an addict is plausibly regarded as a vice (2004, pp. 414–415).

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Husak appeals to virtue theory to appraise addiction, where one could readily hark back to the aretaic views of Plato’s Republic and Aristotle’s Nicomachean Ethics, according to which excellence, broadly speaking, consists of one’s rational mind being in control of one’s emotions and feelings. However, one could also appeal to a Kantian, deontological account of moral action, according to which right acts essentially treat people’s capacity for reason or autonomy with respect, and wrong ones fail to do so. Addiction is a direct assault on a person’s ability to make decisions in the light of deliberation. This is arguably so not merely because the affective and conative sides of our nature come to dominate the intentional, motivational, and volitional sides, but also because of cognitive defects mentioned above, such as failing to appreciate evidence about oneself and about the effects of one’s choices. Hence, becoming an addict and remaining one fail to uphold a duty to treat one’s own rational nature with respect, that is, as the most important value in the world, while helping others to become addicts fails to respect theirs. By this approach, addiction is morally worse, the more degrading of rationality it is. This is a reasonable explanation of the difference between being addicted to cocaine relative to caffeine. Cocaine lends itself more to compulsion than caffeine; there is much more aversion to stopping a cocaine habit than a caffeine one; the money and other resources spent on cocaine will undermine an agent’s other ends much more than those spent on caffeine; and the pursuit of cocaine is more likely to foster unjustified beliefs than one for caffeine. Modern Western philosophy offers an additional familiar ground by which to draw the conclusion that addiction is morally problematic, namely, subjective well-being. By the classical utilitarian approach to right action, one is obligated to produce pleasure and to reduce pain, and by many contemporary versions of the view, one is obligated to increase satisfaction, that is, the fulfilment of desires, and to decrease dissatisfaction. Regardless of how subjective well-being is construed, a utilitarian agent is to include her own, giving it equal weight to that of others. Now, an addict in the short term avoids the intense pain of withdrawal and enjoys the pleasure of obtaining her craved object. However, usually addictions are not sustainable, and it would in most cases be better, in terms of overall expected amount of subjective well-being, to overcome an addiction sooner rather than later. That is particularly because there are ongoing losses during the course of addiction. Specifically, addicts usually

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have to give up larger pleasures (or at least, in the terms of John Stuart Mill, “higher” ones) for the sake of their craved object, and they typically feel shameful, loathsome, and the like for being addicted. Furthermore, while they are addicted, people tend not to bring others as much pleasure as they could have, if anything tending to cause them pain, their interests being sacrificed on the altar of the dopamine rush from the drugs, the games, the bets. Similar remarks apply to the preference-oriented version of utilitarianism. An addict with a supply of his craved object can satisfy his desire for that in the short term, where that desire is the strongest when construed in terms of sheer power to influence action. However, the costs of addiction in the long term are usually expected to be greater. Furthermore, relatively few addicts themselves have second-order desires to desire the craved object, or, alternatively, would rank a desire for the craved object highly relative to other desires, where these are intuitively more relevant to appraising the quality of an individual’s life than whichever desire happens to carry the day in terms of a person’s behaviour. And, again, typically those addicted give much less attention than they could to the satisfaction of other people’s desires. One could also invoke subjective well-being as part of a virtue theory to derive the conclusion that addiction is a vice. For example, consider Thomas Hurka’s (2001) view that vice is largely a matter of, first, loving, that is, “desiring, pursuing, or taking pleasure in,” the bad, where the bad includes pain and failure in the pursuit of an achievement, and, second, hating, or at least neglecting, the good, where the good includes pleasure and achievement. Being hooked on cocaine to the point of not caring about the pain it causes to oneself and others and being unable to satisfy other, higher-order desires plausibly count as vices, according to Hurka’s theory.3 By this general approach, addiction is morally worse, the more harmful it is to the addict and those in contact with him. This is also a reasonable explanation of the difference between being addicted to cocaine relative to caffeine. Roughly, cocaine can be expected to reduce people’s well-being, subjectively construed, more than caffeine. 3  One could also invoke Rosalind Hursthouse’s (1999) theory of virtue, according to which the virtues are constituted by settled dispositions of human persons that advance, amongst other things, “characteristic enjoyment” (1999, pp. 197–216). Addictions to cigarettes, gambling, and pornography do not reliably foster characteristic enjoyments of the species, and instead tend to undermine them.

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These are plausible explanations from the West of what is morally bad and wrong with being addicted and fostering addiction. There are of course objections one could raise, one being the hypothetical case of a person with an inexhaustible supply of his craved object, perhaps heroin, where the addict would be useless at doing much for others were he to get clean; in that case, can utilitarianism explain what is wrong with addiction? Probably not well. However, my aim in this chapter is not really to indicate, negatively, that the Western approaches are limited. It is mainly to appeal to some under-considered, African moral perspectives in order to ground, constructively, some additional appraisals of addiction that merit consideration. While a lack of rationality and felicity might be part of the story about why addiction is immoral, the African tradition of philosophy suggests that there is more to it, if not something else entirely: there is a lack of vitality and community. As I spell out in the next two sections, by characteristically African values addicts are immoral, roughly, for being debilitated and isolated.

2.3   Addiction as Incompatible with Vitality4 Much of the literate work by African moral philosophers in the post-­ independence era implicitly advances one of three values as fundamental (on which see Metz 2015b). One of these is the common good, with the idea being that in all one’s actions one should do whatever one can to meet the needs of everyone (e.g., Gyekye 1997, pp. 35–76). This is not Western utilitarianism, because of its focus on objective well-being and especially because it does not normally permit harming some for a greater good to others. Even so, applying the common good to addiction is unlikely to reveal considerations particularly different from the utilitarian explanations of its wrongness addressed in the previous section. The other two salient African values, vitality and community, are less familiar to a global audience, have not yet been systematically applied to addiction, and highlight moral concerns about it that are distinct and merit serious consideration. Hence, I focus exclusively on them in the rest of this chapter. Placide Tempels (1959) is well known for having written the first “ethnophilosophical” attempt to understand and relate African worldviews to a Western audience, and for having deemed the concept of life-­force to be at 4  Some of  the  phrasing when expounding the  vitalist and  communal ethics has come from Metz (2012, 2013a).

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their heart. Although his work has been vigorously criticized for over-generalizing, one still finds contemporary philosophers from a variety of subSaharan regions placing the notion of life-force, or something close to it, at the heart of their ethics (e.g., Dzobo 1992; Kasenene 1994; Magesa 1997; Iroegbu 2005; Onah 2012) and sometimes specifically their bioethics (Kasenene 2000; Bujo 2005; Bikopo and van Bogaert 2010; Tangwa 2010, esp. pp. 186–188; Rakotswoane and van Niekerk 2017). Life-force has been traditionally interpreted as an intrinsically valuable energy that is imperceptible and constitutes everything that exists. All things in the universe, even apparently inanimate objects such as a grain of sand or drop of oil, are thought to be both good and real by virtue of having some degree of life-force, with plants having a greater share of it than rocks, animals having more than plants, human beings having more than animals, ancestors (whose bodies have died but who live on in an imperceptible realm on earth) having more than humans, and God, the source of all life-force, having the most. All beings in the world are thought to participate in the divine energy. Although this conception of value sprang from a certain religious metaphysics, it need not be tied to one in order to offer a morality that is attractive to a global or otherwise multicultural audience. In fact, often enough life-oriented African philosophers and theologians make value judgements without appeal to highly controversial ideas about the fundamental nature of reality, or at least not explicitly. For example, they say that a human being has a dignity, or otherwise merits moral consideration, in virtue of being able to exhibit a superlative degree of these properties: health, strength, growth, reproduction, creativity, vibrancy, activity, self-motion, courage, and confidence. Similarly, to be avoided are things such as disease, weakness, decay, barrenness, destruction, lethargy, passivity, submission, fearfulness, and low self-esteem.5 Here is a representative statement from Noah Dzobo, a Ghanaian philosopher: (T)here is an urge or dynamic creative energy in life….which works towards wholeness and healing, towards building up and not pulling down….Our people therefore conceive human life as a force or power that continuously recreates itself and so is characterized by continuous change and growth which depends upon its own inner source of power….Since the essence of 5  Interestingly, the Western philosopher whose views most approximate African vitalism is probably Friedrich Nietzsche.

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the ideal life is regarded as power and creativity, growth, creative work and increase have become essential values. Powerlessness or loss of vitality, unproductive living, and growthlessness become ultimate evils in our indigenous culture. For many Africans one of man’s chief ends ….is to multiply and increase, because he is the repository of the life force…. The second greatest end of man is to live productively, i.e., to work, because work is considered as the only way of realizing one’s creative potential (1992, p. 227).

I presume the reader can see the prima facie attractiveness of this orientation towards value without an essential reference to the existence of God. From here on I will drop talk of “life-force” in favour of “vitality” or sometimes “liveliness,” to signal a value that is consistent with a perceptible or physicalist interpretation. Sometimes when vitality is taken to be foundational, well-being is understood in terms of it, so that the more vitality one exhibits, the better off one is (e.g., Tempels 1959, pp. 30, 32; Kasenene 1994, p. 140). That is not implausible, but I instead highlight another feature of a vitalist ethic, namely, its ability to account for virtue (excellence, perfection) as a final good distinct from welfare. It is natural to construe someone who is creating a family, or realizing his powers on the job, or acting consequent to trust in his judgement and ability as not merely a person who is well off, but also a good person. Such a person is not so much satisfying his self-­ interest, but more fostering his self-realization. Conversely, procrastination, laziness, and depression are to be overcome in that they mean an absence of “dynamic creative energy” and hence a lack of human excellence. Whose vitality should one promote, morally speaking? Some would say that one should aim to advance one’s own vitality as much as possible (and, so, traditionally speaking, strive to become an ancestor), where intuitively moral actions such as helping others reliably cause that. Others would contend that one should promote liveliness wherever one can, which in principle entails that it could be right in some situations to sacrifice one’s own liveliness for the sake of others’. Either approach provides an illuminating understanding of why addiction is morally problematic: it is so when, and to the extent that, it inhibits vitality in oneself or others. Here, the long-term effects closely associated with certain kinds of addiction are salient. For example, smoking cigarettes causes an early death, the cessation of all vitality. Cigarettes and related substances, such as meth or alcohol, tend to harm the body in serious ways, making one less able to use one’s powers effectively. And where

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addiction is serving as a coping mechanism for a psychological wound, one is not dealing with the latter to become healthy, say, by developing a more robust and resilient self. Apart from these common effects, the more intuitively “inherent” features of addictive behaviour also tend to inhibit vitality. Instead of being strong, an addict is submissive in respect of the craved object. The time, money, and other resources that could have gone into creative projects instead feed what is usually a passive, repetitive stimulus such as absorbing nicotine or watching a horse race. And then an addict, at least in respect of drugs, is patently one who loses his capacity for self-motion, instead becoming dependent on the craved object to function. I submit that these are powerful accounts of why addiction would be a vice to exhibit in oneself and would be wrong to foster amongst others. One might object that smoking cigarettes and drinking alcohol can enhance vitality, say, by enabling people to cope with stressful jobs or difficult family members. Even where there is not a challenging social environment to deal with, one could think that smoking makes some people more productive than they would be without it; nicotine is (in part) a stimulant, after all. However, in most cases, the enhancement of vitality is merely in the short term, with death and disease being ultimate vitality reducers in the long run. In addition, it is rarely the case that the only way to cope with stressors or to be particularly productive is by ingesting an addictive substance. In those cases where an addiction would be unlikely to have bad long-­ term consequences and would be the only way to actualize one’s capacities on the job to a particularly full extent, the vitality account entails the plausible view that addiction would not be so wrong, and perhaps not wrong at all. Returning to the caffeine versus cocaine example, the former inhibits vitality to only a small degree, one that is by and large compensated for with greater productivity. To be sure, one can become dependent on caffeine and at a certain point be unable to feel awake and do one’s work without it. However, it would not be difficult to sever the tie upon reaching that point, and the dependence neither risks ill-health, nor siphons resources away from other creative projects, nor prevents one from going out of one’s way for others, while for many caffeine improves their abilities to concentrate and to make an effort. If there is such a thing as caffeine addiction––and some (notably Pickard and Sinnott-Armstrong 2013) would suggest that there is not, precisely because of the absence of serious harm––then it is not much of a vice or wrong, and might even be prescribed by considerations of vitality.

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In contrast, while cocaine might temporarily make a user more productive, it does not take long before the following happens: she thinks about it more than the work that needs to be done; it risks her health; and the “comedown” or “crash” she experiences is so deadening as to render her unable to do much of anything––without more of the drug. Here, one can hardly speak of “growth which depends upon its own inner source of power,” as per Dzobo above. An appeal to liveliness, I submit, does a reasonable job of explaining  why some forms of addiction are worse than others. There are also respects in which cocaine and similar addictions often impair other-regard, that is, the awareness of other people’s contexts and interests as they pertain to their vitality. However, I have not emphasized those here, since the considerations are not much different from those in the next section, on the African conception of community.

2.4   Addiction as Incompatible with Community Vitality, as expounded in the previous section, is not an essentially relational property, at least in its secular interpretation. To exhibit features such as strength, growth, self-motion, or creativity is not necessarily to interact positively with other people. Crudely stated, a hypothetical Robinson Crusoe, alone on a deserted island, could in principle display liveliness (even if he would display much more in a society). In contrast, the value of community, or harmony, is relational at the core and unavailable to Crusoe, with basic moral value being constituted by certain ways that people interact or could. Such a relational approach to value is particularly common in the southern African ethical thought associated with ubuntu and botho, which mean humanness in prominent indigenous languages there (Khoza 1994, p. 2; Gaie 2007, pp. 29–30, 36). A maxim widely used to capture moral thought in South Africa and neighbouring countries is “A person is a person through other persons,” which (in part) means that one should strive to become a real person or a genuine human being and do so by relating to other people in certain, positive ways (e.g., Khoza 1994, p. 3; Mokgoro 1998, pp. 16–17; Letseka 2000, pp. 182–183, 185–186).6

6  For a survey of this ethic in the contexts of several sub-Saharan peoples, see NkuluN’Sengha (2009).

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Becoming a real person in this context is far from Hobbesian egoism, since one’s personhood is deemed to be constituted (roughly) by communal or harmonious engagement with others. As one scholar has explained, “Our deepest moral obligation is to become more fully human. And this means entering more and more deeply into community with others. So although the goal is personal fulfilment, selfishness is excluded” (Shutte 2001, p. 30). What is involved in communal or harmonious interaction? Consider some representative remarks from philosophers, jurists, theologians, and related thinkers, particularly, but not solely, from southern Africa: Every member is expected to consider him/herself an integral part of the whole and to play an appropriate role towards achieving the good of all (Gbadegesin 1991, p. 65). (H)armony is achieved through close and sympathetic social relations within the group – thus the notion umuntu ngumuntu ngabantu/motho ke motho ka batho ba bangwe (a person is a person through other persons––ed.) (Mokgoro 1998, p. 17). We (Africans––ed.) say, “a person is a person through other people”. It is not “I think therefore I am”. It says rather: “I am human because I belong.” I participate, I share (Tutu 1999, p. 35). The fundamental meaning of community is the sharing of an overall way of life, inspired by the notion of the common good (Gyekye 2004, p. 16). If you asked ubuntu advocates and philosophers: What principles inform and organise your life?....the answers would express commitment to the good of the community in which their identities were formed, and a need to experience their lives as bound up in that of their community (Nkondo 2007, p. 91).

As I have worked to demonstrate elsewhere (e.g., Metz 2013b, 2018), implicit in these and other characterizations of the virtuous or right way to relate are two distinct properties. Although they have their own logic and value, much of the African tradition considers them to be particularly important (either for their own sake or as a reliable means to something else) when they are found together, as they characteristically are in a family. Specifically, on the one hand, there is considering oneself part of

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the whole, being close, participating, sharing a way of life, and experiencing oneself as bound up with others, which I sometimes express with “identity,” short for identifying with others. On the other hand, there is achieving the good of all, being sympathetic, sharing, advancing the common good, and being committed to others, which I capture with “solidarity.”7 To identify with others is largely for one to think of oneself as a member of the same group or of a common relationship—that is, to conceive of oneself as a “we,” as well as for one to engage in joint projects, coordinating one’s behaviour even-handedly with others to achieve goals. The opposite of identity would be instantiated by a person being divisive by defining himself in opposition to others or seeking to undermine their ends, say, with coercion or deception. To exhibit solidarity with others is for one to care, ideally both emotionally and practically, about others’ flourishing. One sympathizes with others and acts in ways likely to promote their good, which might be a matter of meeting their needs (welfare) or fostering their personhood (virtue). For a person to fail to exhibit solidarity could be for him to be indifferent to others’ interests or to exhibit ill-will in the form of cruelty. The more identity and solidarity, the more communion (or harmony) there is. As with the value of vitality, traditionally speaking the relevant members with whom to commune have included those in an imperceptible realm, namely, ancestors and the “living-dead,” those who have recently shed their bodies but continue to reside nearby on earth. However, the ethic’s attractiveness, at least to a multicultural readership, does not depend on that metaphysically contested perspective, and so I abstract from it in what follows. There are various combinatorial functions that philosophers have ascribed to communion. For example, some contend, in consequentialist fashion, that one should maximize communal relationships as much as possible wherever one can, while others maintain, deontologically, that one should treat people as having a dignity in virtue of their capacity to relate communally. Common ground between both positions is the mid-­level principle that one often has moral reason to establish, maintain, and enrich communal relationships as an end, not merely as a means. Conversely, wrongful acts or bad attitudes are roughly those preventing communion, 7  In the Western tradition, the young Karl Marx’s philosophical views most approximate this ethic, more so than the ethic of care (on which see Metz 2013b).

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or even exhibiting opposite features such as divisiveness and ill-will, a prima facie plausible account of the immorality of actions such as lying, stealing, abusing, kidnapping, and promise breaking. Such principles, which have been applied to other bioethical topics (e.g., Kasenene 2000; Gaie and Mmolai 2007; Murove 2009; Metz 2010, 2017, 2018; Behrens 2018; Ewuoso 2019), are enough to draw out some implications for the immorality of addiction, which, I now point out, often undermines communal relationship. Here are two major respects in which addiction is plausibly immoral for inhibiting an agent’s ability to identify with others and exhibit solidarity with them.8 First, consider the typical mental states of a person addicted to taking drugs or gambling. While it might be true that people who are self-­ absorbed are the ones particularly inclined towards addiction, it is also the case that addiction fosters a focus on the self. When in the midst of craving something, or being averse to withdrawing from it, an addict is unlikely to exhibit much of an other-regarding psychology. Concretely, he is unlikely to be thinking of himself as a “we,” and instead going to be referring to himself as an “I,” one in desperation. Furthermore, he is going to have difficulty empathizing and sympathizing with others, being focused on satisfying his own, powerful desires. Second, the behaviour of a characteristic addict can be expected not to be communal, and, if anything, instead to exhibit the opposite, discordant traits. Addiction routinely involves a reduced ability to govern oneself, that is, to regulate one’s choices according to good reasons, including reasons to cooperate with others. Joint projects become difficult to u ­ ndertake when there is an intense inclination to get a fix, and addicts are well known for being willing to lie, steal, and break promises in order to get it. Furthermore, addiction can make it harder to do what is likely to advance other people’s good, whether their welfare or virtue. Neglect of the needs, whether psycho-physical or socio-moral, of children on the part of parental addicts is a clear instance, with the communal ethic able to explain why this is particularly wrong: actual communal ties have a greater weight than merely possible ones, a partial dimension to ethics (that, traditionally speaking in Africa, has been largely a function of blood ties, on which see Appiah 1998). 8  Addiction’s damage to personal relationships is familiar (for a popular piece, see Marie M 2017), but the point is that it is not easily grounded on an individualist moral philosophy ascribing basic value to rationality or pleasure. The communal-relational values salient in the African tradition, in contrast, provide a plausible anchor.

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Finally, consider the respect in which the communal ethic can account for judgements about some addictions being worse than others. A cocaine addict, unlike a caffeine addict, tends to prioritize obtaining the craved object at the expense of the good of his family, friends, and co-workers. Caffeine does not prompt obsession, barely affecting one’s disposition to enjoy a sense of togetherness with others, participate with them on a cooperative basis, go out of one’s way to help them, and do so consequent to sympathy and for their sake. In contrast, cocaine risks undermining each of these facets, and indeed prompting their anti-social opposites. Returning to the maxim that a person is a person through other persons, many indigenous Africans would say of a cocaine addict that he is “not a (real) person” or is even (like) an “animal” (Bhengu 1996, p. 27; Gyekye 1997, pp. 49–51; Letseka 2000, p. 186; Nkulu-N’Sengha 2009, p. 144), metaphorical ways of saying that, because of the extent to which he directs his attention towards himself, he lacks human excellence to a serious degree. One might object that sometimes addiction can in fact foster communal relationships. One could in particular speak of “joint-addiction,”9 by which I mean a shared addiction to marijuana spliffs. Suppose there were a group of people who identified themselves as those who smoke pot, cooperated with one another to source, prepare, and inhale the drug in a special location with some degree of ritual, and went out of their way to care for each other when together. Then, there would appear to be not just communion in spite of addiction, but rather, more strongly, communion because of it. More familiar are those who congregate outside buildings to smoke cigarettes; they think of themselves as a “we,” bum smokes from one another, listen attentively and sympathetically to each other’s stories, and so on. It appears, therefore, that communion sometimes prescribes addiction, failing to capture its vice or wrongness adequately. However, there are three respects in which joint-addiction and hanging out at the smoker’s door are probably not as respectful or promoting of communion as non-addictive alternatives. In regard to smoking (particularly cigarettes, but also marijuana), the obvious reply is that while there is some communal relationship in the short term, in the long term there is a good risk of cancer, heart attack, and emphysema, which would gravely inhibit one’s ability to relate. 9

 I must credit Ben Smart with the term.

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A second reply, focused more on joint-addiction, is that although there is some communion, it would normally come at the cost of other communal relationships in the present, not merely the long run. Joint-addicts are likely to devote time and attention to other joint-addicts at the expense of intimates such as friends, family, co-workers, and neighbours. Where there have been strong bonds prior to the joint-addicts association, an Afro-communal ethic entails they have moral priority, such that it would be wrong to some real extent to impair them to make new, stoner friends. In addition, the substantial funds being spent on purchasing marijuana (or tobacco) could be better spent on, say, one’s children. The third reply to make to the cases of joint-addicts and smoker’s door attendees is that the communion amongst them is in fact not as rich as one might have initially thought. Granted, there could be real identification amongst them, that is, a sense of togetherness and cooperative participation. However, there could not be substantial solidarity, since that is a function of what is in fact likely to make people’s lives go objectively better, where addiction to inhaling marijuana or tobacco poses a serious health risk. “Helping” someone acquire these plants to smoke is not the sort that morally counts, by the Afro-communal ethic.

2.5   Concluding Remarks on Responding to Addiction My principal aim in this chapter has been to draw on resources in the African philosophical tradition by which to make good sense of why addiction is morally undesirable. Specifically, I have appealed to the under-­discussed values of vitality and community, which ground prima facie plausible accounts of the immorality of salient kinds of addiction: addicts exhibit vice or act wrongly insofar as their habit either undermines l­iveliness, particularly in themselves, or inhibits communal relationships with others. Addiction can be an enervating and isolating condition, one that is at least bad to bring on oneself and wrong to encourage in others. These accounts of addiction’s immorality merit consideration as views to supplement, if not supplant, those that Western ethicists would typically hold, according to which addiction is degrading of rationality or causes pain. As noted at the start, I have in this chapter sought to avoid issues of how to respond to those who are addicted. Although it might be true that, by definition, for something to count as “immoral” means there is pro tanto reason to censure it, it does not follow that the censure should be punitive or stigmatizing––it might instead take the form of guilt. It also does not

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follow that there is, all things considered, reason to censure an addict; if, for instance, censure would foster more of the same behaviour, that is some, perhaps weightier, reason not to do it. I close by suggesting that at least one of the African values appealed to in this chapter to appraise addiction also promises to ground a different, and on the face of it sensible, account of how to respond to it. Here, too, sub-Saharan thought offers an approach that differs from familiar Western ones. It is natural for a Kantian to favour a retributive response to vice and wrongdoing. If what is special about us is our capacity for rational decision-­ making, it appears that respect for that capacity means imposing a negative reaction that is proportionate to the degree to which it was misused. Sometimes the idea is that a person deserves a restriction on her liberty comparable to the sort that she unreasonably imposed on others or even herself. Other times it is that the political community ought to express disapproval of those who have acted wrongly, where the greater the wrongdoing, the stronger the disapproval must be, often justifying a punitive response. And then it is common for utilitarians to prescribe using punishment and related forms of hard treatment as a deterrent. If the aim is to maximize pleasure and minimize pain, sometimes imposing pain on some would serve the function of making them and others fearful of doing wrong in the future. Neither retribution nor deterrence is prominent in sub-Saharan philosophical thought about how to respond to immorality. It would be uncharacteristic of African philosophers to think that an addict needs to be made to suffer in the manner of an eye for an eye or to instil fear in others so that they avoid becoming addicts. Instead, the dominant theme in the African tradition when it comes to responding to vice or wrongness is reconciliation (e.g., Magesa 1997, pp.  272–276; Tutu 1999; Huyse and Salter 2008), roughly understood as the restoration of communal relationship along with the disavowal of how it has been flouted. Normally, reconciliation centrally involves an offender listening to how he has harmed others and then taking responsibility for what he has done, including by undergoing a burden such as labour that would serve to compensate his victims and express remorse for having treated them poorly. This idea, which suggests that addicts should undertake work that would make up for harm done to their victims or would help others overcome their addiction, warrants a full treatment in future research.10 10  For having commented on a prior draft of this essay, I am grateful to Kevin Behrens, Ademola Fayemi, Grivas Kayange, Neil Levy, Yamikani Ndasauka, and Benjamin Smart.

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References Ainslie, G. 2013. Money as MacGuffin: A Factor in Gambling and Other Process Addictions. In Addiction and Self-Control: Perspectives from Philosophy, Psychology, and Neuroscience, ed. N. Levy. Oxford: Oxford University Press. Appiah, A. 1998. Ethical Systems, African. In Routledge Encyclopedia of Philosophy, ed. E. Craig. London: Routledge. Behrens, K. 2018. A Critique of the Principle of “Respect for Autonomy,” Grounded in African Thought. Developing World Bioethics 18 (2): 126–134. Bhengu, M.J. 1996. Ubuntu: The Essence of Democracy. Cape Town: Novalis Press. Bikopo, D., and L.-J. van Bogaert. 2010. Reflection on Euthanasia: Western and African Ntomba Perspectives on the Death of a Chief. Developing World Bioethics 10 (1): 42–48. Bujo, B. 2005. Differentiations in African Ethics. In The Blackwell Companion to Religious Ethics, ed. W. Schweiker. Malden: Blackwell. Dzobo, N. 1992. Values in a Changing Society: Man, Ancestors, and God. In Person and Community; Ghanaian Philosophical Studies, Volume I, ed. K. Wiredu and K. Gyekye. Washington, DC: Council for Research in Values and Philosophy. Ewuoso, C. 2019. Models for Truth-Telling in Physician-Patient Encounters: What Can We Learn from Yoruba Concept of Ooto? Developing World Bioethics 19 (1): 3–8. Frank, L., and S.  Nagel. 2017. Addiction and Moralization: The Role of the Underlying Model of Addiction. Neuroethics 10 (1): 129–139. Gaie, J. 2007. The Setswana Concept of Botho. In The Concept of Botho and HIV & AIDS in Botswana, ed. J. Gaie and S. Mmolai. Eldoret: Zapf Chancery. Gaie, J., and S.  Mmolai, eds. 2007. The Concept of Botho and HIV & AIDS in Botswana. Eldoret: Zapf Chancery. Gbadegesin, S. 1991. African Philosophy. New York: Peter Lang. Gyekye, K. 1997. Tradition and Modernity: Philosophical Reflections on the African Experience. New York: Oxford University Press. ———. 2004. Beyond Cultures; Ghanaian Philosophical Studies, Volume III. Washington, DC: Council for Research in Values and Philosophy. Hurka, T. 2001. Virtue, Vice, and Value. New York: Oxford University Press. Hursthouse, R. 1999. On Virtue Ethics. Oxford: Oxford University Press. Husak, D. 2004. The Moral Relevance of Addiction. Substance Use and Misuse 39 (3): 399–436. Huyse, L., and M. Salter, eds. 2008. Traditional Justice and Reconciliation After Violent Conflict: Learning from African Experiences. Stockholm: International IDEA. Iroegbu, P. 2005. Beginning, Purpose and End of Life. In Kpim of Morality Ethics, ed. P. Iroegbu and A. Echekwube. Ibadan: Heinemann Educational Books.

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Kasenene, P. 1994. Ethics in African Theology. In Doing Ethics in Context: South African Perspectives, ed. C.  Villa-Vicencio and J.  de Gruchy. Cape Town: David Philip. ———. 2000. African Ethical Theory and the Four Principles. In Cross-Cultural Perspectives in Medical Ethics, ed. R.M. Veatch. Sudbury: Jones and Bartlett. Khantzian, E. 1997. The Self-Medication Hypothesis of Substance Use Disorders. Harvard Review of Psychiatry 4 (5): 231–244. Khoza, R. 1994. Ubuntu, Botho, Vumunhu, Vhuthu, African Humanism. Sandton: EKHAYA Promotions. Kripke, S. 1980. Naming and Necessity, 2nd edn. Oxford: Basil Blackwell Ltd. Letseka, M. 2000. African Philosophy and Educational Discourse. In African Voices in Education, ed. P. Higgs et al. Cape Town: Juta. Levy, N. 2011. Addiction, Responsibility, and Ego Depletion. In Addiction and Responsibility, ed. J. Poland and G. Graham. Cambridge, MA: The MIT Press. ———., ed. 2013. Addiction and Self-Control: Perspectives from Philosophy, Psychology, and Neuroscience. Oxford: Oxford University Press. Magesa, L. 1997. African Religion: The Moral Traditions of Abundant Life. Maryknoll: Orbis Books. Marie M. 2017. Self-Centeredness–A Characteristic of Addiction and Other Disorders. Elite Rehab Placement. https://www.eliterehabplacement.com/ blog/self-centeredness-characteristic-addiction-disorders/ Metz, T. 2010. African and Western Moral Theories in a Bioethical Context. Developing World Bioethics 10 (1): 49–58. ———. 2012. African Conceptions of Human Dignity: Vitality and Community as the Ground of Human Rights. Human Rights Review 13 (1): 19–37. ———. 2013a. The Virtues of African Ethics. In The Handbook of Virtue Ethics, ed. S. Van Hooft. Durham: Acumen Publishers. ———. 2013b. The Western Ethic of Care or an Afro-Communitarian Ethic? Journal of Global Ethics 9 (1): 77–92. ———. 2015a. How the West Was One: The Western as Individualist, the African as Communitarian. Educational Philosophy and Theory 47 (11): 1175–1184. ———. 2015b. African Ethics (Rev. edn). In The International Encyclopedia of Ethics, ed. H. LaFollette. Malden: Blackwell Publishing Ltd. ———. 2017. Ancillary Care Obligations in Light of an African Bioethic: From Entrustment to Communion. Theoretical Medicine and Bioethics 38 (2): 111–126. ———. 2018. A Bioethic of Communion: Beyond Care and the Four Principles with Regard to Reproduction. In The Ethics of Reproductive Genetics – Between Utility, Principles, and Virtues, ed. M. Soniewicka. Dordrecht: Springer. Mokgoro, Y. 1998. Ubuntu and the Law in South Africa. Potchefstroom Electronic Law Journal 1 (1): 15–26.

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Morse, S. 2000. Hooked on Hype: Addiction and Responsibility. Law and Philosophy 19 (1): 3–49. ———. 2011. Addiction and Criminal Responsibility. In Addiction and Responsibility, ed. J. Poland and G. Graham. Cambridge, MA: The MIT Press. Murove, F.M. 2009. African Bioethics. In African Ethics––An Anthology of Comparative and Applied Ethics, ed. F.M. Murove. Pietermaritzburg: University of KwaZulu-Natal Press. Nkondo, G.M. 2007. Ubuntu as a Public Policy in South Africa. International Journal of African Renaissance Studies 2 (1): 88–100. Nkulu-N’Sengha, M. 2009. Bumuntu. In Encyclopedia of African Religion, ed. M.K. Asante and A. Mazama. Los Angeles: Sage. Onah, G. 2012. The Meaning of Peace in African Traditional Religion and Culture. http://beeshadireed.blogspot.com/2012/08/the-meaning-ofpeace-in-african.html Pickard, H. 2016. Denial in Addiction. Mind and Language 31 (3): 277–299. ———. 2017. Responsibility Without Blame for Addiction. Neuroethics 10 (1): 169–180. Pickard, H., and S. Ahmed, eds. 2018. The Routledge Handbook of Philosophy and Science of Addiction. London: Routledge. Pickard, H., and S.  Pearce. 2013. Addiction in Context: Philosophical Lessons from a Personality Disorder Clinic. In Addiction and Self-Control: Perspectives from Philosophy, Psychology, and Neuroscience, ed. N.  Levy. Oxford: Oxford University Press. Pickard, H., and W. Sinnott-Armstrong. 2013. What Is Addiction? In The Oxford Handbook of Philosophy and Psychiatry, ed. K.W.M.  Fulford et  al. Oxford: Oxford University Press. Poland, J., and G. Graham, eds. 2011a. Addiction and Responsibility. Cambridge, MA: The MIT Press. ———. 2011b. Introduction: The Makings of a Responsible Addict. In Addiction and Responsibility, ed. J.  Poland and G.  Graham. Cambridge, MA: The MIT Press. Putnam, H. 1975. The Meaning of “Meaning”. In Mind, Language and Reality, ed. H. Putnam. Cambridge: Cambridge University Press. Rakotswoane, F., and A. van Niekerk. 2017. Human Life Invaluableness: An Emerging African Bioethical Principle. South African Journal of Philosophy 36 (2): 252–262. Shelby, C. 2016. Addiction: A Philosophical Perspective. New  York: Palgrave Macmillan. Shutte, A. 2001. Ubuntu: An Ethic for the New South Africa. Cape Town: Cluster Publications.

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Tangwa, G. 2010. Elements of African Bioethics in a Western Frame. Bamenda: Langaa RPCIG. Tempels, P. 1959. Bantu Philosophy, 2nd edn. Trans. C.  King. Paris: Présence Africaine. Tutu, D. 1999. No Future Without Forgiveness. New York: Random House. Uusitalo, W., M. Salmela, and J. Nikkinen. 2017. Addiction, Agency and Affects–– Philosophical Perspectives. Nordic Studies on Alcohol and Drugs 30 (1): 33–50.

CHAPTER 3

Cannabis Use and Addiction in African Communities; a Value or a Vice? Grivas Muchineripi Kayange

3.1   Introduction Different studies on cannabis and addiction in Africa show that this plant is commonly cultivated and locally used by the inhabitants (Bisika et al. 2008; Warf 2014; Duvall 2017; Bourhill n.d). The United Nations Office on Drugs and Crime (UNODC) (2006, 2016)1 reported that the production of cannabis in Africa is around 25% of the total cultivated world-wide. In fact, in the period between 1999 and 2005, 19 out of 53 nations in Africa confirmed high cultivation of cannabis in their respective countries. Interesting for this chapter is that cannabis is consumed by 7.7% of the adult population in various African countries, amounting to approximately 38,200,000 African adults. Apart from this consumption, there are many individuals that use cannabis for other purposes, such as medicine and religious use. All these and other forms raise the number of African adults using cannabis 1  The UNODC’s World Drug Report contains an extended section on the global cannabis situation.

G. M. Kayange (*) Chancellor College, University of Malawi, Zomba, Malawi e-mail: [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_3

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beyond 7.7%. Bearing in mind that in most African nations adulthood starts at 18 years of age, the use of cannabis among teenagers is also becoming common and a serious problem. This range group is not accounted for in the indicated percentage above. This suggests that cannabis is widely used in Africa for both individual consumption and in some cases for business. It is also widely used in other parts of the world such that in 2014, 183 million people used the drug (UNODC 2016). Although there is cultivation and consumption/addiction pertaining to cannabis, one of the crucial problems in the African context has been whether to consider it as a value, hence legalizing its use, or as a vice and hence illegal. This has led to a division among Africans, mainly between the governments and their related laws on one side and members of the different African cultures/communities on the other. Most of the African governments, influenced by international conventions on drugs, view cannabis cultivation and use as illegal except when it is for medicinal purposes. This has led to a great tension, given that some tribes have embraced cannabis as part of their culture. One such case is the Bishelenge tribe, which elevated cannabis to a cultural god (Bishelenge). This elevation leads to an understanding that addiction to this substance is something that must be encouraged, as a way of showing one’s love and commitment to a god.2 In other contexts individuals still believe cannabis has different useful functions apart from medicine, and hence still encourage its consumption as a value. Nevertheless, in recent years (2016–2018), the problem of cannabis has seemed to go in favour of those that want to legalize it. In fact, countries such as South Africa have recently (2018) celebrated the freedom to use cannabis for different purposes. Countries such as Zimbabwe and Malawi are debating on legalizing cannabis in the near future. In this chapter, firstly I intend to explore the use of and addiction to cannabis in different African cultures, building on information from studies in history. Secondly, I explore why and how different cultures have argued for and viewed cannabis as a value. Thirdly, I will investigate and show how governments and some religious groupings have viewed cannabis as a vice and illegal in the society. The development will show how African cultures have been tolerant towards cannabis use and addiction, while the governments and some foreign religions (such as Christianity) have generally been intolerant. This intolerance has generally been justi2

 This will be discussed further below.

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fied by the conception that cannabis is the cause of crime (social problem), and that it has a negative impact on individuals’ minds (altering their behaviour) and the development of nations. Nevertheless, the current trend shows that there is change, as a number of governments are contemplating legalizing cannabis.

3.2   Cannabis Use and Addiction in Africa It is widely agreed by scholars that cannabis use and addiction in Africa may be traced in its history on the continent, starting from Egypt and Ethiopia, and then later in other parts of the continent (Philips 1983; Von Wissman 1891; Khalifa 1975). I will trace the use and elements of addiction in selected nations, such as Egypt, Ethiopia and South Africa, where there is a significant number of studies relative to the history of cannabis in Africa. Firstly, in Egypt we can trace aspects of use of and addiction to cannabis as influenced by the developments in India and Persia. Archaeologists show that cannabis may be traced to around 3000 BCE (Clarke and Merlin 2013). However, its use for intoxication leading to an addiction was first reported in the eleventh century (Nahas 1984). It is in this period that a notable use of cannabis, mainly considered as hashish, started increasing in Egypt. Evidence shows that in the thirteenth century cannabis was already in use by the Sufis. This introduction of cannabis is attributed to Muslim mystics from Syria who promoted it, mainly from the twelfth century. The maximum cannabis addiction was reportedly experienced when Napoleon conquered Egypt around 1798–1800. The element of addiction in this period is well captured in Nahas (1984), who quotes an officer reporting to Napoleon that “The mass of the male population is in a perpetual state of stupor.” Apparently, cannabis was mainly used by the male population in this area. Napoleon reacted by issuing a decree against the use of cannabis in the whole of Egypt. The reason for this decree was that it became an addiction and affected the behaviour of men who were using this plant. The prohibition of cannabis by Napoleon did not last long, given that he retreated from Egypt after a brief presence. When he retreated, the local government immediately rescinded the ban of cannabis (Nash 1984).

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Cannabis use and addiction continued among different classes of people in the nineteenth century,3 where the lower class, literary class, ­theologians, etc. were either addicted to this substance or used for other purposes. For example, the religious were using it for meditation. Apart from Egypt, cannabis use and addiction may be traced to Ethiopia in the fourteenth century. Some academics indicate that it was used between the thirteenth and fourteenth centuries. In this area, it is believed that cannabis was introduced by Arab traders. Commenting on cannabis in Ethiopia, Van Der Merwe (1975a, b) confirmed that Archaeologically, we conclude that some variety of Cannabis sativa was smoked around Lake Tana in the 13th-14th century, in much the same way as it is today. This is evident for pipe 132 (two positive tests), somewhat less so for A2 (one positive test). How and when the plant, and knowledge of its psychoactive properties, reached this area is unknown; an Arabic source seems probable.

In spite of this, cannabis is currently commonly used in Ethiopia, such that in different studies its addiction is listed third after alcohol and Khat (e.g., see Fekadu et al. 2007).4 This cannabis addiction is present among different groups of individuals, including school students in various cities such as Addis Ababa (see Kassaye et  al. 1999). The current studies on prevalence of cannabis addiction in Ethiopia show that there is a high percentage of individuals who are affected by this problem. For example, in a study on ‘Prevalence of Cannabis Use Disorder and Associated Factors among Cannabis Young Adult Users at Shashemene Town, Oromia Region, Ethiopia’ (2016), it was reported that this addiction was at 42.2% among 435 participants in this town. This is a very high percentage and it shows that cannabis addiction is a problem in this area. In West Africa, cannabis use and addiction are commonly noted in relation to countries such as Nigeria, Senegal and Ghana, where this plant is widely grown. It is believed that its presence in these areas increased notably during the Second World War (1939–1945). In the early 1990s the presence of cannabis reached its maximum level in West African countries. This led to a continuous attempt by different nations to eradicate its use

3  For example, during the Second World War (1939–1945), the consumption of cannabis increased in Egypt (see also Khalifa 1975). 4  See also Fekadu et al. (2007).

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and the related addiction. For instance, apart from using cannabis, Nigeria5 is reportedly one of the nations that is widely known for trafficking this plant to the neighbouring West African countries. Similarly, Senegal has produced significant amounts of cannabis, for example in Dakar, and exported it to neighbouring countries for consumption. Gambia and Liberia are also well known for the use of cannabis, which is further thought to be traded in exchange for war machines and related facilities. In East Africa cannabis use and addiction are reportedly high in Kenya, Tanzania and Uganda. Warf (2014) indicated that “Cannabis entered Eastern Africa via Egypt and Ethiopia, most likely carried by Arab merchants. It was certainly used in Ethiopia by the 13th century (Van Der Merwe 1975a, b), where it likely entered via trade routes across the Red Sea.” In Kenya, the high and increased growth in the cultivation of cannabis is indicative of the use of this plant and the possible addiction in the area. Commenting on the increase in cultivation in Kenya, a report on cannabis in Africa by the UNODC 2006, 5) indicates that In East Africa, fairly large-scale cannabis cultivation occurs in Kenya, primarily in the Lake Victoria basin, in the central highlands around Mt. Kenya and along the coast. As much as 1,500 ha of cannabis are estimated to be cultivated in this area, some in the lower farmlands concealed among traditional crops and some in higher altitude areas regarded as national wildlife reserve. Despite two successful, highly publicized targeted raids of 14 farms along Mt. Kenya that collectively destroyed 461 tons of cannabis in 2001 and 2002, police observed an increase in this crop during 2004.

The neighbouring Tanzania has also been instrumental in the production and use of cannabis in the East African region. Large amounts of cannabis are smuggled from Malawi, hence increasing the level of its use and presence in Tanzania. In the southern part of Africa, various countries such as Malawi, Zambia, South Africa and Zimbabwe are well known in terms of the use of cannabis and addiction. In South Africa, Ames indicated that cannabis “was in use for many years before Europeans settled in the country and was smoked by all the non-European races, i.e. Bushmen, Hottentots and Africans” (Ames 1958, 218).

5

 See also Asuni (1978).

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In most of the countries in the southern part of Africa, cannabis was brought by the Arabs, who mainly interacted with the people of these areas through trade (e.g., they traded in ivory and slaves)  (see also Du Toit, 1975, 1980). It is believed that this plant has been used in the southern part of Africa for over five centuries. Warf (2014, 424) indicated this presence in the following words: “known as dagga, psychoactive cannabis has been consumed in southern Africa for at least five centuries. The Dutch wrote of it in 1658, which they described as ‘a dry powder which the Hottentots eat and which makes them drunk’ (Du Toit 1975, 88). It formed an important trade item in exchanges between Dutch and the Khoisan and Bantu speakers in the region, and became commonly used among the Tswana, Zulu, Sotho and Swazis, including contemporary attempts to diversify crops in Malawi (Bloomer 2009).” A version of how this plant was introduced in South Africa indicates that “around 1500 A.D., the fully developed trade routes between Arabia, Turkey, India and Persia with the East African coast, permitted the Arab traders to introduce cannabis to the more southern parts of Africa.”6 The presence, use of and addiction to cannabis in the mentioned areas are further confirmed by the fact that about 70% of the cannabis that is transported to South Africa is grown in Lesotho. Countries such as Malawi and Swaziland are also well known for producing high-quality cannabis. This is consumed in these countries and part of it is exported to the neighbouring countries. It may be concluded that in different African countries, cannabis was used occasionally and, in some cases, it was addictive to those consuming it. For example, it is noted that “Eventually, by 1705, the Hottentots learned the art of smoking. The habit of smoking cannabis, which many tribes called ‘dagga,’ spread from tribe to tribe quite quickly. The primary method in which southern and central African tribes learned of smoking dagga was through their trading relations with the nomadic ‘San’ tribe hunters. ‘The hunters were addicted to smoking and so in exchange for tobacco and dagga they supplied feathers, game, and other products collected in the hunt.’ This is an example showing how addictive it was to the San tribe.” A more general study on the history of the presence of addiction to cannabis (population age between 15 and 64 years) by the United Nations in 2007 gives a picture that covers most of the African nations. For example, 6  https://sencanada.ca/content/sen/committee/371/ille/library/spicer-e.htm#1. India.

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the study shows high prevalence of abuse in Ghana as reported by local studies in 1998, followed by Zambia where a study of 2003 indicated 17.7% prevalence. Senegal in 1996 recorded 16.1% prevalence while Nigeria recorded 13.8% in 2000 and Morocco 11.8% in 2002, Madagascar 9.1% in 2004 and South Africa 8.4% in 2002. The other African nations such as Angola, Chad, Comoros, Egypt and Mali ranged between 0.05% and 8%.

3.3   Cannabis as a Value in African Communities Based on the information above regarding cannabis presence, use and addiction, the important question that needs to be addressed is ‘Is cannabis a value or a vice in African communities?’ If the answer to this question is yes it is a value, then another relevant question is ‘What type of value?’ If the answer is that it is a vice, then the next question is ‘What makes it a vice?’ The discussion above has shown that, although cannabis is believed to have been imported to Africa from the Middle East, it was generally accepted and valued in most communities. The value of cannabis has ranged from the spiritual context to the physical context. This takes us immediately to the second question, ‘What type of value?’ I primarily respond to the above question by providing Table 3.1 that shows the function/use of cannabis in some African tribes/nations. My main interest will be the African traditional context. Firstly, the Table 3.1 suggests that one of the reasons why cannabis was easily accepted in different African cultures was its use for medicinal purposes.7 It was believed by most of the African tribes that it cures different forms of diseases that threaten the lives of individuals in the community. This creates a lot of sympathy towards the use of cannabis, and in most cases leads to addiction among the African inhabitants. For instance, in Malawi in the traditional setting, some individuals think that cannabis helps those that have lost their appetite to regain it. The general belief is that when cannabis is taken an individual immediately 7  “In North Africa, ‘music, literature and even certain aspects of architecture have evolved with cannabis-directed appreciation in mind. Some homes actually have kif rooms, where family groups gather to sing, dance, and relate histories based on ancient cultural traditions.’” https://sencanada.ca/content/sen/committee/371/ille/library/spicer-e.htm#1. India.

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Table 3.1  Cannabis value in African culture Traditional cannabis function

Addiction case or not

Arab traders—North Africa Kafirs of Cape of Good Hope

Psychoactive use Entertainment of visitors

Hottentots

Psychoactive use, snake bite medicine Psychoactive use (hunting) Use in art Entertainment, religion and rituals Jurisprudence use

Addictive Not addictive (occasional) Addictive

San tribe hunters North Africa Baluba tribe Bashilenge Zulu Sotho Malawian tribes as Chewa, Lomwe and Ngoni

Military use Military use, facilitate child birth Medicinal, military and recreation use

Addictive Addictive Addictive Not addictive (occasional) Partly addictive Partly addictive Partly addictive

starts feeling hungry and hence regains his/her appetite. In most cases it is believed that this appetite is very hard to control, such that an individual may eat a lot of food after smoking. It is therefore used by some individuals who have lost their appetite due to depression in their lives. Apart from treating loss of appetite, it was believed that cannabis cured different diseases, as expressed by this passage: “In a number of countries, it was used to treat tetanus, hydrophobia, delirium tremens, infantile convulsions, neuralgia and other nervous disorders, cholera, menorrhagia, rheumatism, hay fever, asthma, skin diseases, and protracted labour during childbirth.”8 Similarly, in Malawi it was used as medicine for different diseases such as measles (Bisika et al. 2008, 81). This importance of cannabis made villagers value it and use it on various occasions, such that in some circumstances it led to addiction among its users. A case that is common in African traditional communities is the popularity of cannabis for expectant women immediately before giving birth. Generally, women go through birth pains, and to avoid the experience of too much pain cannabis was used. This enabled women to go through labour pains without too much difficulty. In some cultures, it was also used to treat psychological pain/pressure that children were going through when 8

 https://sencanada.ca/content/sen/committee/371/ille/library/spicer-e.htm#1

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they were being weaned from their mother’s milk. Commenting on similar practices among the Suto women in South Africa it is noted that “The plant has been used for many purposes in South Africa. Suto women smoke it to stupefy themselves during childbirth; they also grind up the seeds with bread or meahe pap and give it to children when they are being weaned.”9 Secondly, apart from the medicinal effects that were traditionally attributed to cannabis, in some African tribes it was used for religious purposes. In some extreme cases it was conceived and declared as a god. The desire to be in line with the creator of everything encouraged addiction to cannabis among most of the inhabitants.10 As noted earlier, regular use of cannabis in this context is a sign of communion with one’s deity. For example, “The Riamba Cult: One tribe, the Bashilenge, formed their entire religion around the use of cannabis. The Bashilenge call themselves Bena-Riamba, which is translated ‘the sons of hemp.’ This ancient culture regarded marijuana as a god and the pipe used to smoke it was viewed as a symbol of peace. They believed that cannabis had universal magical ­powers and was used extensively to ward off evil spirits (Von Wissman 1891, 312).”11 In order to show one’s commitment to the deity, members of different tribes were encouraged to smoke often to show their closeness to their god (for use of cannabis for rituals see also, Emboden jr 1972; Zetterstrom 1966). The religious value of cannabis in the African context is a reflection of the use of this plant in some Arab countries where it comes from. One of the common practices was that it was used in the context of mysticism by some Arabs. Cannabis prepared the mystics to enter into a deep relationship with their god. It is reported that this plant was used in Ethiopia in some seminaries 9  A brief history of marijuana use in Africa, http://www.topix.com/forum/city/littlefalls-ny/T98BJPF4UVKSG1NAO/a-brief-history-of-marijuana-use-in-ancient-africa 10  “Several tribes such as the Zulu and the Sothos were known to smoke cannabis prior to going to war. ‘Young Zulu warriors were especially addicted to dagga and under the exciting stimulation of the drug were capable of accomplishing hazardous feats.’ There are those historians who also believe that the Zulus were intoxicated with dagga when they attacked the Dutch at the Battle of Blood River in 1838. Similarly, the Sothos tribe used dagga to strengthen their spirits prior to an onslaught.” https://sencanada.ca/content/sen/committee/371/ille/library/spicer-e.htm#1.India. 11  H.  Von Wissman, My Second Journey through Equatorial Africa (London: Chatto & Windus, 1891), p. 312: “In Africa, there were a number of cults and sects of hemp worship. Pogge and Wissman, during their explorations of 1881, visited the Bashilenge, living on the northern borders of the Lundu, between Sankrua and Balua. They found large plots of land around the villages used for the cultivation of hemp. Originally there were small clubs of hemp smokers, bound by ties of friendship, but these eventually led to the formation of a religious cult.”

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where the religious monks intensified their relationship with God through smoking this plant. In some African countries, such as Malawi, cannabis is associated with Rastafarianism, a religion that traces its roots to Ethiopia. Thirdly, in some parts of Africa, such as Malawi, Zimbabwe and Zambia, cannabis was associated with the concept of Black Consciousness, as promoted by reggae artists such as Bob Marley and Peter Tosh. In order to be part of the Black Revolution of liberation from foreign rule, different individuals wanted to be associated with reggae artists, who were commonly believed to be experts in smoking cannabis and were viewed as indisputable supporters of transformation. Many young individuals were therefore attracted to smoking regularly, as this gave them an important cause in their fight against colonialism. Fourthly, in a number of tribes in the African context, different individuals believed that cannabis had an important value in making people work hard and achieve the desired goals in respective areas. For instance, some members of the community smoked cannabis in order to perform various heavy duties. For example, it was used in the context of farming, where some members were smoking to work hard for many hours without feeling fatigue (used for efficiency at work). This applies also to other jobs that require a lot of energy. This tendency to use cannabis regularly was also encouraged by some students who believed that smoking helped them to remember most of the things which they learned (Bisika et  al. 2008, 81). Some used it because they believed that it was important in the context of problem solving. For example, in the context of mathematics, it was thought that those who smoke have a high chance of performing well in this subject. The centrality of cannabis in leading towards success is also introduced in the context of sex. In this context, some individuals used this plant in order to avoid getting tired when they are having sex. It is believed that a man who has this experience will go on and on without easily getting tired. The fifth aspect is that cannabis has an economic value. Due to its demand for various reasons, as per its instrumental value, there is a high economic value that is attributed to this plant. This justifies the existence of a large trade of cannabis in Africa. Countries such as South Africa are reportedly big suppliers of cannabis outside of Africa. Similarly, Malawi has been instrumental in cannabis trafficking in different countries in Africa and beyond. It is this economic value that is taken as one of the reasons that has led some African countries to legalize cannabis, as noted earlier.

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3.4   Cannabis as a Vice and Illegal in African Communities Although in a greater part of African communities cannabis has been viewed as having an instrumental value, it is similarly considered by some as a vice, which needs to be eradicated. Firstly, it is a consequence of international politics where cannabis has been regarded as an unwanted plant for a long period of time (e.g., since the early 1900s). It is associated with various crimes, and thus banned from circulation in several countries, such as Malawi, Kenya and Zambia. It is therefore conceived as illegal in many countries, such that using cannabis constitutes a crime. This is flexible in some countries where one is allowed to circulate with small amounts of cannabis, for example, not beyond three grams. In some countries such as South Africa, cannabis has recently (2018) been legalized. While cannabis was regarded as having an instrumental and economic value in most of the African communities, the political leaders in different settings have seen it as illegal and as a threat to the well-being and lives of the citizens. As early as the third century, the use of this plant was considered illegal in Egypt. In fact, it is noted by researchers that, “since cannabis was outlawed in Egypt in the 3rd century A.D. and was punishable by religious law and judicial authorities, several Muslim communities who wanted to continue to grow cannabis migrated south and introduced cannabis to Ethiopia” (Du Toit 1975, 83). This indicates that the authorities tried to suppress the use of this plant, which was common in Egypt, but all the same, some people still thought that it was important, and hence continued their business in other parts of Africa. The international efforts to regard cannabis’ psychoactive use as a vice and illegal may be traced to as early as 1912 in a meeting of nations that was held at The Hague. Although cannabis was not an important issue in this meeting, with the influence of Italy and the USA it was tabled as an issue to be researched (Lowes 1966).12 Cannabis was continually associated with individuals who were regarded as immoral in different parts of the world. For instance, it was commonly used by criminals, sex workers and gamblers. This led to wide propaganda to declare cannabis’ use as problematic, under the assumption that it was the main cause of various evils in the world.

 See also Peter D. Lowes (1966).

12

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Between 1914 and 1930, different laws were made in the USA which viewed psychoactive use of cannabis and the related business as illegal.13 What is important for this chapter is that African countries such as Egypt and South Africa supported the USA in condemning the use of cannabis as dangerous in their countries. This reaction was mainly political given that cannabis was generally smoked by the natives in South Africa and by individuals belonging to the low class in Egypt. It was thought that these classes of individuals were violent because of using cannabis, and hence a threat to the political stability of these nations. It was in 1961 through the Single Convention that a notable agreement was reached by various nations to view cannabis’ psychoactive use and cultivation as illegal. An exception was made only where it was used for medicinal purpose. This meant that cannabis cultivation for entertainment, other uses outside of medicine, and possession of certain amounts of cannabis came to be regarded as a crime. Similarly, the 1971 Vienna Convention on Psychotropic Substances condemned the cultivation and possession of marijuana in several countries. Although there is a general consensus in viewing cannabis’ psychoactive use and cultivation/trafficking as a vice and illegal in different nations, various thinkers and governments have now questioned this. They have therefore requested a revision of the international laws that go against the use of cannabis apart from medical use (Dell’Alba et al. 1994). There are arguments about the lack of solid evidence connecting certain behaviours with the use of cannabis. For instance, it was shown that in some African traditional cultures cannabis became part of the culture, and this does not necessarily translate into a conception of these cultures as violent. In fact, some of these cultures, in spite of using cannabis, have been friendly to strangers who visit their areas. Cannabis has also united some individuals who have used it for entertainment in their social gatherings. Further arguments revolve around the issue of freedom. Different African cultures have taken cannabis as part of their way of life, for example in the case where cannabis is considered a god (Bashilenge). This has resulted in the understanding that the declaration of psychoactive use, cultivation etcetera is a violation of these people’s freedom of worship. Similarly, freedom of social interaction in cases where cannabis was used as a means for entertainment is jeopardized through making it illegal. 13  See National Commission on Marijuana and Drug Abuse, Marijuana: A Signal of Misunderstanding (1972) (See also Brecher 1972).

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In spite of the different arguments that are put forward against the consideration of cannabis as illegal, some individuals have developed secret mechanisms that help them to continue cultivating and using this plant. This is explained by the continuous interventions by nations whereby large amounts of cannabis are recovered from individuals and destroyed. See, for instance, the following figures that show the continued cultivation of cannabis and the confiscated cannabis in various African countries. For example, the UNODC report of 2005 shows that 25% of cannabis is grown in Africa, followed by North America at 23% and South America at 22%. The Middle East/South-West Asia produces 7%, while Europe, South Asia, East Asia and Central Asia produce about 5% each of global cannabis production. Oceania produces 2% and Caribbean and Central America 2%. This production of cannabis shows that in spite of the efforts to make the plant illegal, secret mechanisms are still put in place by individuals who continue to cultivate this plant. The understanding that cannabis consumption for psychoactive use and cultivation is illegal is reflected in the continuous seizures that are carried out by the anti-drug police or authorities in different African nations. In Table 3.2 these seizures are indicated in the African context. Secondly, different religious congregations have provided religious reasons, whereby any form of smoking is regarded as against God. This is common among most of the Protestant Christian churches, which strongly prohibit the use of cannabis and considers it demonic. The common argument is that a human being is a temple where God resides, and smoking cannabis is viewed as a way of defiling the temple of God. Based on this thinking, different Christian and other religious organizations have condemned the use of cannabis as satanic. Other mainstream religions such as Catholicism and Islam have had the tendency to demonize

Table 3.2 Cannabis seizures in Africa

Year

Cannabis kilograms seizures in Africa

2000 2001 2002 2003 2004 2005

1,493,188 1,290,476 931,190 1,550,706 1,992,677 697,368

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cannabis smoking and make it unwelcome in their religions. This is often connected to the understanding that cannabis is associated with bad behaviours and unreligious individuals.

3.5   Conclusion Based on the conception of cannabis as either a value or a vice, its conceptualization in African communities is two-fold. In the first scenario, a person who is addicted to cannabis is conceptualized as morally good in the society. This is an individual who is needed when there are difficult problems which require a solution. A person who smokes is mainly associated with lack of fear. This makes individuals call for the cannabis addict to deal with danger whenever it comes in the community. He is therefore a very good candidate for doing difficult jobs that require courage in the community. In some circumstances an individual who uses cannabis is a pious religious man. Further, cannabis is valuable for medicinal and related purposes. The second scenario that has dominated most of the African nations is that it is a vice and illegal, and hence the demand for its elimination. It may be concluded that individuals in African nations are still divided as to whether cannabis should be illegal or must be made legal. In the past, there was a growing consensus that it is illegal, evidenced by the anti-­ cannabis campaign of governments that have taken strict measures against individuals cultivating or found in possession of proactive use of this plant. This has generally created fear among the farmers and users of cannabis. In spite of this, a good percentage of African individuals still think cannabis is important. The battle over whether cannabis is a value or illegal remains unsolved in spite of the progress that is present in the legal framework in different African countries. The arguments for and against cannabis still remain among different individuals in the African countries.

References Ames, F. 1958. A Clinical and Metabolic Study of Acute Intoxication with Cannabis Sativa and Its Role in the Model Psychosis. Journal of Mental Science 104: 215–230. Asuni, T. 1978. The Drug Abuse Scene in Nigeria. NIDA Research Monograph 19: 15–25.

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Bisika, T., S.  Konyani, and I.  George Khanyizira Chamangwana. 2008. An Epidemiologic Study of Drug Abuse and HIV. African Journal of Drug & Alcohol Studies 7 (2): 81–87. Bourhill, C.J.G. n.d. The Smoking of Dagga (Indian Hemp) Among the Native Races of S. Africa and the Resultant Evils. Unpublished. Brecher, E. 1972. Licit and Illicit Drugs. Boston: Little, Brown and Company. Clarke, R., and M. Merlin. 2013. Cannabis: Evolution and Ethnobotany. California: University of California Press. Dell’Alba, G., Dupiu, and Jean-Luc R. 1994. For a revision on the international policy on drugs. In Questioning Prohibition: International Report on Drugs. 209–42. Du Toit, Brian. 1975. Dagga: Cannabis Sativa in Southern Africa. In Cannabis and Culture, ed. Vera Rubin. Chicago: Mouton Publishers. 0884092767. ———. 1980. Cannabis in Africa: A Survey of Its Distribution in Africa, and a Study of Cannabis Use and Users in Multi-ethnic South Africa. Rotterdam: A. A. Balkema. Duvall, C.S. 2017. Cannabis and Tobacco in Precolonial and Colonial Africa. Oxford Research Encyclopedia of African History. Online Publication Date: Mar 2017. https://doi.org/10.1093/acrefore/9780190277734.013.44. Emboden, William A., Jr. 1972. Ritual Use of Cannabis Sativa L. In Flesh of the Gods, ed. Peter T. Furst. New York: Praeger Publishers. Fekadu, A., A. Alem, and C. Hanlon. 2007. Alcohol and Drug Abuse in Ethiopia: Past, Present and Future. African Journal of Drug and Alcohol Studies. 6 (1): 41–53. Kassaye, M., Hessen, T. S., Fassehaye, G., and Teklu, T. 1999. Drug use among high school students in Addis Ababa and Butajira. Ethiopian Journal of Health and Development. Volume. 13 (2). Khalifa, A.M. 1975. Traditional Patterns of Hashish Use in Egypt. In Cannabis and Culture, ed. V. Rubin. The Hague: Mouton. Lowes, Peter D. 1966. The Genesis of International Narcotics Control. Geneva: Librairie Droz. Nahas, G.G. 1984. The Escape of the Genie: A History of Hashish Throughout the Ages. New York: Raven. National Commission on Marijuana and Drug Abuse. 1972. Marijuana: A Signal of Misunderstanding, Appendix Vol. I. Washington, DC: U.S Government Printing Office. Philips, John. 1983. African Smoking and Pipes. The Journal of African History 24 (3): 303–319. UNODC. 1994. Questioning Prohibition: 1994 International Report on Drugs. Brussels: International Antiprohibitionist League. ———. 2006. The World Drug Report 2006. www.unodc.org. Retrieved on 12 Aug 2018.

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———. 2016. The World Drug Report 2006. www.unodc.org. Retrieved on 12 Aug 2018. Van Der Merwe, J.  1975a. Cannabis Smoking in 13th–14th Century Ethiopia: Chemical Evidence. In Cannabis and Culture, ed. Vera Rubin. Chicago: Mouton Publishers. ———. 1975b. Cannabis Smoking in 13–14th Century Ethiopia. In Cannabis and Culture, ed. V. Rubin, 77–80. The Hague: Mouton. Von Wissman, H. 1891. My Second Journey through Equatorial Africa. London: Chatto & Windus. Warf, B. 2014. High Points: An Historical Geography of Cannabis. Geographical Review 104 (4): 414–438. Zetterström, Kjell. 1966. Bena Riamba: Brothers of Hemp. Studia Ethnographica Upsaliensia 26 (2): 151–166.

CHAPTER 4

The Moral Question of Addiction: An African Philosophical Perspective Wilfred Lajul

4.1   Introduction This chapter discusses the philosophical perspective of addiction in Africa, well aware of difficulties in defining the concept in terms that are more precise. Reflecting on this concept, Sussman S. and Sussman A.N. provide five definitional elements in this concept, namely, appetitive motive, preoccupation, loss of control, temporal satiation, and occurrence of negative consequences. They observed that giving the concept addiction scientific specificity may fail because, whereas in science water can be theoretically and specifically defined as H2O, the concept of addiction does not lend itself to scientific and theoretical specificity (2012: 204). Sussman S. and Sussman A.N. posit that addiction simply referred to “giving over” or being “highly devoted” to a person or activity, or engaging in behaviour habitually could have positive or negative implications (2012: 195). However, over the years, the meaning of addiction kept on changing from considering it as an overpowering urge to a disease nuance and from a connotation of imbalance of the central nervous system to

W. Lajul (*) Makerere University, Kampala, Uganda e-mail: [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_4

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neurological underpinnings (Sussman and Sussman 2012). Underlying these descriptions is the idea that addiction has to do with a habitual positive or negative indulgence or devotion to a person or an activity. The implication is that addiction can be either a behavioural disorder, which is moral, or a disease, which is physio-mental. The problem is that emphasizing addiction as a behavioural disorder places it purely in social sciences. Otherwise, taking addiction as a physical problem locates it in medical science. While addiction can be both a social and a medical problem, this does not answer the question whether an addict is morally responsible for his or her addictive condition or not. An addict may be morally responsible if it is within his or her power to control overindulgence. On the other hand, an addict is not morally responsible if addiction is a disease; this would be an imbalance of the central nervous system, or a neurological problem. Beyond purely medical or social science, this chapter places the question of addiction in African philosophical ethics. This ethics can be understood in the context of African social philosophy. Like any other social philosophy, African social philosophy may be derived from three angles. The first considers humans as perfect in themselves as they associate with others only based on usefulness. The second views humans as incomplete in themselves and have meaning and purpose only as members of a community. The third angle holds that individuals possess the inalienable worth of their own and moral personalities; nevertheless, they are essentially related to the community (Nell-Breuning 1972: 375–376). Kaphagawani (1998, 2004) identifies three theses in an attempt to explain the concept of personhood in Africa. These include the Tempelian ‘force thesis’, Mbitian ‘communalism thesis’, and the Kagamean ‘shadow thesis’. He equally attempted to distinguish the West African ‘constitutive thesis’ from the East and Southern African ‘dynamic thesis’. Analysing Kaphagawani’s theories, Lajul opines that “What Kaphagawani calls the West Africa (constitutive) and the East and Southern Africa (dynamic) elements of a person do supplement each other” (2017: 44). Besides, Lajul thinks that the claimed West African constitutive thesis might be more widespread than what is known, since even in East Africa, they have these constitutive understanding of a human person. This chapter understands the difference between extreme communitarianism and moderate communitarianism, yet adopts moderate communitarianism as advocated by Gyekye (2003). The chapter finds it difficult

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to accept the normative concept of a human person as advocated by Menkiti. This is because though a human person is a relational being, where the community plays an important part in determining the selfhood of human beings, human person cannot be reduced to mere products of a collective as Teffo and Roux affirm (1998: 145). This is because in traditional African social philosophy, the community is essentially composed of individuals who are very important in their own rights, although they are also closely and strongly related to the community. Whereas an individual is a corporate or social being, as supported by a number of African authors, he or she is also an individual in his or her own rights. A human person is inalienably an individual and cannot be relegated to the second position in terms of importance. However, an individual is essentially social, since the role of society in his or her life cannot be ignored because they need society to fulfil some of their needs. In discussing addiction, the majority of authors are informed by Western social philosophy, which emphasizes individuals and their unique places in society. In Western philosophy, addiction for that matter is an unfortunate disorder or a disease that needs treatment. Consequently, society may consider addicts as victims and never as culprits of their actions. On the other hand, society may condemn addictive behaviours of an individual, calling it a crime, an immoral behaviour that needs to be stopped. This Western understanding is turned around by placing addiction in an African social philosophy. This is because African philosophy takes an individual as an inalienable person that lives within a corporate social setting. Ontologically, an individual is constantly in a dynamic relationship with others, the world, and God. As a social being, an individual derives a number of his/her habitual behaviours from society. On the other hand, a unique person that an individual is also is a result of personal choices. Therefore, one cannot understand addiction in Africa without taking into considerations these three basic complementary dimensions of an individual: the ontological, the social, and the personal. The philosophical background of Western philosophy with its emphasis on specificity, individuality, and criticality ignores these social and ontological dimensions of an addict. While using a critical and analytical approach, this chapter investigates different literature on this subject, critically analysing and discussing them, presenting the African philosophical perspective of addiction, and elucidating its variance with Western philosophy.

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4.2   Literature and Theory The basic literature and theories surveyed in this section will be divided into two perspectives: addiction and African philosophy. On the question of addiction, we look at the literature and theories that take addiction as a physical disorder and those that take addiction as a behavioural disorder. The literature on African philosophical perspective considers the concept of personhood. Addiction as a Physical Disorder White (2000a) argues that the concept of addiction, particularly alcohol addiction, as a disease is not a contemporary one. It is as old as ancient Greece and Egyptian civilizations. He writes: The conceptualization of chronic drunkenness as a disease did not originate in America. References to chronic drunkenness as a sickness of the body and soul and the presence of specialized roles to care for people suffering from “drink madness” can be found in the ancient civilizations of Greece and Egypt. Isolated and periodic references to chronic drunkenness as a disease, and even occasional calls for state-sponsored treatment, continued through the centuries before the first European migrations to America. (White 2000a: 47)

Benezet (1774) challenged the then prevailing view of alcohol as a gift from God and called it a ‘bewitching poison’. Rush (1814) explicitly referred to acute and chronic drunkenness as an ‘odious disease’ and a ‘disease induced by a vice’. Beecher (1828) added that addiction is both a moral disorder (moral evil) and a physical disorder (disease). He said, “Intemperance is a disease as well as a crime, and where any other disease, as contagious, of as marked symptoms, and as mortal, to pervade the land, it would create universal consternation” (Cited in White 2000a: 48). Woodward (1938) described how intemperance was a “physical disease which preys upon his (the drunkard’s) health and spirits [...] making him a willing slave to his appetite”. Sweetser believed many individuals “addicted to intemperance” were vulnerable to such alterations because of hereditary or accidental circumstances (1828: 49). The concept of addiction as a disease provoked another sentiment as White (2000b) described it in another article, which looks at this concept

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as an escape from moral responsibility. One of those who reacted in this manner was C.W. Earle (1880) who stated: It is becoming altogether too customary in these days to speak of vice as disease [...]. That the responsibility of taking the opium or whiskey [...] is to be excused and called a disease, I am not willing for one moment to admit, and I propose to fight this pernicious doctrine as long as is necessary. (Cited in White 2000b: 74–75)

Other thinkers like Harris expressed their discontent with the disease concept of addiction. “As we do not, either in name or management, recognize drunkenness as the effect of a diseased impulse; but regard it as a habit, sin, and crime, we do not speak of cases being cured in a hospital, but ‘reformed’” (1874: 77; cited by White 2000a: 48). Besides, leaders of the Franklin Reformatory attacked the disease theory as “a weak apology for the sin of drunkenness” and a “blasphemy against God” (White 2000a: 48). At the same time, they portrayed the inebriate as the victim of a society that through its promotion of drinking seduced the innocent into an unbreakable habit (Harris 1874). On the other hand, advocates who had formed the American Association for the Cure of Inebriety (AACI) have four founding principles on which this association was founded, namely, 1. Intemperance is a disease. 2. It is curable in the same sense that other disease are. 3. Its primary cause is a constitutional susceptibility to the alcoholic impression. 4. This constitutional tendency may be either inherited or acquired. (White 2000b: 75)

Besides, authors like Nakken believed that the disease of inebriety had multiple causes, such as heredity, illness, emotional excitement, and adversity, and presented itself in quite varying patterns (1996: 76). On the contrary, White admits that at the end of the nineteenth century, “The disease concept as a purely medical concept fell out of favour” (White 2000b: 78). According to him, this is in tandem with the fall of the treatment institutions in which it had been imbedded. The demedicalization of addiction rose in the wake of alcohol and drug prohibition movements that took their turn trying to resolve America’s alcohol and other drug problems. Temporarily swept away was the language

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of ‘disease’ and many elements of this embryonic concept: b ­ iological vulnerability (propensity), tissue tolerance, morbid appetite (craving), progression, obsession, and behavioural compulsion (Ibid.). In presenting the theory of addiction as a disease, we have seen two opposing tendencies: those supporting the theory and those opposing the theory. In the end, there is the general disapproval of the theory that addiction is a disease. The major argument in support of this argument is that this theory is a social construction and not derived from scientific knowledge. Reinarman argues: [...] addiction-as-disease did not emerge from the natural accumulation of scientific discoveries; its ubiquity is a different species of social accomplishment. The disease concept was invented under historically and culturally specific conditions, promulgated by particular actors and institutions, and internalized and reproduced by means of certain discursive practices. (2005: 308)

Reinarman then traces the social construction and cultural dissemination of addiction-as-disease to show how it achieved its status as the dominant framework for understanding drug problems. He demonstrates that although the brain is centrally involved in drug use behaviours, the question of whether this new neuroscience research has identified a specific locus of addiction-as-disease in the brain is not clear (2005: 309). He observes that at the moment, “it is not clear if there is a site of pathology in the brain that distinguishes repetitive drug taking from, say, sex, sailing, symphonies, and other activities people learn to repeat because they provide pleasure” (Reinarman 2005: 309). The real problem is that such questions have little relevance, since the disease concept preceded this brain research by decades and took hold for reasons unrelated to neuroscience (Reinarman 2005: 309). Meyer further posits that the findings of other investigators starting in the late 1970s and new findings on the neurology of addictions bring us to the conclusion that the “disease concept remains controversial” (1996: 162). In any way, this does not mean the support for the theory has completely vanished. One can still find modern literature in strong support of the theory that addiction is actually a disease. For example, Nakken defines addiction as “An illness in which people believe in and seek spiritual connection through objects and behaviours that can only produce temporary sensations” (1996: 5).

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Addiction as Behavioural Disorder Behavioural addictive disorder has been defined as “cravings and out-of-­ control behaviour” (American Psychiatric Association 2013). According to Rosenberg and Feder (2014), the concept of behavioural addiction is new in American psychiatric history. However, this concept existed since the time of the ancient Greece. Rosenberg and Feder observed that “In ancient Greece, where organized gaming was part and parcel of daily life, Emperor Commodus possessed hedonistic and irresponsible gambling habits that may have contributed to the decline of the Roman Empire” (Rosenberg and Feder 2014: 1). In America, it was only in the 1800s that attention was drawn to this phenomenon. In 1812, Benjamin Rush, the founder of the American Psychiatric Association, called attention to the potentially pathological nature of excessive sexual desire (Rosenberg and Feder 2014: 1). Rosenberg and Feder claim that it was not “until 2010 that the Diagnostic and Statistical Manual Work Group for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), added the term behavioural addictions to the set of official psychiatric diagnoses” (2014: 1). From the above, we can talk of behavioural as well as chemical addictions (Ibid.: 2). Among the behavioural addictions, the first to be included was gambling disorder, which is a non-substance-related disorder. Later on, Internet-related behavioural addictions and impulse-control disorders were added to the list of behavioural disorders. Behavioural disorders shared key features with substance abuse, such as salience in one’s emotional and cognitive processing, pursuit of the addictive behaviour for the purpose of mood modification, development of tolerance, experience of withdrawal, tremendous conflict over behaviour, and relapse despite one’s best intentions (Ibid.: 2). Rosenberg and Feder outline key behavioural addictions that show impulsivity and compulsivity in the behaviour trends or which are sometimes called impulse-control disorders. These are “gambling, Internet (i.e., online gaming, Internet addiction, and social networking addiction), food, sex, love, shopping (i.e., compulsive buying disorder), and exercise addictions” (2014: 3). Rosenberg and Feder capture what Griffiths defines as behavioural addiction by six core components: salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse. These six components are:

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• Salience, which means the behaviour, dominates one’s thinking and ­feelings making it the most important activity in a person’s life. • Mood modification refers to the emotional effect the behaviour provides to an individual, which serves as a coping, numbing and tranquilizing strategy. • Tolerance is the increasing escalation in intensity, recklessness, destructiveness and ego-dystonic nature of the behaviour as required to achieve the former mood-modifying effects. • Withdrawal symptoms are the unpleasant feelings and/or physical effects (e.g., the shakes, moodiness, irritability) that occur when the person is unable to engage in the behaviour. • Conflict refers to discord between the person and those around him or her, conflicts with other activities, or intra-psychic conflict and/or ­subjective feelings of loss of control. • Relapse addresses the tendency for repeated reversions to earlier patterns of excessive behaviour to recur and to the most extreme patterns of excessive behaviour soon after periods of control. (Rosenberg and Feder 2014: 3; Griffiths 2005)

In general, there is no much disagreement on the concept of behavioural addiction among different authors. What is silent is whether all consider it a moral evil, of which an individual is directly responsible. Sussman et al. (2011a, b), in explaining behavioural addiction, state that the “the behaviour becomes increasingly more automatic and less under one’s control-­ability”. The question that is not answered is whether what is automatic and out of one’s control can still be considered a moral evil. Like many other authors, they are silent about this. African Philosophical Perspectives African philosophical perspective, borrowing from commonly known social philosophy with three alternative views on the human person, as mentioned in the introduction above, is equally divided. The first group considers humans perfect in themselves and society is needed only because of usefulness. Secondly, humans are incomplete in themselves because society defines them and gives them meaning as members of a community. Lastly, humans are unique individuals with inalienable worth of their own, yet essentially related to the community (Nell-Breuning 1972: 375–376). Western philosophy seems to be the main subscriber to the first view. It regards humans to be complete in themselves because of their autonomy,

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freedom, ability to self-determination, and self-propelling capacities to become what they want to become. Society is only important if, as far as, it helps to promote this individual project. Criticizing this Western concept of the human person and contrasting the African view with the Western one, Menkiti maintains that in African philosophy, “it is the community which defines the person as person, not some isolated static quality of rationality, wills or memory” (1984: 172). Menkiti argues that Western philosophy considers human personhood to be defined by some essential qualities of rationality, wills, and memory. African philosophers are divided between the two remaining views. The first group is usually called exaggerated communitarianism, who thinks that individual personhood is conferred by society. Key proponents of this view are Kenyatta (1965), Dickson (1977), Menkiti (1984), Nkrumah (1966), Senghor (1964), and Nyerere (1987). Menkiti (2004) calls it normative thesis, which states, “the community plays a role both as catalysts and prescriber of norms in transforming an individual from a biological project into a full person” (Menkiti, cited in Lajul 2017: 44). Menkiti states “that in the journey of individual towards personhood, the community’s role is to guide the transformation of that was basically biologically given into full personhood, since the individual himself or herself cannot carry through the transformation unassisted” (2004: 325). Again, he adds that “as far as Africans are concerned, the reality of the communal world takes precedence over the reality of individual life histories, whatever these may be” (Menkiti 1984: 171). This implies that a human person comes into the world just like a biological project, incomplete. Society transforms him or her into full personhood. Besides, the communal world of an African is prior to the personal world of any individual. The second group of African thinkers, which this chapter adopts, is called moderate communitarianism. The key proponents of this view are Gyekye (2003) and others like Teffo and Roux (1998) and Lajul (2017). Criticizing exaggerated communalism, Gyekye thinks that to say the community confers personhood on the individual, and so the individual’s identity is merely derivative of the community, is wrong. Gyekye himself states, “The community alone constitutes the context, the social or cultural space, in which the actualization of the possibilities of the individual person can take place” (Gyekye 2003: 353). Commenting on Gyekye’s view, Lajul maintained that “Gyekye (2003) accuses Menkiti and his proponents of imbuing the human person with an exaggerated social dimension, substituting individual moral roles with that of the community

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to which an individual belongs, and confusing the nature of the human person” (Lajul 2018: 72). In his own words, Gyekye states, “Failure to recognize this [the importance of the individuality] may result in pushing the significance and implications of a person’s communal nature beyond their limits [...] thus obfuscating our understanding of the real nature of the person” (2003: 353–354). Supporting this view, Teffo and Roux opine that “although the community plays an important part in determining the selfhood of human beings, human person cannot be reduced to mere products of any kind of collectively or community” (1998: 145).

4.3   Discussion In this section, we are going to discuss the different theories mentioned above. From these theories, we can identify two trends of thinking: addiction as a disease and addiction as a behavioural disorder. Addiction as a Disease In this section, I want to ask, at what point is addiction a disease? In response to this question, Reinarman (2005) thinks the disease theory is a social construction, while Possi (1996) says addiction is a disease from the point of view of its effect on the brain. Possi identifies several effects of addiction on an individual, like brain damage, behavioural disorders, instability in reason, low academic performance, temporal insanity, and so on (1996: 123). Now if addiction, like the one Possi is referring to, which is drug addiction, can cause brain damage, or temporal insanity, then would it not be right to say that indeed addiction is a disease? This chapter notes that this is a strong argument, but we should differentiate addiction from its effects. Possi, whose main work was rightly defined as “Effects of drug abuse [...]”, does not make this essential distinction. To consider addiction as purely a disease has some serious theoretical and practical problems, as some authors reviewed have already indicated. Theoretically, this view ignores the contexts in which addictions grew in society. Addiction as a disease is a theory that attempts to look at addictive behaviours just as an individual human struggle to cope with problems they face in life. This understanding takes humans to be individuals that find themselves in society, and not as both individuals and social beings that are born and raised within societies.

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Jean-Jacques Rousseau already insinuated that all humans are born innocent, but societies make them what they are. “[...] for Rousseau man in his primitive nature was good” (Copleston 1985: 67),1 but it was society that put him everywhere in chains. Even though one may not fully agree with Rousseau, one cannot deny that there are habits humans adopt or learn from society. Aristotle puts it differently, that virtue is a habit that is learned and inculcated through repeated actions. Likewise, vice is an evil learned through repeated actions. If this is the case, then humans acquire many vices by repeatedly living them. However, humans adopt some of the vices from societies that practise them. However, as we have seen, those who support the disease concept of addiction maintain that addicts may be genetically prone or susceptible to such behaviours. This has been very difficult to prove even by medical science. Reinarman has already observed that there is no grounded scientific knowledge, which shows what part of the brain is responsible for repeated behaviours different from those others like sex, sailing, symphonies, and other activities people learn to repeat because they provide pleasure. Besides, Rossow and Clausen discovered that collective drinking is not necessarily the cause of alcohol addiction in Africa. This is because higher risks in alcohol consumption corresponds to higher average mean concumption of the collective. “Consequently, a strong association is observed between the mean consumption and the proportion of heavy drinkers; thus, the higher the mean consumption, the higher the prevalence of heavy drinkers, – and vice versa” (Rossow and Clausen 2013). The implication is that society and their cultures have a strong stake in the promotion or demotion of addictive behaviours. This does not confirm the theory of addiction as a disease, but of addiction as primarily a social problem. Societies play big roles in the promotion and demotion of addictive behaviours. This also does not exonerate the roles played by individuals in acquiring addictive behaviours. From the practical point of view, although antagonists of the disease concept of addiction propose that addiction is a moral vice, this chapter thinks the problem is more than ethical, because addictive problem is imbedded in human society. 1  See Rousseau’s first part of the Discourse on the Origin and Foundation of the Inequality of Mankind.

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Addiction as a Behavioural Disorder Given the general agreement among different authors that behavioural addiction is not necessarily a disease, what is not clear is if it is not a disease, is it then a moral evil? None of the authors that I have surveyed address this question. My question remains, is behavioural addiction a moral evil for which an individual is responsible? I could not get this answer directly from these authors, yet that is the main concern for this chapter. We shall try to answer this concern when looking at African philosophical perspective of addiction. Tentatively, I would say that the answer is not an automatic yes or no. In the view of this chapter, we should first establish the basis of such ethical judgement that considers an action ethically right or wrong. What is clear from the literature surveyed is that a distinction exists between substance addiction and behavioural addiction (Sussman et  al. 2011a, b: 2; Rosenberg and Feder 2014). However, when it comes to the core elements of addition, a number of authors agree that both chemical or substance addiction and behavioural addictions have similar components, which are salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse as discussed above (Rosenberg and Feder 2014; Griffiths 2005). From the point of view of their symptoms, both chemical and behavioural addictions are the same as outlined above. However, when it comes to what they entail, the former is clearly the overindulgence in the use of addictive substances, while the latter is the overinvolvement in addictive behaviours. What are missing in the literature reviewed are the deeper issues behind what we call addictions. It is not enough just to classify addictive behaviours as chemical as opposed to behavioural, or as a disease or not. It is equally important to investigate the context in which addictive behaviours sprout. From these contexts, a better understanding of addictions and how they can be managed can be realized. Secondly, the context in which we want to discuss addiction in Africa is the African metaphysics and social philosophy. This metaphysics and social philosophy is the basis for understanding addiction in Africa, which we are going to investigate in the following section.

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African Social Philosophy of Personhood African metaphysics and social philosophy helps us to discover that the community is essentially composed of individuals who are very important in their own rights, but who are also closely and strongly related to each other. From this, we can derive ontological, communal, and individual responsibility ethical principles. The ontological ethical principle states that “what humans do, springs from the wellspring of their being and their activities are reflections of that wellspring”. This ontological principle is derived from African ontology, which does not separate being from force as its attribute, but maintains that being is dynamic. Africans speak, act, and live as if beings were forces and forces were beings (Tempels 1998; Onyewuenyi 1991). Being is not defined a priori by considering its essence, but a posteriori by considering its ways of acting, the way it interacts with other (beings) in its environment (Kagame 1956: 102). The communal responsibility principle states that whatever an individual does affects the society in which that individual lives, and vice versa. Actions of individuals affect society and actions of society equally affect individuals. This means human action has a social dimension because much as they affect the individuals that commit them, they also affect positively or negatively not only the other members of society but also the environment within which an individual lives. In the context of addictions, the influence of society in promoting habitual patterns of behaviour and substance intake cannot be blamed on the individuals alone. Unfortunately, when such individuals, who are influenced by society, develop addictive out-of-control behaviours, the society is also affected. Equally important is the individual responsibility principle, which states that certain actions affect only the individuals or the immediate family members of those that perform them. For such human actions, an individual must take full responsibility to not only own them but also accept their consequences. In the context of addiction, what one repeatedly does without exercising control or restraint, which eventually leads to habitual patterns of behaviour or substance intake, such actions will eventually cause personal health deterioration. Such human actions and practices will affect primarily that individual and should be fully taken care of by the individuals concerned, because they have individual responsibility over them.

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4.4   Implications From the foregone literature reviewed and discussions, we seem to arrive at the central issue this chapter has been battling with, whether addictions are moral evils of which every addict is ethically responsible or not. Secondly, the chapter identifies the basis of this ethics by which we can judge the rightness or wrongness of this practice and behaviour. Beginning with the second concern, which is the basis of judging the rightness or wrongness of addiction, this chapter found out that this is determined by the kind of philosophy that the human person adopts. This is because a human person is the basic subject of addictions, in both Africa and elsewhere. The right understanding of this subject is vital not only in understanding addiction in order to make good judgement about it but also in handling the prevalence of addictions. When the understanding is that an individual is perfect because he is autonomous, self-determining, and self-propelling to become what he or she wants to become, then addiction is heavily a moral responsibility of an individual. It means when an individual does not take sufficient charge of himself/herself to choose between right and wrong actions or patterns of behaviour, then that person will develop vulnerable addictive patterns of behaviours. This, in the view of this chapter, will be too simplistic and we think it is not the right way to address moral question and problems of addiction. Secondly, if our understanding is that the human person is just a biological project, that is incomplete, and one whose personhood can only be conferred by society, then again, why blame an individual addict? Maybe the society has not done sufficient work to mould this person into a more responsible being who is capable to distinguish right from wrong and has become an addict. This way of understanding addiction is equally problematic, since most of the blame would go to society. Our finding is that the third understanding of the human person as both a social being and a unique individual puts us in a better perspective to understand any addictive phenomena. This is because this way of understanding an individual places responsibility squarely on the individual without exonerating the society within which the addict acquires addictive behaviours. The second finding is that because an individual is social and at the same time unique, it is important to understand this social philosophy. This philosophy takes an individual to be a product of the ontological, social, and personal attributes that work together to groom who an individual becomes.

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The ontological attributes of the individual are related to the dynamic realities around him, like God, fellow humans, and the environment. This ontological constitution makes humans what they are and the wellspring of their actions. If the relations within this constitutive ontological entity are healthy, then the individual will develop healthy relations with self as manifested in self-control and harmonious dealing with others. On the other hand, if this ontological constitutive relation is injured (before birth, in birth, or after birth), then there will be disharmony in human dealings with self, others, and the world around him. This may explain deficiencies in what Sussman and her colleague called imbalance of the central nervous system or neurological disorder. This way of looking at the human person is different from Western metaphysical viewpoints, which takes a human person to be a perfect individual, who is incommunicable, carrier of all attributes, self-conscious, and equipped with the power of self-determination. It is also different from the African exaggerated communitarianism, which takes an individual to be incomplete and a mere product of society. Moderate African communitarianism metaphysics would refute this proposition; they would argue that this human person is a corporate individual, connected to the world, to other humans, and to God. Whatever happens in this dynamic relationship with the world, others, and God affects his or her balance, harmony, and peace. This chapter argues that among the many evils that affect humans, addiction being one of them is a result of a broken harmony in the dynamic ontological symbiotic relationships among created things. This disharmony creates emotional imbalance in the individuals and makes them lose self-control or look for how to cope with the pains deriving from this disharmony. It creates fear and insecurity in the individual who attempts to escape from those pains through substance intake or queer behaviours to soothe or numb the deeper inner void, pains, and state of helplessness. The third finding has to do with whether an addict is morally responsible for his or her actions and behaviours. Are humans ethically responsible for the disharmony described above? Western philosophy would automatically say if humans are the carriers of all their attributes, they are self-conscious and subjects of self-determination, then yes; they are blameworthy in all senses. African exaggerated communitarianism would also say, no, it is the society that has failed this individual because as a person, he/she is only a biological project that society guides, directs, and transforms into full personhood. Nevertheless, moderate African communitarianism would

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ask, is it just the individual responsible for the creation of this disharmony? Is society not equally responsible for disharmonizing this ontological relationship? The view of this chapter is that just like the individual, society equally plays a role in the creation of this disharmony, by destroying basic ontological values of society, like nature, man, and God. We have also found out that in as much as human beings are affected by the disharmony in nature, human activities too disharmonize nature. Referring to the value of nature, we found out that economic and human activities are degrading the environment and nature at an alarming rate, creating environmental degradation and global warming. The modern man now believes that he/she can create himself or herself in the language of Nietzsche (1980: 562–564) or should manipulate the laws of nature to find answers to human problems in the language of Kant ([1787] 1990: 22). At an ontological level then, both the human individual and society have a role to play in creating a paradigm shift in the way we understand and use nature, so that nature does not hurt man. We have also found out that the African communal responsibility principle states that evil is a social reality because it does not only affect the individual who commits it but also the society within which this individual lives. This principle states that “whatever a member of a community does, affects the community collectively; and whatever the community does collectively, equally affects the individual members of that community” (Lajul 2014: 119). Society is also the communal context within which an individual is born, grows, and acquires values for life. This means that an addiction that is negative or positive definitely does not only affect that individual concern but also the society in which that addict lives. Although individuals demand protection and assistance from society, society also has its demands on individuals. Sometimes social demands are too high for an individual to cope with, so the individual slides into escapism from social blame. Some addicts slide into solitude and avoidance of the community by hiding behind the power of substance or lopsided behavioural trend. In such suicidal loneliness, the individual indulges more deeply into the addictive substance or behavioural pattern. This may explain what Sussman and her colleague called addictive overpowering urge. Lastly, we have also found out that the individual responsibility principle is important in understanding and dealing with addictions. This principle states that “for any action taken in secret, against self or against another member of the same community, the responsibility rests with the individual” (Lajul 2014: 121). This implies that an individual too has

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deliberate choices to make in the process of living and must own the consequences of those personal choices. These individual choices make members of society to be praiseworthy or blameworthy for what they do. Addictions that come out of personal habitual choices are clearly, according to this ethic, the moral responsibility of the individual. It means such addictive behaviours or practices can be avoided if an individual makes personal efforts to avoid making wrong choices and concentrates in making right ones.

4.5   Conclusion In conclusion, we can say despite the fact that the concept addiction is difficult to define with scientific specificity, addiction should be understood as the habitual positive or negative indulgence into some chemical or behavioural activity by an individual. Because it is both chemical and behavioural, it is both a social and a medical problem. However, deep behind these disciplinary issues, addiction is certainly both a personal and a social problem. As a personal problem, addiction robs an individual of self-control, mastery, and director of one’s personal actions, making it difficult to get out of addictive habits. As a social problem, addiction is often influenced by society inasmuch as it also affects the same society. The biggest problem with addiction and the effort to overcome it, however, have been the philosophical tenets in understanding it. When one uses purely Western philosophy, which considers a human person to be an individual that is incommunicable, self-conscious, and self-­ determined, then an addict is only a helpless victim or a responsible culprit. In either case, such philosophical tenets de-contextualize the human person and the process of acquiring or fighting addictive behaviours. Not all African philosophical tenets offer good perspectives to understand and address problems of addiction. Only moderate communitarianism as an African metaphysics and social philosophy gives the right perspective to this problem. This philosophical tenet takes an individual to have ontological, social, and personal attributes. The human person is also constituted of body, soul, and heart. As a body, a human person is affected by addictive practice at the terminal end. In that, over time an addict acquires diseases due to repetitive substance consumption and adherence to bad behavioural practices. At the level of the soul, addiction destroys the inner peace and equilibrium, which destabilizes the individual. This often goes beyond the

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physical body, because it affects an individual’s will power and destroys a person’s inner ability of self-control. The dynamic symbiotic harmony that normally creates this inner peace is affected, so is the relationship of that individual with self, others, God, and the environment. At the level of the heart as the seat of character and fountain of psychic and personality traits, an individual is disorganized by addiction. This personality, which is the wellspring guiding and influencing a person’s choices and activities, is disorganized by creating queer personality traits. What is important for this chapter is to understand that to determine the moral responsibility of an addict, one has to go slow. This is not because addiction is just a disease, because if it is a disease, then the disease is only an effect of an addiction. Otherwise, the social context should never be lost, since whatever evil or good done by an individual equally affects the society in which that individual lives. This may not be unique to African philosophy, since African philosophy is not an antithesis of other philosophies. Other peoples of the world can equally share African philosophical view. However, what is unique about addiction in Africa is that for it to be managed, one needs to restore one’s harmonious relationship with society, the gods, and the environment. This interpretation is important and encompasses physical healing in Africa. In traditional Africa, physical healing is not taken in isolation, but in symbiotic unity, including restoration of harmony with the gods, the ancestral spirits, and the world in which we live. One of the results of this lack of inner harmony is addiction that is spreading like wild fire, affecting both their victims and society in which they live. The solution is not just to condemn or blame the individuals that have become addicts and later victimized for addictive prevalence. Society that induces and at times promotes these addictive vices is equally to blame. The solution does not lie in the blame game, but in taking both social and personal responsibilities to address this malaise.

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CHAPTER 5

An Ubuntu Approach to Addiction-Response Framework in Malawian Schools Chikumbutso Herbert Manthalu

5.1   Introduction Increases in alcohol, drug, and substance abuse among primary and secondary school learners have been an issue of concern worldwide as well as in the Malawi public domain. By and large, addiction has been analysed in psychological and social terms. Rarely has the philosophical dimension of addiction come to the fore and considered in efforts of combating it. However, particular conceptions of human nature inevitably underlie and partly inform approaches for addressing addiction. There has not been much research on addiction in Malawi, let alone on the philosophical foundation of conceptualising it. Besides, the available dominant approaches to preventing addiction and supporting addicts are rooted in an individualistic conceptualisation of human nature that unduly and exclusively privileges the moral value of personal autonomy, marginalising the relevance of communalistic obligations of care that are cardinal in addressing addiction. This chapter argues that

C. H. Manthalu (*) Chancellor College, University of Malawi, Zomba, Malawi e-mail: [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_5

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the predominantly individualistic and neoliberal models of education prevalent in both Malawian schools and globally are incompatible with the cultivation of the virtues of care that are cardinal in addressing addiction. Focusing on Malawian schools, this chapter argues that frameworks for preventing and identifying addiction and supporting addicts in Malawian schools must be grounded in ubuntu ethics because of their unique obligations to provide care to others. This chapter contends that a communalistic ontological conceptualisation of the human person and the subsequent scope and breadth of moral obligations of care such a conceptualisation places on members are indispensable in the development of a meaningful framework of combating addiction in the school in societies such as those of Malawi. Specifically, the question of the role of the teachers in identifying and preventing addiction in learners and providing due support to addicts is largely dependent on the school community’s ontological conceptualisation of a human person and its consequent moral duties. This chapter therefore argues for ubuntu considerations in the conceptualisation and implementation of addiction-response frameworks in Malawian schools. The chapter highlights the prevalent individual-centric and neoliberal models of education obsessed with developing an autonomous individual and equipping her with knowledge and skills for job market competition as the modern ultimate and arguably exclusive aims of education and school practices. The chapter therefore argues that this renders impossible benefitting from duties grounded in the relational being of teachers, learners, parents, and guardians. Thus, modern education, by largely and arguably focusing on the autonomous being of an individual detached from social relations and ignoring the relational being of concrete human beings other than abstract transcendent human beings, risks sustaining the prevalence of the school. This is because such an obsessive focus on individual autonomy ignores the reality of the indispensability of human relations of care the victim has with individuals and social institutions. The actual learner (other than an abstract one) is a being who exists in a particular social context and whom teachers owe further obligations of care beyond the positivistic ones defined by the school as a public institution. If recognised, such non-paternalistic relations between the teacher and learner can prevent addiction and offer meaningful support to addicts. As such this chapter proposes that meaningful approaches to addiction should include ubuntu’s relational rationality and not only the prevalent agent-centric one.

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Addiction and Ontology of the Human Person Across the world, drug and substance abuse are on the increase. The youths are a particular group that has been hit by the problem of drug and substance addiction. Thus far, there has been scanty research about the prevalence of addiction among the youths in Malawi, particularly in secondary or primary schools. Such a lack of research about drug and substance use and addiction translates into an absence of robust addiction-response mechanisms in Malawi public schools. Addiction scarcely comes to the fore as a central problem affecting learners and educational institutions in Malawi. As a result, most schools in Malawi do not have capacity and structures for preventing, identifying, and helping overcome addiction among learners as it is an unrecognised reality. Nevertheless, there are some studies that show the prevalence of substance and drug abuse among youths of schoolgoing age in Malawi, therefore implying that understudied addiction affects the school. For instance, alcohol and marijuana were the most common substances people were using in Malawi (Braathen 2008, p. 31). This is largely because there is scarce enforcement and compliance with alcohol buying regulations in alcohol-selling outlets (Braathen 2008, p. 51). Substance use and addiction however are expressed through learners’ behaviour in the school (Marimuthu 2015, p. 67). In other words, some of the behaviours that learners display in the school are influenced by drug abuse and addiction, yet teachers and school authorities respond to such behaviour in a generic manner. The concept of addiction mostly refers to behaviour associated with substance use creating a substance dependence disorder (Chassin et  al. 2007, p.  30). Substance dependence leads to compulsive drug taking (Chassin et al. 2007, p. 30). Thus addiction is a compulsive behaviour that nevertheless has acknowledged consequences that are negative socially and on one’s health (Chassin et al. 2007, p. 30). Understanding the phenomenon of drug abuse requires a multi-faceted approach to adequately comprehend the many dimensions of the phenomenon (Petrus 2015, p. 182). Despite addiction being a physiological and psychological matter, it is worth realising that managing and overcoming addiction has philosophical dimensions. This is particularly the case in the school, where addiction exists in a context of relationships between teachers and the learners. Understanding the phenomenon of drug use requires a multi-faceted approach to adequately comprehend the many dimensions of the phenomenon (Petrus 2015, p. 182).

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The conception of human nature of a community ideally underlies and informs the relations between the learners and teachers in the school. Ultimately, the teacher-learner relationship conceptualisation has a great impact on the approaches and success in combating addiction. The question of teachers’ preventing and identifying addiction in learners and providing due support to addicts is largely dependent on the school community’s ontological conceptualisation of a human person and consequent moral obligations generating from the conceptualisation. What this entails is that understanding the contextualised philosophical conception of the person is cardinally central in addressing addiction. This is because there is no single and comprehensive conception of being a concrete (as opposed to an abstract) human being for all the people of the world. The relevance of considering the ontological conceptualisation of the human person is necessitated by the fact that being a person is contextualised in the philosophical perspective of the mainstream of the community. Addressing the problem of addiction ought not to ignore the fact that learners in a school exist in a community of their own that, nevertheless, exists in the mainstream community with a given conception of human nature. As such, there are, for instance, variations across human societies as to how addiction and the addicted person should be conceived and addressed; is addiction an individual matter or a community one? What should be the role of teachers in the school in combating addiction? Are teachers only public officials whose norms of practice are strictly formal? To what extent are the home, teachers, and the wider community morally obliged to help resolve addiction? The State of Addiction in Malawi and Sub-Saharan Africa Information on substance abuse among schoolgoing youths in Africa is scanty (Bandason and Rusakaniko 2010, p.  1). In a study conducted in Harare secondary schools, Bandason and Rusakaniko (2010, p. 4) reports that with a mean age of 16 years and most of the students falling in the range of 16–17 age groups, 9.7% reportedly use marijuana and 62.6% drink alcohol (Bandason and Rusakaniko 2010, p. 4). Twenty-six percent of those who do not smoke, however, peer reported smoking friends (Bandason and Rusakaniko 2010, p. 5). Bandason and Rusakaniko (2010, p. 6) reports that on average 25% of ­secondary school learners experimented with smoking and 7% are regular daily smokers (Bandason and Rusakaniko 2010, p. 6). Bandason and Rusakaniko (2010, p. 7) holds that during adolescence, children are most influenced by peers, and as such any intervention strategy

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should actively consider peer influence. Given that the adolescent stage is one of exploration and adventurous experiences, Bandason and Rusakaniko (2010, p. 7) holds that it is necessary to make learners aware of the dangers of indulging in risky behaviour. Bandason and Rusakaniko (2010, p.  7) therefore holds that it is mostly incumbent upon schools to start from an early age to help keep the learners safe because they may easily relapse into an addiction (Bandason and Rusakaniko 2010, p. 7). In a study conducted among university students in Malawi, Zverev (2008) reports that 72% of respondents revealed that they consume alcohol (males 78% and females 63%) (Zverev 2008, p.  28). Among males, 38% drink at least two or more times per week, while 12% of females drink at least more than twice per week (Zverev 2008, p.  29). Alcohol use among Malawi university students was reportedly higher than in some developed nations (Zverev 2008, p. 30). According to the Malawi National Youth Policy, more than 50% of drug- and alcohol-related cases in Malawian courts involve young people as the accused (Ministry of Youth and Sports 2013, p. 3). With respect to the challenge of drug and substance abuse, the Malawi National Youth Policy expresses commitment to ensure that “information on the effects of tobacco, alcohol and intoxicating drugs is accessible to all young people to protect them from effects of substance abuse” (Ministry of Youth and Sports 2013, p. 20). There is also an expression of commitment to ensure “establishment of rehabilitation centres for youth drug addicts” and also “enforcement of regulations and by-laws regarding usage of tobacco, alcohol and intoxicating drugs among young people is advocated” (Ministry of Youth and Sports 2013, p.  20). Interestingly there is no special emphasis or focus on schools in the addressing of drug addiction challenges. According to the policy, addicts are going to be directed to rehabilitation centres. The National Youth Policy concedes that it is unknown as to how many youths are engaged in substance and alcohol abuse in Malawi (Ministry of Youth and Sports 2013, p. 48). Nevertheless, alcohol consumption among the youths has increased in Malawi with the introduction of liquor sachets that are packaged in affordable quantities for mostly youth consumers (Hoela et al. 2014, p. 100). Most youths drink out of peer pressure (Hoela et al. 2014, p. 102), and therefore students are greatly affected by access to cheap alcohol and it affects their education (Hoela et al. 2014, p. 103). Petrus (2015, p. 194) holds that there exists a connection between drug abuse, gangsterism, and violence. In other words, though not every drug user in the school may

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exhibit violence, there is a very great likelihood that those actively perpetrating different forms of violence and harassment in the school may have a drug use and abuse connection. Substance and drug abuse mostly if not always lead to poor academic performance and unsafe sexual behaviours (Rudatsikira et  al. 2009, p.  216). Skipping school, truancy, and drop in grades are some of the indicators associated with drug use (Marimuthu 2015, p.  67). Teachers may be more capable of identifying drug use triggers in a learner than parents (Marimuthu 2015, p. 68). A collaboration of the two beyond the rigid producer-consumer and teacher-learner relationships has great potential to prevent and overcome drug use that leads to addiction. Gratifying an addiction sends the addicted person even out of his/her way to find money to satisfy his/her drug crave (Marimuthu 2015, p. 68). An addicted person can even steal from his or her relations just to gratify his or her crave (Marimuthu 2015, p. 68). Given the nature of addiction and how average Malawian youths are socio-economically constrained, it is quite hard to expect an addicted person not to display odd antisocial behaviour among peers and with teachers or the education institution. It is here where the neoliberal framework of education becomes problematic. There is no attempt to meaningfully, caringly, and cooperatively engage the learner to establish the nature of challenges he/she is facing that are leading to academic underperformance and failure. This is because the learner is just an individual whose affectivity is ignored, and the challenges impressed upon the affectivity are also ignored as not part of the teacher’s core duties and terms of relationship and engagement with the learner. Under such approaches to education, the learner is conceptualised largely only in terms of his or her academic attainment. There is no emphasis on and requirement for the cultivation of relationship between teachers and learners, so that outside the contexts of academic performance, the teacher may detect some challenges or hints about probable addiction and may caringly engage the learner.

5.2   Autonomy, Neoliberalism, the School, and Addiction Market values characterise educational institutions today. By and large, individualism and neoliberalism influence and shape the aims of education, conceptualisation of the learner, curriculum content, the nature of

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school experiences, and the nature of relations between learners and teachers (Pais and Costa 2017, p. 4). The prevalent individual-centric and neoliberal models of education aim at developing an autonomous individual and equipping her with knowledge and skills for job market competition as the modern ultimate and exclusive goals of school practices and education. In education, the neoliberal ideology understands the individual, including the learner, as an “economically self-interested” being who is a “rational optimizer” and the best judge of her own interests and needs (Olssen et al. 2004, p. 1381). The motivation and dominance of individual-centrism and neoliberalism has a profound effect on the nature of relationships and consequent duties between teachers and learners. One of the inherent nature of conventional education is that the school is by nature of its goals and aims a community of hierarchical relationships. The authority and expertise that the teachers possess and their age as adults contrasts with the immaturity of the learners and their lacking of specialised knowledge they seek to acquire through the facilitation of the expert teachers (Bradshaw 2014, p. 4). The learners are the objects of authority. In other words, the nature of relations between learners and teachers in the school is one that is not egalitarian (Mitra and Gross 2009, p. 527). The unequal and hierarchical power relations of the school influence the nature of relations between teachers and learners in the school. The relations are generally role based, where insofar as each performs his or her expected role, there is harmony. Thus, for instance, as long as the learner attends classes timely, does her homework, and in principle adheres to all the school rules and regulations, there is ostensibly a harmonious relationship between the learner and the school. Furthermore, the interest of the teacher in the progress and well-­being of the learner is primarily grounded in whether the learner is performing his or her expected functional roles or not (Beets and Le Grange 2005, p. 1200). Furthermore, modern education is influenced by the idea that education should promote the good and well-being of the learner (White 2010, p. 17). Under this perspective educational experiences must foster learner autonomy. The pursuit of autonomy therefore defines and characterises school experiences and relationships between teachers and learners. The hallmark of autonomy is that it discourages intrusion and paternalism. In the school, there is a pronounced delineation of private and public spheres such that ultimately relationships between the teacher and the learner are couched only in terms of positive and negative duties the two sides owe

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each other. The individual-centric conception of autonomy thrives on clear duties. Such duties are not compatible with accommodation of certain virtues that may superficially seem to be in violation of a duty. For instance, the implication is that the teacher is not expected to assume certain aspects of the parenting responsibility of the home of the learner. This is perceived as intrusion into the learner’s private sphere. It is usually conceded that the classroom is a simulation and microcosm of the wider society (Eikenberry et al. 2009, p. 119). Without necessarily reproducing the power relations of the society that are mostly iniquitous and in need of reform by the very school, the school situation should, however, be aware of the care needed to protect and nurture children and all minors as is the concern of the wider society such as in homes. In this case, the concern of society to protect children and minors is not adequately addressed only in terms of legal codes and regulations that strictly delineate learners’ freedoms and define teachers’ functions and roles. Rather, addressing the concern lies beyond fulfilling legal codes and regulations. Addressing such concerns constitutes in availing the care that is responsible for developing the virtues that make humanness and autonomy possible (Held 2006, p. 81). It is worth noting that state and legal apparatus such as legal tools that protect children by defining their rights and negative rights adults have towards them are built on a presumed existence of certain virtues that enable civic life (Kymlicka 1997, p. 25). Such virtues of civility are produced in homes and the school is expected to nurture them further. What is evident is that an obsession with and exclusivity of positivistic autonomy-centred aims of education that ultimately shapes school practices is to the detriment of the learner. Such approaches to learning and education are inadequate insofar as they are incompatible with care provision. It is instructive to bear in mind that the dominance of positivistic conceptions of human nature where the individual human being is conceived as a detached transcendent autonomous rational person for whom matters of affectivity are purely personal and discretional pushes to the peripheral the role of virtues of care. This is why generally in the modern school the teacher’s core duties do not include care obligations. In the understanding of modern educational relationships, the teacher must be a public official governed only by norms of positivistic duties in his or her relationships with learners. The teacher is restrained from assuming a parenting role and responsibility as that is ostensibly tantamount to intruding into the private sphere of the learner and parents. The restraint

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is governed by the dread of paternalism, where the learners are conceived as developing autonomous rational choosers who can or should be accorded the space to make decisions especially about their private lives. Such a background of the school that is characteristically and exclusively grounded in positivistic duties poses a major challenge in identifying and preventing drug and substance abuse that ultimately lead to addiction. The school, though being one of the most ideal grounds to make early identifications of addiction risk, identify the addicted, and offer them adequate support for recovery, is regrettably generally incapacitated from exploiting its full and meaningful potential in overcoming addiction. Addiction is a phenomenon that expresses itself in various forms. With respect to the school setting, such phenomena as truancy, aggressive behaviour, violent behaviour, and most antisocial behaviour usually accompany drug and substance use and addiction (Petrus 2015, p. 194). Ultimately such practices affect the academic performance of the learner. Without necessarily holding that exhibition of such behaviour always entails addiction, it is however arguable that it is almost impossible for someone who is addicted to not ultimately have the addiction affect his or her academic performance or exhibit some antisocial behaviour. Sustaining the crave of an addiction takes the addicted individual a long way into indulging in antisocial and at times even criminal behaviour (Marimuthu 2015, p. 67). For Malawian youths who live in a particular socio-economic setup, sustaining an addiction is bound to manifest through different forms of inappropriate behaviour. The major challenge with the current school frameworks is that the lack of the virtue of care in the relations between the teacher and the learner prevents teachers from making due and diligent follow-ups on a learner’s antisocial behaviour. When a learner’s performance drops, the teacher only reports that in the end of term report to parents. The implication is that it is up to the parents to probe what is leading up to the underperformance. It is also important to recognise that what counts as hints for possible drug use and addiction may not always necessarily be expressed through explicit violation of certain established school rules and norms. Just like a parent, a teacher is able to notice a strange bonding or friendship develop between students that intuitively look mystical and not transparent. Alternatively, since drug and substance abuse affect the judgement of a person, a learner who is typically introvert may occasionally oscillate towards the extreme of being extrovert.

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These are tendencies a teacher may observe based on his or her knowledge and experiences with the learners. Even when a red flag is raised about such sudden swings of behaviour in the learner who has not violated any school rule, the teacher is restrained from making efforts to engage the leaner to establish the cause of such sudden emotional changes. Doing so would require a framework of relationships that goes beyond positivistic duties. It would require that among the relationships between the teacher and the learner, there be a commitment to care. The teacher as a provider of care would thus be compelled to engage the learner to establish whether there is drug involvement. Thus, education’s pursuit of the autonomous citizen detached from social relations sustains the perpetuation of addiction in the school as it ignores the reality of the indispensability of human relations of care the victim has with individuals and social institutions. Upon recognition, caring and non-paternalistic teacher-learner relations would go a long way in both preventing addiction and offering meaningful support to addiction victims. As such this chapter proposes that meaningful approaches to addiction should include ubuntu’s relational rationality and not only the prevalent agent-centric one. It is instructive to note that generally there is a relationship between substance use and delinquent behaviour in the school (Carney et al. 2013, p. 448). As such in a context of care in the school, the teacher needs to be proactive and initiative of engagement with a learner when hallmarks of involvement with drugs emerge. This requires a communalistic type of relationship between the teacher and learners not one where the learner is just a general transcendent individual being, a knowledge seeker stripped of any other forms and sources of concrete being. Carney et al. (2013, p. 453) hold that early engagement in delinquent behaviours among learners is among the most major predictors of engagement in further delinquent type of behaviour. Adverse experiences during childhood may predispose adolescent youth to use alcohol that may lead to addiction (Kabiru et al. 2010, p. 11). What this entails is that teachers must reach out to the learners. To reach out to learners who are struggling with adverse childhood conditions is untenable under a market model of relationships between the teacher and learner that typify modern education. This is where the ubuntu paradigm of conceptualisation of human relationships would help prevent and manage addiction in the school. This is because ubuntu is grounded in care ethics. The teacher cares for the wellbeing of the learner and is not only concerned or satisfied with the learner

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fulfilling the tasks of the school. The school as a caring environment should be able to dig into the motivation of learners mostly engaged in delinquency. Effectively treating drug and substance addiction is not a matter of focusing on the individual addict only. Focus should equally be on the community both literal and the one close to the individual. In a South African study (Meade et  al. 2015, p.  83), it is shown that addicts who attempt to quit with or without the role of drug treatment services relapsed due to the influence of their drug-using peer networks where the drug is at the centre of the people’s social relations such that the addicts perceive that the only way of ensuring there is no relapse is moving out of the community. By and large addiction is conceived as a medical condition treatable by medication (Meade et al. 2015). In this case the addiction victim is isolated and the addiction conceptualised in relation to an individual as internal to him or her. But there are aspects of the life of the community that ought to constitute part of the prevention, support, and recovery of the individual. The victim needs care from the teacher and community. Largely and exclusively reducing addiction to a medical condition detaches the individual from the community. The victim is on his or her own. Overcoming addiction is between the victim and the medication only. In the school the dominance of the individual-centric ideology of neoliberalism results in regarding the learners as competitors (Ramose 2010). Teachers are only facilitators of a fair competition. The ontological nature of the competition is adversarial where one brings out one’s best solely to have an advantage in the competition in the school that replicates and has impact on the wider competition of the wider society beyond the school (Ramose 2010, p. 297). Under such a context of individual competition, there is a strong tendency to look at and regard learners as autonomous individuals solely responsible for being themselves. Part of the competition requires minimal interference by the facilitator teacher who regards each of the competitors as adequately equipped and generally autonomous in as far as choice making within the ambits of the school and available legislation that protects children and minors is concerned.

5.3   Ubuntu-Responsive Frameworks to Addiction It is instructive to bear in mind that the school exists in a socio-cultural context that has particular worldviews, opportunities, and unique challenges. As such, the operations of the school occur in and are informed by

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a context that has a presupposed shared understanding of being human and the relationships that would also determine how to conceptualise and actualise common goals for the community such as educational goals (Etieyibo 2017, p. 315). Since the nature of ubuntu ethics centrally values the ideals of sharing and caring as both the ends and means for social cohesion (Etieyibo 2017, p. 319), one can draw the implication that ubuntu ethics is incompatible with indifference to the concrete situation of the other, by restricting one’s obligations to violation or lack thereof of the entitlements of the other. It is therefore imperative that the philosophy underlying the general routines of the school and teaching and learning experiences as well as the teacher and learner relationship should be connected and in harmony with the general philosophy of the socio-cultural context under which the school exists for the education to be consistent with the lived experiences of the community (Venter 2004, p. 155). Education must necessarily be connected with the worldviews of the community in which the education is taking place (Venter 2004, p. 156). Understanding Ubuntu It is instructive to note that there do exist other normatively valid conceptualisations of human nature besides the prevalent individual-centric one. One such alternative conception of human nature is that of ubuntu ethics. Ubuntu ethics is grounded in both transcendence of the individual and the primacy of the principle of social bond (Cornell and Muvangua 2012, p.  3). Unlike the individual-centric conceptualisations of human nature that necessarily prioritise individual autonomy, ubuntu ethics understands human existence to be enabled by an intertwined web of ethical relations and obligations to and with others (Cornell and Van Marle 2012, p. 353; Waghid and Smeyers 2012, p. 13). The social bond is not understood in the sense of a result of an aggregation or an overlap of collective individual interests of separate detached individuals who cooperate only for self-­ interests. Rather, the social bonds are a result of concrete normative mutual obligations whose fulfilment is cardinal in the realisation of our respective individuation such that I do not acquire my full self-realisation and being human insofar as the being of the other is compromised and cannot flourish (Cornell and Muvangua 2012, p. 3). In ubuntu thought, it is not possible to detach the concrete relationships of care one has with others from one’s embeddedness and such that the care one gets from

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others in the community that “is not outside each one of us, but is inscribed in us” (Cornell and Muvangua 2012, p. 5). In other words, ubuntu is an “interactive ethic … in which who and how we can be as human beings is always shaped in our interaction with each other” (Cornell and Van Marle 2012, p. 353). As such ubuntu places at the centre the virtues of empathy, connectedness, and mutuality which ultimately demand an interactive engagement with the others one is in community with. Thus, the most profound nature of ubuntu is its interactive nature. In individual-centric ethics, being an individual human being is primarily premised on possession of a rational will-making capacity that places moral obligation on others to respect your agency (Meyers 2005, p.  27). However, in ubuntu thought, being human or personhood is about both autonomy and social obligations to the interests of others (Murungi 2004, p. 522). In other words, in contrast to the social contract tradition behind the individual-centric conception of human nature that society is a social construction, in ubuntu thought, “human beings are not social beings because they socialize with one another. [Rather] they socialize with one another because they are social beings” (Murungi 2004, p. 523). This does not entail that in ubuntu ethics the community is absolute over individual interests, hence easily relapsing into totalitarianism. Rather, ubuntu demands “mutual recognition and respect complemented by mutual care [for] and sharing” with others one is in community with in the exercise of one’s agency (Ramose 2003, p. 297). In ubuntu ethics, “personhood is derivative from relationship with other persons, hence it is not an incorrigible property of the individual but something that is shared with others and finds nourishment and flourishing in relationships with others” (Murove 2014, p. 42). The implication here is that although the enterprise of being a person values the ideal of autonomy as being primary, autonomy is not the exclusive primary property of being human. Being human is a project that is enabled by concrete support from concrete others. The uniqueness of ubuntu ethics lies in its being a “relational rationality” founded on the reality that concrete human beings depend on one another for the attainment of ultimate well-being (Murove 2014, p. 37). This is why, among others, the most central virtues of ubuntu ethics include the virtues of “kindness, compassion, respect, and care” (Murove 2014, p. 37). In other words, ubuntu makes cognisance of the reality that to be an individual person is to be both supported by and obligated to others in order to actualise oneself. The ubuntu conception of personhood

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“articulates our inter-connectedness, our common humanity and the responsibility to each that flows from our connection” (Letseka 2012, p. 54). Ubuntu ethics places high normative premium on such moral values as “love, generosity, and compassion” as having intrinsic worth (Bell 2002, p.  71), which the individual-centric conception of personhood regards as without intrinsic moral worth. It is necessary to have ubuntu considerations in the conceptualisation and implementation of addiction-­ response frameworks in Malawian schools. The School, Ubuntu and Addiction What poses as a great challenge to the prevention and identification of addiction and support of addicts in the school is the presupposed framework of relationships between teachers and learners that typifies modern neoliberal education. The relationships between the two are arguably couched up in individual-centric terms only. However, there are certain core virtues that are deemed incompatible with ideals of individual-­ centrism that are nevertheless central in addressing challenges of addiction. The individual-centric model of human relationships in the school coupled with its neoliberal motivations for education practice renders addiction almost invisible as the engagement between teachers and learners is governed by almost fixed positivistic duties, roles, and responsibilities. The mathematics teacher, for instance, conceives his or her role as primarily constituting in facilitating learners’ absorption and familiarity with mathematical concepts. The positivistic conception of being a teacher restricts interaction with learners to only developing and enacting efficient and effective pedagogical experiences that are stimulating. In as far as there is enactment of such pedagogy, the teacher feels satisfied. The mathematics teacher is under no compulsion to find out the source of some strange behaviour in some other learner. In any case most schools in Malawi have established rules of conduct that basically enforce student discipline. Any act of indiscipline is heard in the context of the established and fixed rules of conduct. All the teachers have to do is to establish learner responsibility and then mete the appropriate punitive sanction as per the school discipline regulations. What lacks in such modes of teacher-learner interaction is the ubuntu virtue of care. The ubuntu virtue of care will demand a new understanding of the relationship between the teacher and the learner. Initially it would demand a new understanding of the aim of education and the role of the

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school in achieving those aims. Without undermining the place and value of promoting individual autonomy and self-actualisation, ubuntu ethics would demand inclusion of the virtue of care as being central especially in the school where minors require reasonable guidance and protection given their incontestable vulnerability. Ubuntu ethics would in principle break down the divide between the home and the school in as far as care provision is concerned. Whereas the individual-centric conception of the individual and education has rigidly demarcated public and private spheres, and where care is relegated to the private sphere only, an ubuntu education is cognisant that a concrete individual acquires autonomy through and from the support from care providers in the family and the community. Given the interconnectedness of ubuntu, the teacher who is the adult among minors in the school is not expected to freeze his or her care-giving responsibility to the minors. The minors too do not cease to be in need of due care, especially in the school where there is a strong risk of misjudgement in their endeavours of exercising individual autonomy. In other words, the school is a microcosm of the community; hence the care minors need must constantly be availed by teachers without conflating it with paternalism and indoctrination. The collective influence of the individual-centric and neoliberal models of human relationships in the school renders the teacher to be detached from the concrete experiences of the learners on the grounds that such phenomenon pertains to the private sphere. The interaction of the teacher and learners under these models is governed by norms that are public and hence necessarily exclude care (Benhabib 1992, pp. 158–9; Held 2006, p. 81). The teacher therefore lacks motivation for initiative in trying to follow up on portrayed leads of possible addiction in the learner on the mere basis that it is outside his or her formal duties. The market influence of the school makes the learner regard such engagement by the teacher as intrusive into the learner and parents’ private sphere. The ultimate result is that due and holistic care-giving to the learner is halted by the public private divide that characterises the school. However, it is worth recognising that the average student spends much of his or her active time of the day in the school than at home. Hiding the care the school can give the learner is restricted to enforcement of and conforming with the rules and regulations of the school, which hides away the opportunity for the teacher to act on possible leads of drug and substance use among learners not in a policing manner but rather in a caring manner as society expects of adults.

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The neoliberal framework of school relations also complicates provision of support to identified drug addicts. Generally, the conduct of one addicted to drugs in the school would more often than not manifest through violation of school rules of conduct in one way or the other (Carney et al. 2013). For the school and teachers to effectively support a learner struggling with an addiction, it is imperative that they operate under the motivation of care. The teacher under the influence of the virtue of care will not interact with learners with indifference who face the consequences of their addictive behaviour. Giving hope to the addicted learner, taking special interest in them whilst they face ostracism from fellow students and the wider community would go a long way in helping the learner recover from the addiction. Such support can only spring from a paradigm of care. What is evident is that the individual-centric model of education and paradigm of the school owing to its autonomy commitment and strict public vs. private spheres divide renders identification of possible engagement in addictive behaviour difficult. It effectively restrains the teacher from acting in making initiatives that may avert addiction, stop it, or support learners who have fallen prey to addiction. The neoliberal conceptualisation of education and education practice takes out care from the school as the learners are regarded as equal competitors who are arguably exclusively solely responsible in how they turn out in the competition of the school. The role of the teacher in this competition is to only facilitate equal grounds of competition. Excluding care provision in the school creates a chasm between the school and the home. The learners that need care while in the home somehow are deemed as self-sufficient and generally autonomous the moment they are in the school where they are only expected to fulfil some criteria of standard conduct that cannot always tell much of their behaviour deviance due to drug abuse involvement. Given the proliferation and ease in accessing illicit drugs due to globalisation and information technological communication, by not emphasising care, the school increasingly becomes a very fertile ground for promotion of drug use as the learner has far much lesser accountability than the home. It should be clarified that a caring model of the school does not suggest surveillance and paternalistic practices by the teacher that override the autonomy of the learner. Rather, the interconnectedness principle of ubuntu ethics generates concern for the flourishing not of oneself but also of the other such that the lack of flourishing of the autonomy of the other

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affects one’s flourishing. You have not fully achieved your personhood as long as that of the other is being suppressed by factors you can help resolve. The teacher therefore cannot be indifferent to the likely symptom involvement in drug behaviour by the learner on the grounds that guiding them on how to handle themselves is the preserve of their parents and life skills subjects in the school. Neither can suppression of the autonomy of the learners be justified unless it is for more autonomy (Rawls 1999, p. 56). The principle of interconnectedness would still demand the teacher to provide the care to the student which the parent who is absent from the school domain would provide. This way the teacher becomes a reasonable parent to the learner, an advisor, a guider, and mentor to the learner. Such roles are clearly not only unaccommodated but incompatible with the exclusively individual-centric and neoliberal models of modern education. Yet it is the absence of such ideals that is making drug and substance use and addiction invisible in the school or be detected only when the substance use and addiction get out of control; however, the teacher is in a more strategic position to make due interventions if the education and school paradigms allow.

5.4   Conclusion The problem of addiction is largely conceived as a psycho-social one. Hardly is it regarded as having a profound philosophical dimension. The school as a community of aspiring autonomous beings who are also highly vulnerable to addiction is strategic in both curbing and spreading of addiction. The neoliberal frameworks of education that conceptualise the learner in generalised terms, stripped of social-cultural aspects that make him/her a concrete being, render the flourishing of care provision in the school by teachers almost impossible. This is because in the school relations between the teacher and the learner are strictly governed by positivistic obligations. Neoliberal frameworks of education goals and practice are inherently incompatible with and repulsive of care commitments in the school. However, the autonomous individual cannot attain such capacity without concrete care provided by the community. As an ethics of care, ubuntu conceptions of education and the learner are ideal for the identification, prevention, and support of addicts. This is largely because it places related concern for and duty to care on the teacher, requiring him or her to go beyond the positivistic commitments of the school establishment. Unless the school context intentionally and actively

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cultivates virtues of care, regrettably, the school will only passively facilitate addiction other than curb it. All efforts and interventions against addiction that leave the chasm in the teacher-learner relationship unattended or restricted to positivistic commitments, will fail to address the problem.

References Bandason, T., and S. Rusakaniko. 2010. Prevalence and Associated Factors of Smoking Among Secondary School Students in Harare Zimbabwe. Tobacco Induced Diseases 8 (10): 1–9. Beets, P., and L. Le Grange. 2005. “Africanising” Assessment Practices: Does the Notion of Ubuntu Hold Any Promise? South African Journal of Higher Education 19 (Special Issue): 1197–1207. Bell, R.H. 2002. Understanding African Philosophy: A Cross-Cultural Approach to Classical and Temporary Issues. New York: Routledge. Benhabib, S. 1992. Situating the Self: Gender, Community and Postmodernism in Contemporary Ethics. Cambridge: Polity. Braathen, S.H. 2008. Substance Use and Abuse and Its Implications in a Malawian Context – Pilot Project 1. Oslo: SINTEF Health Research. Bradshaw, R. 2014. Democratic Teaching: An Incomplete Job Description. Democracy & Education 22 (2): 1–5. Carney, T., et al. 2013. The Relationship Between Substance Use and Delinquency Among High-School Students in Cape Town, South Africa. Journal of Adolescence 36: 447–455. Chassin, L., et al. 2007. Age-Related Differences in the Meaning of Addiction. Drug and Alcohol Dependence 87: 30–38. Cornell, D., and N.  Muvangua. 2012. Introduction. In Ubuntu and the Law: African Ideals and Postapartheid Jurisprudence, ed. D.  Cornell and N. Muvangua, 1–27. New York: Fordham University Press. Cornell, D., and K. Van Marle. 2012. Exploring Ubuntu: Tentative Reflections. In Ubuntu and the Law: African Ideals and Post-Apartheid Jurisprudence, ed. D. Cornell and N. Muvangua, 344–366. New York: Fordham University Press. Eikenberry, A.M., et al. 2009. Improving Quality and Creating Democracy in the Classroom: Student Management Teams. Administrative Theory & Praxis 31 (1): 119–126. Etieyibo, E. 2017. Moral Education, Ubuntu and Ubuntu-Inspired Communities. South African Journal of Philosophy 36 (3): 311–325. Held, V. 2006. The Ethics of Care: Personal, Political, and Global. New  York: Oxford University Press. Hoela, E., et al. 2014. Context and Consequences of Liquor Sachets Use Among Young People in Malawi. African Journal of Drug & Alcohol Studies 13 (2): 96–107.

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Kabiru, C.W., et  al. 2010. Self-Reported Drunkenness Among Adolescents in Four Sub-Saharan African Countries: Associations with Adverse Childhood Experiences. Child and Adolescent Psychiatry and Mental Health 4 (17): 1–13. Kymlicka, W. 1997. Education for Citizenship. Political Science Series (40): 1–35. Letseka, M. 2012. In Defence of Ubuntu. Studies in Philosophy and Education 31: 47–60. Marimuthu, B.A. 2015. “An Emotional Rollercoaster”: Vignettes of Family Members of Illicit Drug Users. Acta Criminologica: Southern African Journal of Criminology Special Edition No 3/2015: Illicit Drugs: Local and International Realities 2015 (Special ed(3)): 83–95. Meade, C.S., et  al. 2015. Addiction and Treatment Experiences Among Active Methamphetamine Users Recruited from a Township Community in Cape Town, South Africa: A Mixed-Methods Study. Drug and Alcohol Dependence 152: 79–86. Meyers, D.T. 2005. Decentralizing Autonomy: Five Faces of Selfhood. In Autonomy and the Challenges to Liberalism: New Essays, ed. J. Christman and J. Anderson, 27–55. New York: Cambridge University Press. Ministry of Youth and Sports. 2013. National Youth Policy. Lilongwe: Ministry of Youth, Sports. Mitra, D.L., and S.J.  Gross. 2009. Increasing Student Voice in High School Reform: Building Partnerships, Improving Outcomes. Educational Management Administration & Leadership 37 (4): 522–543. Murove, M.F. 2014. Ubuntu. Diogenes 59 (3–4): 36–47. Murungi, J. 2004. The Question of an African Jurisprudence: Some Hermeneutic Reflections. In A Companion to African Philosophy, ed. K. Wiredu, 519–526. Malden: Blackwell. Olssen, M., J.  Codd, and A.M.  O’Neill. 2004. Education Policy: Globalization, Citizenship and Democracy. London: Sage. Pais, A., and M.  Costa. 2017. An Ideology Critique of Global Citizenship Education. Critical Studies in Education: 1–16. Petrus, T. 2015. “They Smoke It, Then They Go ‘Mal’…”: An Anthropological Perspective on the Drugs-Gangs-Violence Connection and South Africa’s National Drug Plan. Acta Criminologica: Southern African Journal of Criminology Special Edition No 3/2015: Illicit Drugs: Local and International Realities 2015 (Special ed(3)): 180–195. Ramose, M.B. 2003. The Ethics of Ubuntu. In The African Philosophy Reader, ed. P.H. Coetzee and A.P.J. Roux, 2nd ed., 379–386. London: Routledge. ———. 2010. The Death of Democracy and the Resurrection of Timocracy. Journal of Moral Education 39 (3): 291–303. Rawls, J. 1999. A Theory of Justice. Revised. Cambridge, MA: The Belknap Press of Harvard University Press. Rudatsikira, E., et al. 2009. Prevalence and Predictors of Illicit Drug Use Among School-Going Adolescents in Harare, Zimbabwe. Annals of African Medicine 8 (4): 215–220.

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Venter, E. 2004. The Notion of Ubuntu and Communalism in African Educational Discourse. Studies in Philosophy and Education 23: 149–160. Waghid, Y., and P.  Smeyers. 2012. Reconsidering Ubuntu: On the Educational Potential of a Particular Ethic of Care. Educational Philosophy and Theory 44 (sup2): 6–20. White, J. 2010. The Aims of Education Restated. e-Book. Oxon: Routledge Taylor & Francis Group. Zverev, Y. 2008. Problem Drinking Among University Students in Malawi. Collegium Antropologicum 32 (1): 27–31.

PART II

Addiction in Literature and Popular Culture

CHAPTER 6

Oral Traditions: A Tool for Understanding Alcohol and Drug Addiction in Swaziland Telamisile Phumlile Mkhatshwa and Gloria Baby Malambe

6.1   Introduction Contemporary Swaziland is still deeply rooted in oral traditions—that is, Swaziland continues to disseminate its cultural values through verbal discourse. The New World Encyclopaedia defines oral traditions as a “way for a society to transmit history, literature, law and other knowledge across generations without a writing system.” Indeed, Swazi people use different oral avenues to share knowledge and cultural values. Songs, poems, proverbs, riddles and folktales dominate in instilling respect and moral values. Against this cultural backdrop, contemporary Swaziland faces a rise in alcohol and drug addiction amongst both young and old people. Drug addiction is a chronic disorder that involves compulsive drug use (Berke and Hyman 2000). An addict cannot function without drugs, such that if he/she does not get drugs, he/she experiences serious withdrawal symptoms. On the other hand, alcoholism refers to “compulsive and uncontrolled consumption of alcohol beverages usually to the detriment of the

T. P. Mkhatshwa • G. B. Malambe (*) University of Swaziland, Kwaluseni, Swaziland e-mail: [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_6

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drinker’s health, personal relationships, and social standing.” (Balali-­ Mood 2014, 3) Similar to other drug addictions, alcohol addiction involves an uncontrollable urge to imbibe alcoholic drinks. Since alcohol is a drug, in this chapter, we put alcoholism and drug addiction on the same pedestal. Usually, drug abusers are labelled “addicts” after years of drug use; however, Wise and Koob (2014) argue that drug addiction includes the “early signs of compulsive drug taking and the cravings” as opposed to “the subsequent bodily consequences that often—as with nicotine and alcohol, for example—develop only after a long history of drug self-administration” (257). We concur with Wise and Koob’s definition of drug addiction because early compulsive tendencies indicate that an individual is already dependent on a drug. Describing the alcohol problem in Swaziland, the Swaziland State of the Youth Report (2015) states that 58.9% of out-of-school youth drink alcohol on a daily or weekly basis. In 2012, Swaziland was number three in the top 20 countries with adults who consumed the most beer (Live Science 2012). With regards to drugs, Swaziland is popular for growing first-grade cannabis or marijuana and illegally exporting it. Most families in the Hhohho and Shiselweni regions live off selling cannabis, which makes this drug readily available to the general public (Dlamini and Makondo 2017). The constant availability of cannabis and alcohol, as well as Swazi cultural traditions, makes the Swazi society complacent about alcohol and drug addiction. In addition, the physical structure of the traditional Swazi homestead encourages drinking and drug addiction. The Swazi homestead has many individual huts that house the grandmother, father, wives and children. Notably, there are two huts used for cooking—one hut is for cooking food and the other hut is reserved for brewing and preparing traditional beer (Vilakati and Msibi 2006). This means each Swazi home has a specific hut that readily provides beer on a daily basis for visitors and family members, especially the father, umnumzane. The brewing hut contains necessary brewing paraphernalia, such as lihluto and siguca. Lihluto is a traditional strainer used to prepare beer while siguca is a traditional clay pot used to store beer. The fact that the homestead has a well-equipped brewery indicates that beer plays a central role in Swazi people’s lives. Although having a traditional brewery at home may seem hospitable to guests, it makes family members and even minors prone to alcohol abuse and alcohol addiction. Furthermore, the traditional homestead has a specific place called umjono, whereby the family head, the father, goes to

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smoke cannabis using the traditional smoking pipe, lushawulo. The father may go to umjono at different times of the day to smoke in peace. No one is allowed to disturb him during this time. Even if visitors come to see him, they are told that he is not available (Vilakati and Msibi 2006). This traditional set-­up makes drug use acceptable, such that male children might aspire to head families so that they have their own umjono, where they can smoke in peace. The fondness for beer does not end at the family level. It extends to the community and entire country. Annually, the Swazi people host the Buganu or Marula Ceremony, where women from all regions of the country brew marula beer (buganu) at home and take it to the royal residence. Murye and Pelser (2018) corroborate that marula “brew is largely consumed during traditional festivals” (307). This countrywide event takes place when the marula fruit is ripe—around January–February. During the marula ceremony, women drink and dance with royalty for the entire weekend. Although this ceremony is a jovial and pleasant event, it promotes uncontrolled drinking. Even when the women are drunk, society uses euphemistic terms such as bajabulile, meaning they are happy, as opposed to directly saying they are drunk. Such euphemism promotes the drinking culture amongst women and makes Swazi people complacent about alcohol abuse. Moreover, the marula season negatively affects the youth. Schoolgoing children, especially teenagers, miss classes or drink marula beer at school. In a study conducted by Dlamini and Makondo (2017), Swazi schoolgoing teenagers confessed that “during the marula season they had plenty of marula alcohol because there were many naturally growing marula trees in their area.” (658) Also worth noting is that all Swazi ceremonies involve beer. That is, women brew traditional beer for weddings and funerals. The ceremonies would be incomplete without beer. Highlighting the attitude of Swazi people towards alcohol and drug abuse, the Youth and Public Policy in Swaziland (2015) states, “Swaziland has two common types of substance abuses and are regarded as socially acceptable; alcohol and marijuana.” (67) This statement reveals that Swazi people accept and condone alcohol and drug addiction, which is very concerning. The Swazi society’s laxity might suggest that a reasonable amount of the Swazi people view and understand alcoholism and drug addiction differently from most societies. Thus, in this chapter, we discuss how Swazi people define and conceptualize addiction—specifically, alcoholism and drug addiction. Since oral traditions dominate in Swaziland, we argue

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that Swazi oral traditions may function as a tool that provides insight into how Swazis view addiction. Hence, we analyse three Swazi oral traditions: songs, proverbs and traditional terms in order to understand how Swazi people perceive addiction. We also evaluate how oral traditions may encourage the increase of alcohol and drug addiction, and worse, the general complacency towards addiction. This work is grounded on sociological criticism. The sociological approach was propounded by Kenneth Burke (1971) in his article, “Literature as Equipment for Living.” Burke postulated that literature is composed within a specific cultural context. He argued that “Literature, like the people who write, it is always embedded in a set of circumstances.” (McGowan 2003, 119) Thus, the sociological approach studies the symbiotic relationship between literature and the society that produces it. This involves examining how literature impacts individuals and the society. Sociological criticism is relevant to this work because we analyse how Swazi oral literature affects and influences the Swazi people’s perception of alcoholism and drug addiction. We hypothesize that the so-called modern problem of drug and alcohol abuse in Swaziland stems from deep-­ seated Swazi oral traditions. In the first section of the chapter, we analyse four Swazi songs that are sung by both men and women. No one individual can claim to have composed these songs. As oral literature, the songs are passed on from one generation to the other through word of mouth and are made anew in each performance and context. After discussing the songs, we analyse Swazi proverbs that are linked to addiction, and finally, present traditional siSwati terms that relate to addiction.

6.2   Songs and Addiction Music and dance sit at the centre of Swazi people’s everyday life. Swazi people break in song during festivals, cultural ceremonies, weddings, drinking sprees, when working or hunting. As much as songs entertain, they also function as a window through which we see how most Swazi people view alcoholism. Some of the songs that reveal Swazi people’s view of alcohol addiction are Pikiliyeza, Mine Bengidzakiwe, Ngiyawufela Etjwaleni and Amnandzi Emambawu. The song Pikiliyeza is a celebratory song that is sung by both men and women during gatherings. It is commonly sung in shebeens, and is accompanied by a forceful and vigorous male dance called sibhaca.

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Pikiliyeza Sikuva ngendzaba Pikil’yeza Kants’umnandzi kangaka Sikuva ngendzaba Pikil’yeza Kants’umnandzi kangaka

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Pikiliyeza We hear about you through hearsay Pikiliyeza We did not know that you taste this great We hear about you through hearsay Pikiliyeza We did not know that you taste this great

The term pikiliyeza refers to a type of beer which is brewed at home or local shebeens, and has a high alcohol content. The title of the song Pikiliyeza suggests that the song eulogizes the beer for its ability to swiftly intoxicate whoever drinks it. Further praise is indicated by the persona directly speaking to the beer, personifying it. Such personification accords the beer power and hints at extreme satisfaction on the part of the persona who drinks pikiliyeza. The simple repetition of the word pikiliyeza shows that this beer is an important subject that deserves recognition. As much as the word pikiliyeza refers to a type of beer, it is metaphorically used to directly refer to alcoholics. For instance, if a community member is perpetually drunk, people mock that individual by referring to him or her as pikiliyeza. This suggests that the individual embodies alcoholism and is beyond redemption. Although society’s mockery of drunkards may suggest that Swazis criticize alcoholism, the entire song sends a different message. The second line of the song sikuva ngendzaba means that the personas have all along been hearing about the power of pikiliyeza through hearsay, but now, they are tasting the beer first-hand. The plurality of the personas indicated by the plural subject concord/si-/in sikuva reveals that a huge population of Swazis eulogize the beer. The word ngendzaba means that a lot of people rave about the power of pikiliyeza, which shows that alcoholism is a common problem in Swaziland. In the line Kants’umnandzi kangaka, the personas marvel at the great taste of pikiliyeza and regret missing out all this time. Kants’umnandzi kangaka also suggests that the personas sing the song while drinking the beer. This creates curiosity even in someone who has not yet drunk pikiliyeza; he/she will want to taste the beer too. The entire song reveals the problematic perception held by a number of Swazi people that pikiliyeza beer tastes great and everyone should drink it. Ironically, the song may foretell calamity that will inevitably befall alcoholics. The compound noun pikiliyeza is made of two words, lipiki (pick) and liyeza (is coming). A pick is a tool with a wooden handle and sharp

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iron used to dig the soil. A pick is generally used in traditional settings to dig graves in preparation for one’s funeral. Liyeza means that something is coming. The word pikiliyeza could mean that death is coming, that is, the person who drinks pikiliyeza is digging their own grave. More so, because of the high alcohol content in pikiliyeza. The second song, Mine Bengidzakiwe, is a lively dance song sung by women when gathered at ceremonies such as at the marula ceremony. This song indicates that although alcoholism is generally common and accepted among men, Swazi women also consume a lot of alcohol. Mine Bengidzakiwe Mine beng’dzakiwe Ungabokhiyela lomunye ledlaleni Nawe mfati uyay’tsandza lendvodza Mine beng’dzakiwe Ungabokhiyela lomunye ledlaleni Nawe mfati uyay’tsandza lendvodza Beng’dzakiwe bo

I was drunk I was drunk Don’t lock the other wife in the kitchen Oh Woman, you love the husband I was drunk Don’t lock the other wife in the kitchen Oh Woman, you love the husband I was drunk, my goodness

The song is in the first-person voice of a Swazi woman confessing to being drunk, and rationalizing her behaviour. Notably, the persona is a married woman, she has a husband and a sister-wife. Commenting on the decorum of married Swazi women, Mdluli (2007) says, “women are supposed to behave as minors within the institution of marriage.” (98) The Swazi society generally expects wives to be respectful and docile; however, this persona is a drunkard. In the title and first line, she says, “I was drunk.” The personal pronoun “I” shows that she feels proud of her behaviour. Bengidzakiwe suggests that the persona habitually drinks, hence the response she gets from the other women is ungabokhiyela. The/bo-/in ungabokhiyela shows that the persona has the tendency to get drunk and lock her sister-wife in the kitchen. Also, bengidzakiwe means the persona was highly intoxicated to the point that she mistakenly locked her sister-wife in the kitchen. The song further reveals one of the causes of alcoholism amongst Swazi women. That is, marital problems and stress make some women drink on a daily basis to forget their problems. The line Nawe mfati uyay’tsandza lendvodza means the persona deeply loves her husband and cannot accept the polygamous set-up. Sharing her husband frustrates the persona such that she locks the sister-wife in the kitchen to get the full attention of her husband. The persona uses her drunken stupor to justify acts of jealousy,

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hence the repetition of Mine beng’dzakiwe. In the last line of the song, Beng’dzakiwe bo, she uses bo, which shows annoyance towards the Swazi society, which forces her to accept the sister-wife and not lock her in the kitchen. This song indicates that some Swazi women depend on alcohol to assuage marital stress. Interestingly, the song Mine Bengidzakiwe has transcended generations. Although originally a traditional song, it was remixed by DJ Simza and Sabside into a house music song in 2007. For most of 2007 and 2008, the hit song played in dance clubs and radio stations. The popularity of the song indicates that the drinking culture also plagues Swazi modern and young society. Ngiyawufela Etjwaleni is another song sung by women during traditional gatherings. This is a low-tone song, which is accompanied by a swaying dance. Ngiyawufela Etjwaleni Ngiyawufel’etjwaleni Maye mine Ngiyabutsandza tjwala Zichananaza Zichananaza

I Will Die Drinking Beer I will die drinking beer Oh my I love beer It makes one rejoice It makes one rejoice

The title and first line Ngiyawufel’etjwaleni means “I will die drinking beer.” This female persona is committed to drinking for the rest of her life, which suggests that she is an alcoholic. Although the persona is aware that alcoholism results in death, she would rather die than stop drinking beer. We assume that this woman is a mother and needs to care for her family, but she prioritizes beer over her family. The line Maye mine shows that she feels deep satisfaction when drinking alcohol. Ironically, the expression maye could also decry her hopelessness as an alcoholic. On the one hand, the persona enjoys beer, but on the other, she feels trapped by alcohol such that she laments her state using maye. The persona openly declares her love for beer in Ngiyabutsandza tjwala. It is very strange for a Swazi woman to openly profess her love for alcohol because women need to uphold high moral standards. However, the persona feels unapologetic about her addiction, which shows that some Swazi women openly discuss alcoholism. The lexical item zichananaza does not carry specific meaning in the SiSwati language. Zichananaza implies that the singer is drunk, thus uttering nonsensical words. The

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simple repetition of zichananaza suggests that the persona is at the height of excitement and enjoyment. The last song Amnandzi Emambawu is also sung by women. This is a happy dance song, which women sing when celebrating, especially during drinking sprees. Amnandzi Emambawu Amnandzi Emambawu Adibanis’umcondvo wami Emambaw Adibanis’umcondvo wami

Beer Tastes Good Beer tastes good It makes me confused Oh beer Makes me confused

The above song celebrates the good taste of beer. In the line Amnandzi Emambawu, the persona feels deeply satisfied by beer such that she begins to praise its taste. She enjoys being “high” or intoxicated. The second line shows that part of the beer’s greatness comes from its ability to confuse her. Kudibanisa umcondvo refers to utterly confusing someone, such that they do not know whether they are coming or going. Further, Kudibanisa umcondvo might mean driving someone mad or making an individual lose their mind. This line shows that excessive drinkers temporarily go mad during a drunken stupor, and as health practitioners indicate, in the long run, alcohol alters one’s brain and disrupts cognitive function. Despite explicitly stating the dangers of drinking, the persona celebrates beer. Her behaviour suggests that she depends on alcohol and thus fails to make rational decisions to protect her health. The song also suggests that the persona’s desperate need to forget about problems makes her drink emambawu. This thought correlates to the observation we made in the song Mine Bengidzakiwe—that stress and frustration significantly contribute to excessive drinking amongst Swazi women.

6.3   Proverbs and Traditional Terms and Addiction Swazi people commonly use proverbs in their speech. A proverb is “A piece of folk wisdom expressed with terseness and charm.” (Okpewho 1992, 226) Short, proverbial utterances accurately and vividly describe situations, thus reflecting the richness of a language. Swazi proverbs indicate that Swazis value beer. Since proverbs are accepted as “truths,” the messages contained in Swazi proverbs about addiction might contribute to the prevalence of alcoholism and drug addiction. For instance, the proverb Bungacitseka bugayiwe means a total disaster, and is used when

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one talks about an unforeseen calamity. The basic image used in the proverb is the spilling of brewed beer. The subject concord/bu-/in bungacitseka and bugayiwe refers to tjwala or traditional beer. Kucitseka refers to spilling a liquid and kugaya, in this case, refers to grinding the sorghum in preparation to brew beer. Bugayiwe also indicates that the beer is well prepared and ready for consumption. This shows that the community or family members were eagerly waiting to drink the beer and they feel devastated by the waste of the valuable drink. The proverb equates the spilling of brewed beer to an absolute disaster, and such an image reveals that Swazi people value and love beer. Although this proverb when used in everyday life generally refers to a predicament, it reveals the subconscious love and appreciation of alcohol by Swazis. While most proverbs that pertain to alcohol valorize beer, some Swazi proverbs hint at the danger of imbibing beer. The proverb ungivukela esiswini njengetjwala means you are revolting against me—like alcohol in the stomach. Kuvukela means turning against someone or unexpectedly rebelling. The term implies that the two people concerned were once close friends, but now, one of them betrays the other. This proverb warns drunkards that although alcohol is appealing and luring, it has the potential to betray one. The betrayal may include nausea, stomach ache, hangover and driving one to act foolishly or violently. Although this is a warning to drunkards, it does not touch on the serious dangers of alcoholism, yet “alcoholism is a problem in Swaziland and it has implications both on the individual, affecting their health, employment, mental state and relationships.” (Mavundla et al. 2015, 67) The proverb generally cautions about the short-term effects of drinking alcohol and obscures the long-lasting effects of alcoholism. The proverb’s silence on the dangers of alcoholism is more worrying because it suggests that some Swazi people do not even conceptualize alcoholism, let alone address it. As mentioned earlier, the most prevalent drug in Swaziland is cannabis. Cannabis is used by both the young and old on a daily basis. The proverb Kubhema ngelwemvu proves that smoking cannabis is largely acceptable in Swaziland. Kubhema ngelwemvu denotes smoking with a smoking pipe made from a lamb’s horn. This figurative expression connotes suffering or being mistreated by someone. For instance, if an individual’s boss is unyielding and domineering, the employee might say, Ngibhema ngelwemvu, meaning I am tormented by my boss. Our interest in this proverb lies in the basic image—the smoking pipe. Here, we have an abnormal and frustrating situation, whereby the smoker uses a pipe made from a lamb’s

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horn. The/lwe-/in lwemvu refers to lushawulo, the traditional smoking pipe. A normal smoking pipe is made from a cow’s horn and this allows the smoker to smoke comfortably and put sufficient cannabis in the horn. However, in this proverb, the smoker complains because unlike the cow’s horn, the lamb’s horn is smaller and skewed, which makes it difficult to smoke. The fact that Swazi people composed this proverb shows that smoking is a huge part of their lives and they derive pleasure from it. Highlighting the longstanding prevalence of drug abuse in Swaziland, Rätsch (2001) notes that traditionally, Swazi people had dagga smokers. Rätsch says, in “Swaziland there used to be wise men the ‘dagga smokers,’ who used hemp ritually. Twice a day, at sunrise and again at sunset, they would smoke female hemp in water pipes up to ten meters in length.” (130) Such a cultural practice is concerning as smoking cannabis poses serious health hazards and various mental illnesses such as schizophrenia (Koen et  al. 2009). Unfortunately, Swazi cultural norms obfuscate the catastrophic effects of smoking cannabis. Figurative expressions such as uyatidlela also indicate that alcohol addiction is a foreign concept to Swazis. By foreign, we mean that although alcoholism exists, Swazi people do not perceive it as alcoholism. The verb kutidlela denotes eating food; however, in another context, kudla euphemistically refers to excessive drinking or alcoholism. For instance, it is culturally unacceptable to say that an adult is a drunkard, sidzakwa; rather, you say uyatidlela. The term uyatidlela equates alcoholism to the natural practice of eating and connotes that drinking is as essential as eating food. This euphemistic term condones drunkards and rationalizes alcoholism. Such a view makes Swazi people complacent about drunkards. Even when a drunkard needs professional help with addiction, they lightly say uyatidlela. Another issue of concern is the formative/-ya-/in uyatidlela. The/-ya-/presents a sympathetic tone and implies that society is understanding and forgiving of alcohol addiction.

6.4   Conclusion The discussion in this chapter shows that alcohol and drugs such as cannabis play a huge part in Swaziland. From analysing the songs, proverbs and some phrases, it is clear that some Swazi people do not necessarily understand addiction as a serious condition. The euphemistic and general terms used to name and speak about alcoholism and drug addiction obscures the dangers of compulsive drug use. Culturally, male adults may

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drink and smoke on a daily basis in the comfort of their homes. Although women are discouraged to drink excessively, cultural events such as the marula ceremony and songs indicate that alcoholism is rife among Swazi women. Generally, the society condones alcoholism and drug addiction. As a result, a huge population of Swazis, male and female, young and old, smoke cannabis and drink excessively. The traditional values largely influence modern Swazis. Thus, in fighting drug addiction, stakeholders need to understand how the Swazi cultural milieu enables and encourages drug use. They need to come up with strategies that address cultural problems as opposed to assuming that alcoholism and drug addiction is merely a modern phenomenon.

References Balali-Mood, M. 2014. Alcoholism – The Worst Addiction. Asia Pacific Journal of Medical Toxicology 3 (1): 3–3. Berke, J.D., and S.E.  Hyman. 2000. Addiction, Dopamine, and the Molecular Mechanisms of Memory. Neuron 25 (3): 515–532. Burke, K. 1971. Literature as Equipment for Living: Critical Theory Since Plato. New York: Harcourt Brace Jovanovich. Dlamini, P.G., and D. Makondo. 2017. The Prevalence of Drug and Substance Abuse Among School Going Teenagers in the Shiselweni Region of Swaziland. International Journal of Innovation and Applied Studies 20 (2): 652–660. Koen, L., R.  Jonathan, and D.J.H.  Niehaus. 2009. Cannabis Use and Abuse Correlates in a Homogeneous South African Schizophrenia Population. South African Journal of Psychiatry 15 (1): 8–12. https://doi.org/10.4102/sajpsychiatry.v15i1.99. Live Science. 2012. https://www.livescience.com/18493-global-alcohol-consumption-top-countries.html. Accessed 30 Oct 2018. Mavundla, S., et  al. 2015. Youth and Public Policy in Swaziland. Berlin: Youth Policy Press. McGowan, J.  2003. Literature as Equipment for Living: A Pragmatist Project. Soundings: An Interdisciplinary Journal 86 (1/2): 119–148. Mdluli, S.R. 2007. Voicing Their Perceptions: Swazi Women’s Folk Songs. Muziki: Journal of Music Research in Africa 4 (1): 87–110. https://doi. org/10.1080/18125980701754629. Ministry of Sports, Culture, and Youth Affairs. 2015. Swaziland State of the Youth Report 2015. Mbabane: Ministry of Sports, Culture, and Youth Affairs.

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Murye, A.F., and A.J. Pelser. 2018. Commercial Harvesting of Marula (Sclerocarya birrea) in Swaziland: A Quest for Sustainability. In Selected Studies in Biodiversity, ed. Bülent Sen. https://doi.org/10.5772/intechopen.76606. New World Encyclopedia. http://www.newworldencyclopedia.org/entry/Oral_ tradition_(literature). Accessed 30 Oct 2018. Okpewho, I. 1992. African Oral Literature: Backgrounds, Character and Continuity. Bloomington: Indiana University Press. Rätsch, C. 2001. Marijuana Medicine: A World Tour of the Healing and Visionary Powers of Cannabis. Rochester: Healing Arts Press. Vilakati, T., and T.  Msibi, eds. 2006. Giya Sigiye. Manzini: Macmillan Boleswa Publishers. Wise, R.A., and G.F.  Koob. 2014. Development and Maintenance of Drug Addiction. Neuropsychopharmacology 39: 254–262.

CHAPTER 7

Sex Addiction in Contemporary African Fiction: An Analysis of Selected Works of Short Fiction Beaton Galafa

7.1   Introduction Short fiction in every society draws its inspiration from people’s routine way of life in that given society. As such, theme, plot, characterization, setting, and other aspects are largely influenced by the social and political conduct that become characteristic of people in particular contexts and epochs. Changes in time result in varieties in the crafting of literary works from time to time and region to region. Although short fiction in Africa is as diverse as its people, there have been recurring themes in various writing periods due to a shared social, cultural, and economic plight. The rise of short fiction on the continent has witnessed its themes evolving from spirit stories of the Ogbanje and Abiku in Life is sweet at Kumansenu by Abioseh Nicol (though they never completely fade away—as the spirit children themselves, who keep being reborn) through political and economic upheavals in Ngugi wa Thiong’o’s Minutes of Glory to male chauvinism in Jennifer Makumbi’s Let’s tell this story properly.

B. Galafa (*) Zhejiang Normal University, Jinhua, China © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_7

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However, in addition to these traditional themes in African short fiction, more recent works have confronted the subtlety of sex—exploring the theme from narratives focusing on flirting to those that paint vivid images of the very act of sex. The rise in erotic short fiction in contemporary African literature today can be attributed to continued cultural exchanges between Africa and other societies—in particular, the West—in the process gradually diluting the conservatism that has characterized African writing for a long time. Again, such conservatism has been a direct influence of the values and beliefs of African societies, which shape the kind of literature the continent’s writers produce. The appearance and rise of erotic short fiction has introduced to the world an in-depth exploration of a theme that has been repressed for a long time due to its sensitivity in most African societies: sexual addiction. An explicit exploration of sexual addiction would not be expected to appear in African literary outlets that easily when sex remains a taboo in general discourse in most societies. In a post-conference collection of essays and articles on sex and culture in postcolonial Africa, Nwabueze (2017) argues that most societies on the continent battle with a contradiction in attitude towards sex and sexuality. Generally, a lot of Africans evade explicit discourse on sex, and ‘in the cities and villages, overt public display of affection is not too common’ (Nwabueze 2017). While there are changes in the society pertaining to how matters of sex and sexuality are addressed, African literature has, for a long time, fallen short of reflecting the changes. Although literature in many African societies—especially through orality—has, for a long time, served as a platform for addressing the taboos of explicit discussions on sex, it is only now that sex is escaping subtlety as a theme in works of short fiction. Its emergence offers insights into dark corners of African society that were almost unexplorable through imagination before. By and by, the reflections of the literary works point to the existence of not only sex as a social phenomenon, but the long suppressed discourse on sexual addiction. The existence of erotic short fiction in contemporary African literature and its open coverage of sex have led to an even further realization of the prevalence of sexual addiction in the society. In relation to this, the chapter generates responses to questions on critical areas relating to the conception of addiction by Africans, the gender parity, the age gap as well as the moral dimensions of addiction—all within the context of sexual addiction.

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The chapter analyses six diverse anthologies—one of which is an exclusive collection of erotic short stories and poems. The works are: Sext me: Poems & Stories (Jalada 2014), My Maths Teacher Hates Me and Other Stories (Writivism 2015), Your Heart Will Skip a Bit and Other Stories (Writivism 2016), Suubi (African Writers’ Trust 2013), and Valentine’s Day Anthology 2015 (Shercliff and Bakare-Yusuf 2015). These anthologies were published under different initiatives between 2014 and 2017. Containing works of short fiction by both emerging and established African writers from across the continent, they are a good representative sample from which an understanding of the extent of sex addiction in African societies can be comprehensively developed.

7.2   Understanding Sexual Addiction The concept of sexual addiction has, with time, generated multiple academic perspectives that have all contributed to an in-depth understanding of the phenomenon. Riemersma and Sytsma (2013) note that sexually addictive behaviour has been recorded even in the most ancient texts, such as the Bible, and that it has taken on many different names. These have included satyriasis in men and nymphomania in women. Griffiths (2004) makes a similar observation, noting that some of the names include ‘the Casanova type, compulsive promiscuity, compulsive sexuality, Don Juan(ita)ism, Don Juan Syndrome, Don Juan Complex, erotomania, hyperaesthesia, hypererotocism, hyperlibido, hypersensuality, idiopathic sexual precocity, libertinism, the Messalina Complex, oversexuality, pansexual promiscuity, pathologic multi partnerism, pathologic promiscuity, sexual hyperversion and urethromania’. Carnes (1999) defines sex addiction as any sexually-related, compulsive behaviour which interferes with normal living and eventually becomes unmanageable, although he has also described it as a pathological relationship with a mood altering experience (Carnes 1999). This is in line with Riemersma and Sytsma (2013) who define the phenomenon as a disorder characterized by compulsive sexual behaviour that results in tolerance, escalation, withdrawal, and a loss of volitional control despite negative consequences (p. 308). Similarly, Weiss (2016) defines sexual addiction as ‘a dysfunctional preoccupation with sexual fantasy, often in combination with the obsessive pursuit of casual or non-intimate sex; pornography; compulsive masturbation; romantic intensity and objectified partner sex’.

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Several diagnostic criteria have been developed for sexual addiction in various studies. Riemersma and Sytsma (2013) have gone even further to distinguish between what they call classical and contemporary addiction, adding three specific diagnostic criteria. In the study, Riemersma and Sytsma (2013) argue that contemporary sexual addiction is a rapid-onset addiction distinguished by chronicity, content, and culture. ‘Aetiology stems from chronic exposure to sexually graphic online content, the uniqueness and intensity of which are theorized to facilitate rapid-onset addiction and to disrupt normal neurochemical, sexual, emotional, and social development particularly when occurring early in the developmental process’ (p. 307). Their study argues that contemporary sex addiction is the product of a toxic trilogy: chronicity, content, and culture. ‘Repeated and chronic exposure to sexually graphic content that is reinforced by a highly sexualized culture creates a “perfect storm” in which addictive sexual behaviour may arise’. They then describe classical sexual addiction as having its aetiology in a history of abuse, insecure attachment patterns, and disordered impulse control (Riemersma and Sytsma 2013: 307). Similarly, Karila et al. (2014) developed a list of signs of sexual addition. In their study on sexual addiction and hypersexuality, they came up with eleven sexual aspects characterizing victims of compulsive sexual behaviour. Some of the aspects include out-of-control sexual behaviour, inability to stop the sexual behaviour, persistent pursuit of high-risk behaviour, presence of the tolerance phenomenon etcetera (Karila et  al. 2014). In addition to the signs, they also came up with diagnostic criteria that were modelled on the criteria for diagnosing other addictive behaviours. This includes the recurrent failure to resist impulses to engage in a specified sexual behaviour; increasing sense of tension immediately prior to initiating the sexual behaviour; pleasure or relief at the time of engaging in the sexual behaviour; and the development of tolerance levels to pleasure among others (Karila et al. 2014). An extension of the diagnostic criteria leads to the adverse consequences of sexual addiction that characterize the addicts. The understanding of these various perspectives of sexual addiction provides a strong standing point from which the contemporary literary works of fiction can be analysed. It offers clear insights into possible explanations behind certain behaviours—and contributes to the general discourse of how sexual addiction is perceived in Africa through the literary lens.

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7.3   The Concept of Sexual Addiction in Selected Works The notion of addiction to sex in the works of fiction under review manifests itself in various forms. Though not exclusively explicit as it varies from story to story, its representation offers insights into authorial interpretation of sex and sexuality, and therefore provides a basis for understanding how most societies in Africa perceive sexual addiction. In the short fiction from the selected anthologies, experience and themes mostly focus on celebration for sex and sexuality. In this celebration, sex is presented as a normal social activity probably marking the various stages of human life, from childhood (through the hypersexual stages) to its chronicity in adult life. The transcendence of hypersexuality into sexual addiction is clear in works such as Sex Ed for village boys by Alexander Ikawah (2014). The story details the sex life of young boys and girls through the lens of the narrator, his friend Mangwana and several other non-key characters. First, their obsession with sex is depicted in their primary school endeavours where they indulge in sex even behind their desks in class—at times, with the teacher right in front. This sense of addiction—although still at a mere sexual curiosity level in the children’s tenderness—appears right from the onset as evidenced in the following text: The most I had seen of sex by the time I joined secondary school was during an evening prep session back in primary eight when I dropped my eraser accidentally. I bent under my desk to find it and there, underneath the last desk on our row, Nancy Wendo was playing with my friend Mangwana’s penis, Caroline had her skirt pulled all the way back on one side, laying bare her big fat thigh, and Mangwana had his hand inside her white knickers… (p. 2)

However, a careful observation of details in the description of the scene by the narrator demonstrates cognizance of adult sexual acts by his classmates. The explicit sexual acts his classmates indulge in appear to be a recreation of scenes in graphic adult content in cinema and other forms of entertainment. This might allude to an early exposure to pornography. The depiction of sexual addiction in the story continues. A pornographic magazine is found at the school premises—a primary school as it is—for which none of the pupils admits ownership. By coincidence, the magazine finds its way into the narrator’s hands as the head teacher orders

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him to throw it into a burning fire nearby. Although he eventually does throw it into the fire, he first rips a page out of it, which he then uses for masturbation under cover in a restroom. These two incidents might have resulted from mere curiosity on sex and sexuality. Nonetheless, they are also revealing of an early exposure to graphic sexual content, which characterizes contemporary sexual addiction (Riemersma and Sytsma 2013). This hypersexuality as it is—often evolving into sexual addiction through the thematic and experience interconnectedness in the various works—renders it a trope at such a young age. It also appears explicitly in Kudinyana by Linda Musita (2014). The uncontrolled desire for sex is depicted right from the title Kudinyana, explained in a footnote by the author as what kids in the 1990s called sex in Kiswahili. Set in Tanzania, it portrays the addiction to sex as something that starts at a very young age in the society. Still out of curiosity and a probable exposure to sexual content, primary school-going children organize orgies. Comprehension of the element of early exposure to graphic content emanates from, among other aspects, lines in which the children refer to sexual acts between adults. For instance, as Pete and Wallace argue over a girl, they insult each other’s parents through a graphic description of sexual intercourse. Wallace mocks Pete’s mother by joking that she engages in sexual intercourse with her dog. It is the description of the sex scene that points to exposure to graphic sexual content. Of Pete’s mother, he says: What do you know about my mother when yours kamatanas with Popsy. That dog always barks loud and long when she goes out to give it food. Do you want me to show you how she puts Popsy on its back, parts its back legs, sits on its penis, holds its front legs and starts bouncing up and down? (Musita 2014: 9–10)

Such a vivid description only resonates well with someone who has once stumbled on cinematic or photographic representation of adult content, again pointing to the diagnostic criteria of sexual addiction put forward by Riemersma and Sytsma (2013). Contrary to the moral conservatism that African societies are associated with, the experience in this story is, on the whole, a true reflection of life, of sexual curiosity to most children, save for the graphic description of sex, which brings in the concept of possible addiction in its contemporary form. The assumed exposure to graphic sexual content also appears in Pete’s provocative statement, which alludes to re-imagination of a violent sexual scene when he says, ridiculing Pete,

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‘Like how your mother screams when your father gives her kei in her mkundu mnuko. Kuma ya mamako na makende zimestunya’ (Musita 2014: 9). A complete sense of this violent sex scene becomes clearer upon literal translation of the Kiswahili texts into English—explicit reference to a sexual scene that can only be viewed in an adult movie. From the ambiguities of sexual curiosity and hypersexuality versus addiction in very young characters in the literary works, the ambivalence transcends into clearer diagnostic cases of sexual addiction as children migrate into adulthood. In Richard Oduor’s Sex on a Train Wagon (2014), the male character, Tommy, starts his sexual exploits with his family’s housemaid just in his early teens when he is in Class 8, the last in primary school in Kenya, where the story is set (Oduor 2014). ‘He had seen a good number of legs and breasts since then but had largely avoided romantic attachment’. Tommy’s avoiding a romantic relationship in his continued sexual exploits with various partners indicates his addiction to sex. He has developed what Griffiths (2004) refers to as the level of tolerance in sexual addiction: Sex addicts gradually increase the amount of sexual activity because the current level of activity is no longer sufficiently satisfying (i.e., they build up tolerance). As tolerance develops, individuals may find themselves seeking out more unusual sexual experiences, more frequent sexual experiences, and more graphic pornography. (Griffiths 2004: 198)

Here, the character’s engagement in sexual affairs is devoid of any emotional attachment. It is strictly for pleasure, of course, until he realizes that he finally is addicted to his current girl (who is even already committed to someone else). Sexual addiction in the transitioning of an African from childhood to adulthood reappears in Ed for village boys (Ikawah 2014), where the main character details how naughty they (him, his age mates/classmates) were to a female teacher from university, lusting for her, and how they used to sex around with girls in their village when they were in secondary school. In one instance, the narrator explains how upon escorting a friend, Mangwana, he is offered sex with his friend’s girl as a token of appreciation for his scout role in his friend’s moments of ecstasy—which is his first time indulging in sex, and the last with Mangwana’s girlfriend as after that, Mangwana returns to an old friend he had opted to leave out this day (Ikawah 2014). In this work of fiction, they call it combi—combination

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sex. The narrator, in his description of the sex scene which he indulges in with Mangwana’s girlfriend, alludes to the graphic content he had seen while in primary school in that magazine—and what he would probably repeatedly see in his consequent exposures to porn material. This allusion is subtle, contained in the description he provides when he says, ‘I moved her legs so she was splayed out like the woman on the magazine page, and I stared’ (p. 5). The obsession over sex—and therefore, the addiction to it—is recurrent even throughout adulthood, not just in the transitioning period. For instance, in Sex on a Train Wagon, the narrator makes reference to the idea of an orgy inside a wagon of an old train that does not function (Oduor 2014). Although the narrative centres on Tommy and Natasha—the two main characters—the reference to the orgy signals that such an activity is part of the society, that it is nothing new. This is a story about two young lovers—aged twenty-seven and twenty-two, respectively—who are addicted to sex, with the female character not satisfied because her lover does not explore more during their sexual endeavours. What avails itself in this story is an explicit reference to sexual addiction, and its negative effects (right within the frames of sex and sexuality—not legal or moral repercussions). We are driven straight into the theme of sexual addiction first when the narrator lays bare the expectations and frustrations of Natasha in the following excerpt: She knew what he was going to do: yank off her panties, lift and pin her to the wall, undo his belt and shake his waist till his jeans were scrambled on the floor, then bulldoze into her. Rough and wild. She liked it sometimes. She did not like it sometimes. Addiction is a bad thing. When one is addicted, one uses the same formula to solve the same equation. She was a girl of many formulas. She did not want it that way today. (p. 24)

This text is a reassertion of the observation by Griffiths (2004) that ‘sex addicts gradually increase the amount of sexual activity because the current level of activity is no longer sufficiently satisfying’. The female character appears to be equally addicted as she always wants to experiment with other ways of having intercourse. Her dissatisfaction levels also appear in the fact that she is already in a relationship with someone else, but still engages in sexual activities with this male character for nothing but more sexual self-gratification. ‘Natasha knew Tommy was better than the midget asymmetrical boy with the cricket-voice that was her boyfriend’ (Oduor 2014: 25).

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In addition, Tommy’s determination to proceed with their encounter—for just one last time—in the wagon even when he knows that the wagons are not very safe pinpoints his resolve to indulge in sex at whatever cost. A month before the scene which is the focus of the entire story, a dead body was discovered in the wagons. Tommy knows this, but he hides it from Natasha because she would object to this recent meeting at such a place. Ironically, Natasha also knows that the wagons are not a safe place. ‘Natasha was impressed that the double-doors had not been cut off and sold as scrap metal. They gave the wagon a safe freedom. She could lock herself inside if she sensed danger’ (Oduor 2014). The pair’s cognizance of insecurity to their lives in the setting and their continued sexual exploits in the wagons attest to a diagnostic aspect of sexual addiction put forward by Griffiths. According to him, ‘the sex addict experiences severe consequences due to sexual behaviour and an inability to stop despite the adverse consequences’ (Griffiths 2004). Although there is no threat of imminent death on his subsequent list of the consequences, the situation with Tommy and Natasha provides an excellent rear view into how dangerous sexual addiction can become—and contributes generally to the discourse on the prevalence of sexual addiction in African societies. In Lagos Doesn’t Care by Socrates Mbamalu (2016), Seun, a poor Lagos resident battered by the country’s economic depression despite being a law graduate for over five years now, regularly has sex with one of the girls in his neighbourhood, Rashidat. Rashidat is a recent secondary school graduate waiting on fate to decide her destiny. Although it starts with him coaxing her, the girl soon becomes addicted, as told by the narrator: ‘As for Rashidat, she had become more emboldened after the first encounter. She was about eighteen. He never had to invite her to his room again. She came on her own’ (Mbamalu 2016). Although this would eventually lead him into trouble—Rashidat being ‘about’ eighteen and therefore still working through her future under parental guidance—Seun is too addicted that he ignores any possibility of plunging into adverse consequences. This is another representation of addiction—this time, traversing different levels of an African’s social and human development presented in the literary works. Sexual addictive disorder (addiction) includes recurrent failure to resist impulse to engage in a specified sexual behaviour—sex with a minor, in the case of Seun (Goodman 1993). This is also in line with the diagnostic criteria posited by Griffiths (2004) where the addicted individual ignores the threat of any possible adverse consequences and proceeds to engage in the specific sexual behaviour.

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It should be pointed out that the sexual addiction at this level is more than the perplexity of childhood sexual exploration. It, rather, results from the need for satisfaction of lust, not out of mere curiosity since its occurrence is recorded amongst mostly mature characters. Whereas the conversation between Tommy and Natasha in Sex on a Train Wagon creates the impression that they might be university students or graduates—and anything in between—there is no explicit reference to their level of education as is the case in Lagos Doesn’t Care and Sex Ed for village, where the main characters through which sexual addiction is portrayed are university students and graduates—depicting the various levels at which sexual addiction continues to exist. Compulsive masturbation, a recognizable behaviour of sexual addiction (Griffiths 2004), also comes in to play a central role in works detailing adult sexual life, such as Bound by Anne Moraa (2014) and Binyavanga Wainaina’s The idea is to be sealed in (2015). In the latter story, masturbation is chronic and compulsive. The character masturbates several times every day: It was here that he first masturbated, and soon enough, several times daily. The idea of being sexually vulnerable left him uncomfortable. That somebody would see his availability from sweat on his nose. He liked to leave his toilet into the world refreshed, neutered, and with enough enchant and novels in his bag to carry him through the day. (Wainaina 2015: 17)

In Bound, Alex and Ochiri are the main characters, with the earlier described as owning every woman because of his sexual feats. However, Ochiri’s satisfaction only comes through masturbation such that she always complements their sexual intercourse with a shower where she gets the desired satisfaction. But Alex is depicted as a man who has satisfied all the women he indulges in sex with, which brings into a reader’s mind the question of what could have possibly gone wrong this time around. Alex himself too is always contemplating the same. The fact that her satisfaction comes through masturbation might point to, among many interpretations, the possibility that she is so much addicted to the act that it would be hard to satisfy her by any other means. Discourses on dissatisfaction during sex as chronic masturbation’s side effects are popular among youths in many African societies, and this might be the authorial presentation of such popular discourses. Ochiri’s self-gratification masturbation connects her sexual life to the notion of addiction as explained by Griffiths (2004).

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She has attained the tolerance level. ‘As tolerance develops, individuals may find themselves seeking out more unusual sexual experiences, more frequent sexual experiences, and more graphic pornography’ (Griffiths 2004). This leads to psychological torture for the male character—but Ochiri cannot do otherwise.

7.4   Gender Representation In the literary works under review, the gender question comes into existence in the representation of the various perspectives towards sexual addiction. There is a parity pertaining to how male and female characters are depicted in relation to perceptions towards addiction. Some of the stories reflect chauvinistic dominance that relegates female characters to sex objects for various reasons. This is discoverable in works such as Nkatha Obungu’s Bobbitt wars (2014), in which the female character finds herself in a situation in which she has to indulge in sex with her boss—albeit against her conscience—for survival at her workplace. In the story, the male character’s sexual addiction feeds on objectifying the female character—his secretary. Her helplessness draws sympathy from readers, especially in the following lines: ‘His hand is still on my leg. It makes a rapid ascent up my thigh. I remain quiet. I think of warm food and a roof that doesn’t leak’ (Obungu 2014: 18). The sympathy gained leads to interpretations of sexual addiction inflicting more damage on the psyches of vulnerable women in workplaces. Just like in the other contexts pertaining to adverse consequences of sexual addiction, as discussed by Griffiths (2004), the boss cannot stop this sexual behaviour due to addiction—however consequential it might be to his very professionalism. The helplessness of the woman also enjoys a vivid depiction in It’s a Night Job by Joanita Male (2013) in which the protagonist—a university student—works as a hooker to earn a living. Although she is portrayed as the pinnacle for sexuality, the implication of her story is the sexual addiction of men who leave their families for sex with hookers in hide-outs. This is not an unfamiliar discourse in an African society. There is a tone of regret throughout It’s a Night Job (Male 2013) although she appears to suppress this tone between the pomp in her sexual exploits and the art of reading into her clients’ psyche. This resonates with the diagnostic aspects of sexual addiction in women, as proposed by researchers such as Carnes (2006) and Rinka (2013). Pushing the regret to her mother, herself a retired sex worker (kicked out of the profession due to old age and loss of

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taste), she is clear in her contemplations that she might have to quit the job sometime. ‘There’s a shadow of regret behind every smile she wears, maybe this is the effect of the night job’ (Male 2013). The reference here is to the protagonist’s mother, who had once been in the same business as the daughter. The sexual behaviour of Tommy in Sex on a Train Wagon (Oduor 2014) is also characteristic of the objectification of women. Although his relationship with the ladies might reflect consented sexual exploits on both parties, the lack of compassion characterizing the existence of such relationships is indicative of sexual addiction traits in men. The desire surrounding the male character’s sexual life is centred on objectification. His lack of emotional engagement with the women is indulging in intercourse, which denotes the objectification that characterizes sexual addiction in men (Rinka 2013). In some instances, the portrayal of women as mere subjects of sex relegates their essence in the discourse of sexual addiction to a level of insignificance in the stories, except where they serve as prostitutes. This chauvinistic influence on the stories comes out clear in Bound, where the male character is described as ‘owning every woman’ (Moraa 2014). The idea of ‘owning’ does not seem to include the woman as a sexual partner who delves into the act out of her own will, as an affair of sex addicts, but rather, as always forced into it—and by implication, rendering the man the focus of the addiction story. It is within the same lens that although the vivid description of the sex scene and the related circumstances in Sex on a Train Wagon point to the contrary, it is only the male character who the narrator explicitly acknowledges as being addicted to the lady despite boasting of past sexual experiences without any romantic attachments. But a careful read shows that if at all there was any explicit reference to sexual addiction, it had to relate to the female character, appearing to be at the centre of the lovers’ sexual endeavours. While some stories tow the lines of traditional discourses in society with masculine power being at centre stage, there are some stories in which addiction comes out through the celebration of sex through the feminine figure. The experience of such works aims at turning around the tables, telling the woman’s side of the story, where she does not have to be regarded as a mere object of sex without any control over sex and sexuality. Some studies indicate that while they may want a showering of ­attention or praise, women who struggle with sexual addiction mostly look to sex for power or control, with a postulation that female sex addicts

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are more likely than men to use sexual fantasies, either alone or with partners (Rinka 2013; The Ranch 2016). The entry into Transaction by Wanjeri Gakuru (2014) is a clear attestation to this notion. The story starts with the main character, a young lady who has just turned nineteen but has never had sex in her whole life, deciding how she wants to control her sex life. ‘You’ve just turned nineteen and are sitting in a tiny hotel room fiercely reciting to yourself that from this day forth the things that get trapped between your teeth and your thighs will be nobody else’s business but your own’ (Gakuru 2014). Later, although the protagonist has never had intercourse, she is worried that the sexual partner she has might be an amateur, and therefore, unable to satisfy her when she says: Your earlier worries about his amateur skills are confirmed. Chickening out already? You begin to assess the situation. You could stop…or you could get on top; crush his body under your weight, trap him within your spindly web of stretchmarks and take what you carefully saved up in order to pay for. (Gakuru 2014: 33)

This contemplation creates an atmosphere of sexual addiction from which she possibly learnt about sexual satisfaction (since before the act, she is a virgin, yet she raises concern for satisfaction already—even suggesting to herself means of ridding herself of such a worry in case it turns out real). Of particular interest is the fact the protagonist pays a man to have sex with her, which depicts the power of the woman too to explore sexuality while assuming total control over the whole sex scene. The protagonist’s worries of satisfaction also fit into the narrative of sexually addicted females tending to fantasize a lot about sex (The Ranch 2016). Sexual addiction also comes into play in a very different way in Madam by Tiffany Kagure Mugo (2015). Unlike most works where male figures are at the centre stage of sex and sexuality, Madam offers a new dimension to the narrative. The main character is a lady who frequents bars and other similar places in her pursuit for self-sexual gratification, which she attains through paying men for sex. Just like Natasha in Sex on a Train Wagon, the protagonist in Madam is in a committed relationship, yet her craze for diversity drives her into sexual addiction. Her social conduct is misinterpreted by society as resulting from insecurity (a psychological state), boredom, or latent childhood, yet she knows it is none of these (Mugo 2015). The narrator puts it straight in the following excerpt, discarding the male chauvinism that informs the norms and virtues in the Madam’s society:

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Neither was it based on a need to prove something or mask some hidden pain. It was a desire for the act itself. Some people liked chocolate. Others liked wine. She liked sex. People seemed to find it incomprehensible that a woman would simply want it so she did not waste her breathe explaining. (p. 10)

This is a form of the protagonist’s rebellion against the objectification of females in sex and sexuality. This representation counters the reality of life in most African societies, including within the story, which is highly characterized by masculinity and chauvinism. Madam’s tendency of keeping her heels on in the course of her sexual endeavours also emanates from both the desire to demonstrate an exertion of power as well as fantasizing as posited by The Ranch (2016) in relation to sexual addiction in women. The representation of both genders in the selected works of short fiction balances the notion of sexual addiction as a phenomena that exists in both men and women, although there have not been many studies exploring the feminine aspect of sexual addiction (The Ranch 2016). The representation tows the lines of arguments posited by scholars before (Carnes 1999, 2006; Fattore et  al. 2014; The Ranch 2016). It is apparent that men—as represented by the male characters in the fiction—tend towards ‘behaviours that objectify their partners and require little emotional involvement’. Specific examples of these behaviours would be anonymous sex, prostitution, pornography, exhibitionism, and fratteurism (Carnes 2006). Women, on the other hand, tend towards ‘behaviours that distort power’—either in gaining control over others or being a victim—as evidenced throughout their roles in the selected stories—from submissiveness in some to a total control of their sexual lives in others. Carnes (2006) equally includes sexual conquest, working as prostitutes, and sadomasochism as perfect diagnostic examples of women who are addicted to sex.

7.5   Age and Addiction to Sex The concept of sexual addiction contains varying perspectives across different ages. In relation to teenagers, Sussman (2007) notes that the appropriateness of sexual behaviour among teens is subject to divergent views. However, there are still noticeable differences between adolescent and adult sexual addiction. The first significant difference is that ‘occasional sexual behaviour often may not be considered abnormal in adults, whereas it may or may not be considered abnormal in youth because of the p ­ otential

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of such behaviour to interfere with emotional development and adjustment’ (Sussman 2005). In addition to that, Sussman (2007) argues that high-risk situations may differ between adolescents and adults. He notes that adolescents may be relatively likely to sexually act out while not being responsible for the care-taking of others. ‘Thus, they may bring worry to their parents or friends but not someone dependent on them (not including teen parentage)’ (Sussman 2007). While there is extensively available scholarly treatment of addiction from adolescence upwards, literature on sexual addiction before adolescence is rare. Most of the studies that appear to touch on the connection between children and sexual addiction do so in an attempt to connect childhood conditions that might have influenced compulsive sexual behaviour in adulthood. This has also led to divided opinion based on varying results from studies. For example, Riemersma and Sytsma (2013) argue that ‘classic sexual addiction emerges from a history of abuse, insecure attachment patterns, and disordered impulse control, often presenting with cross addictions and comorbid mood disorders’. Hatch (2014) also supports this argument by confirming that there is indeed a link between abusive conditions children go through and sexual addiction in their latter stages of life. However, a study by McPherson, Clayton, Wood, Hiskey, and Andrews (2013) found that ‘there is a lack of evidence regarding the nature of the relationship between childhood trauma and sexual compulsivity in adulthood’. In the contemporary short fiction under review, sexual addiction is recurrent across a range of age groups. From the various anthologies, it appears right from childhood and keeps manifesting itself until adulthood. However, at some point, it stops. There is no further exploration of the theme among very old people—this is noticed through the absence of aged characters in the stories. Characteristic of most societies, sexual exploits start at a very young age that we might be tempted to be oblivious to any suggestions leading to it as signalling sexual addiction. In Kudinyana (Musita 2014) and Sex Ed for village boys (Ikawah 2014), for example, the depiction of sexual addiction is blurred by the fact that it is children who display chronic sexuality features. However, a psychological perspective suggests otherwise. A read on Gallacher’s (2017) description of normal sexual behaviour reveals that what is depicted in the two works of short fiction is not normal sexual behaviour in children. In an article on sexual behaviour in children, she describes children’s sexual behaviour as concerning (thus pointing to worries of sexual addiction) when one of the following traits

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manifests in it: happens between children several years apart in age; behaviour continues despite parenting strategies (such as discipline); causes harm or potential harm (physical or emotional); and simulates adult sexual acts (Gallacher 2017). In Kudinyana, Banju, a twelve-year-old boy, has intercourse with his baby sister, Pinky, who is only six. The children hold orgies regularly, and are conscious of how their parents would react if they caught them red-handed. The endeavours between Banju and Pinky, and the conversations about sex that engulf the discourse prior to one of the orgies as well as the sexual habits are all a manifestation of sexual addiction, and as explained elsewhere, allude to early exposure to graphic content—a diagnostic feature of sexual addiction. The age ranges are different in story after story. In some stories, sexual addiction exists amongst university students who are in their teens and early twenties, while in other works, it is encountered through exploits of the working class. The impression which works such as Sex Ed for village boys (Ikawah 2014) create is that traits of sexual addiction remain prevalent in children’s sexual character as they grow into adulthood. This explains why the theme and experience of sexual addiction remains consistent and relevant throughout the story as its experience takes us through different age levels of the characters—from primary school through secondary to university. In Lagos Doesn’t Care (Mbamalu 2016), the main character dates both a teen and his land lady who is in her forties, with whom he regularly has intercourse. In Bobbit Wars (Obungu 2014) too, there are two workmates, a boss and his secretary, in a sexual relationship. Throughout most of the works in the anthologies, cases of sexual addiction are mostly manifested through adults. However, all the characters, drawing from the setting, plot and experience of the stories, belong to age ranges that are sexually active.

7.6   Morality and Addiction to Sex From the short fiction under review, there are multiple perspectives towards sexual addiction with regards to morality. In instances of sexual addiction in children as depicted in Kudinyana (Musita 2014) and Sex Ed for village boys (Ikawah 2014), it is in everyone’s conscience that sexual addiction is morally wrong. This is why when Mr. Oyoo, the head teacher, finds a pornographic magazine stuffed between the branches of the tree from which the school bell hangs in the latter, the atmosphere becomes tense. As the

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narrator in the story puts it, ‘the school was a Seventh-day Adventist school, and some things were bigger than mere punishment, so he cancelled all classes and called an impromptu assembly for all of us in primary six through eight’. This gives insights as to where the strict moral responsibility and its consequent repercussions in cases of deviancy stem from. Kudinyana (Musita 2014) represents a similar situation where the children indulging in sexual activities are aware of their moral reprehensibility. This is why even Pinky, the youngest of them all, threatens her elder brother that if he does not let her touch his ‘kanyamo’, she will reveal to their parents that her brother did ‘bad manners’ with Schola. Upon issuing such a threat, her wish is granted, immediately. However, in most of the stories, where the sexual addiction concerns adults, it is mostly in celebration of sex and sexuality, with a missing touch on morality. The repercussions of the addiction might, however, be an unconscious attempt to demonstrate how dire the consequences are to the reprehensible characters in society. For example, in it’s a Night Job (Male 2013), the regret that the protagonist’s mother’s face wears speaks of the immorality that is suppressed within the plot of the story. In the stories that celebrate femininity and depict a shift of power over sexuality from the man to the woman, the discourse simply does not give room to perspectives of morality—although there is often implicit reference to the cognizance of its reprehensibility. This lack of moral dimension to such stories portrays a divide in terms of sexual addiction and morality—sexual addiction is a morally reprehensible sexual conduct among the youth, while for adults, it appears normal.

7.7   Conclusion To sum up, there are a number of issues that we learn through our digging into contemporary African short fiction. In all the works in the five anthologies, there is erotic fiction, pointing to the changing patterns in discourse towards sex and sexuality. These two are the origin of the notion of sexual addiction, which has been noticed to be prevalent in most of the works, thereby leading us to an informed opinion on the existence of sexual addiction in African society and its multiple perspectives. Also, the analysis depicts a conscious shift in the representation of women in sex and sexuality as trapped in the theme of sexual addiction, which is the focus in most of the stories. Contemporary short fiction in Africa shows that sexual addiction is not considered much of a moral problem.

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However, the recurring theme of sexual addiction in contemporary short fiction has not been exploited fully in Africa. Both scholarly and non-scholarly literature on the phenomenon in literary works are almost non-existent. This might result from the fact that it is only recently that the subtlety of sex is being embraced in the works—though discourses around sex still remain a taboo at many levels. For future research, therefore, it would be vital if the rise of erotic fiction—often creating space for the emergence of sexual addiction in fiction—was to be brought into general literary discourses. This would open debates on whether the celebration of sex and sexuality contained therein must be upheld as such—mere celebration, or whether it should be treated as representative of a crisis in sex and sexuality hidden in the African society.

References African Writers Trust. 2013. Suubi: A Collection of Short Stories and Poems from the African Writers Trust’s Creative Writing Programme Produced in Association with the British Council. Kampala: AWT. Carnes, P.J. 1999. Editorial: “Cybersex, Sexual Health, and the Transformation of Culture”. Sexual Addiction & Compulsivity 6: 77–78. Carnes, P. 2006. Women and Sex Addiction. Counsellor 7: 34–40. Fattore, L., M. Melis, P. Fadda, and W. Fratta. 2014. Sex Differences in Addictive Disorders. Frontiers in Neuroendocrinology 35: 272–284. Gakuru, W. 2014. Transaction. In Sext Me Poems and Stories, ed. K.  Hampton, A. Moraa, and T. Gabonewe, 31–34. Nairobi: Jalada Africa. Gallacher, C. 2017. Sexual Behaviour in Children: Warning Signs and Alarming Trends. Protect Young Minds. https://protectyoungminds.org/2017/04/27/ problem-sexual-behavior-children. Retrieved 8 Oct 2018. Goodman, A. 1993. Diagnosis and Treatment of Sexual Addiction. Journal of Sex and Marital Therapy 19 (3): 225–251. Griffiths, M. 2004. Sex Addiction on the Internet. Janus Head 7: 188–217. Hatch, L. 2014. The Myth of the ‘Normal’ Childhood: Why Are You a Sex Addict? Psych Central. https://blogs.psychcentral.com/sex-addiction/ 2014/01/the-myth-of-the-normal-childhood-why-are-you-a-sex-addict/. Retrieved 15 Oct 2018. Ikawah, A. 2014. Sex Ed for Village Boys. In Sext Me Poems and Stories, 2–9. Nairobi: Jalada Africa. Jalada. 2014. Sext Me Poems and Stories. Nairobi: Jalada Africa.

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Karila, L., A. Wéry, A. Weinstein, O. Cottencin, A. Petit, M. Reynaud, et al. 2014. Sexual Addiction or Hypersexual Disorder: Different Terms for the Same Problem? A Review of the Literature. Current Pharmaceutical Design 20 (00): 1–9. Male, J. 2013. It’s a Night Job. In A. W. Trust. Suubi. Retrieved on January 20, 2018, from http://africanwriterstrust.org/wp-content/uploads/2013/03/ suubi.pdf Mbamalu, S. 2016. Lagos Doesn’t Care. In Your Heart Will Skip a Bit and Other Stories: The Writivism Flash Fiction Anthology, ed. Writivism, 34–39. Kampala: Bahati Books. McPherson, S., S. Clayton, H. Wood, S. Hiskey, and L. Andrews. 2013. The Role of Childhood Experiences in the Development of Sexual Compulsivity. Sexual Addiction & Compulsivity: The Journal of Treatment & Prevention 20 (4): 259–278. Moraa, A. 2014. Bound. In Text Me Poems and Other Stories, ed. K. Hampton, A. Moraa, and T. Gabonewe, 20–23. Nairobi: Jalada Africa. Mugo, T.K. 2015. Madam. In My Maths Teacher Hates Me and Other Stories, ed. Writivism. Nairobi: Jalada Africa/Writivism. Musita, L. 2014. Kudinyana. In Sext Me Poems and Stories, 9–15. Nairobi: Jalada Africa. Nwabueze, E. 2017. Sexuality and Culture in Postcolonial Africa. Saarbrücken: Lambert Academic Publishing. Obungu, N. 2014. Bobbitt Wars. In Sext Me Poems and Stories, 16–19. Nairobi: Jalada Africa. Oduor, R. 2014. Sex on a Train Wagon. In Sext Me Poems and Stories, 9–15. Nairobi: Jalada Africa. Riemersma, J., and M.  Sytsma. 2013. A New Generation of Sexual Addiction. Sexual Addiction & Compulsivity: The Journal of Treatment & Prevention 20 (4): 306–322. Rinka, E. 2013. Sexual Addiction and the Female Client. The Faculty of the Adler Graduate School. http://alfredadler.edu/sites/default/files/Rinka%20MP% 202013%20.pdf. Retrieved 24 Oct 2018. Shercliff, E., and B.  Bakare-Yusuf, eds. 2015. Valentine’s Day 2015 Anthology. Lagos: Ankara Press. Sussman, S. 2005. The Relations of Cigarette Smoking with Risky Sexual Behaviour Among Teens. Sexual Addiction & Compulsivity 12: 181–199. ———. 2007. Sexual Addiction Among Teens: A Review. Sexual Addiction & Compulsivity: The Journal of Treatment and Prevention 14: 257–278. The Ranch. 2016. Are There Gender Differences in Sex Addiction? The Ranch, July. Wainaina, B. 2015. The Idea Is to Be Sealed. In Valentine’s Day Anthology, ed. E. Shercliff and B. Bakare-Yusuf, 11–13. Lagos: Ankara Press.

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Weiss, R. 2016. Hypersexuality: Symptoms of Sexual Addiction. Retrieved June 7, 2018, from Psych Central: https://psychcentral.com/lib/hypersexualitysymptoms-of-sexual-addiction/ Writivism. 2015. My Maths Teacher Hates Me and Other Stories. Kampala. https:// jaladadotorg.files.wordpress.com/2015/06/my-maths-teacher-hates-me-andother-stories-pdf.pdf. Writivism. 2016. Your Heart Will Skip a Beat and Other Stories. Kampala: Bahati Books.

CHAPTER 8

Popular Culture and Representations of Addiction: Understanding Malawi Urban Music in the Narratives of Drugs and Sex Dave Mankhokwe Namusanya

8.1   Introduction At the turn of the century—or just at the close of the last one—a new genre of music appeared in Malawi. At a loss as to what to call this type of music, for it could not be properly categorised as it did not belong to any of the genres that Malawians were used to, it was called urban music. It remains unclear as to who did this christening, whether the producers of the music, the audience or the media. Nevertheless, over the years, it has been identified as urban music. It is not that this new genre of music is just for ‘urbanites’ or the ‘elites’ for it to be called thus. It might, however, be that it is due to its producers’ intent to divorce from the ‘local’ that got it the name (if it was labelled by the musicians) or it might be that commentators assumed that the music appealed to an urban populace (if the labelling was by the audience) or even that the way the producers carried or conducted themselves, especially in videos of the songs, had more of an urban tilt (if the media did the labelling).

D. M. Namusanya (*) Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_8

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In the years that have gone by, the term ‘urban music’ has come to be understood as a blanket description of the new genre of music that cannot be identified as ‘local’. It is important, however, to highlight that in more recent years, urban music has been a genre that is neither foreign nor local as it has enthused its foreign rhythmical approach with local instrumentation to create a genre one would hardly call Malawian, but also would not call non-Malawian. Even the videos made of the music are mostly divorcing from that urban tilting and are mostly showcasing people in what is considered ‘traditional attire’ in rural settings. Spurred by the rise of internet usage and music sharing sites, urban music has asserted itself as one of the most valuable music genres in Malawi (Mughogho 2017). It now commands a huge listenership,1 a significant amount of downloads from music websites and its producers are regarded as celebrities and influential such that companies and organisations have started courting them for advocacy as well as brand promotion (Chavi 2017; Kumwembe 2017; Music in Africa 2015). At the same time, however, urban music has largely been unregulated. As most of it is not produced for the radio, but for the audience—and can be directly delivered to them through Messaging Apps as well as music download websites that can sometimes have untraceable owners—censorship of the music has been weak. It is usually self-censorship that drives the tone and approach of urban music. This has, in turn, left urban music as a medium in which raw, undiluted and unedited perspectives of Malawians are portrayed. This chapter aims to discuss how urban music presents addictions in Malawi—specifically of sex and drugs (alcohol and marijuana). It will focus on an urban musician, Mafo, as its subject. Mafo has been selected as it has been noted that he is among the urban musicians that have hardly been tampered with by institutional/organisational affiliation or support; and he is, therefore, well placed to provide a mirror into the nature of addiction of drugs and sex in Malawi; also, as one of the most followed among young people—especially those hard to reach in areas fondly called the ‘ghettos’2—his music does not only reflect the situations of the people who like the music, but also has the ability to have a 1  MBC Radio 2 has a programme, Made on Monday, specifically dedicated to urban music. The contents of the programme generate a healthy discussion on social media (mostly driven by hashtags). 2  Usually, parts of a city in which the most economically disadvantaged families live.

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significant influence on them, especially young people at the stage of charting their own attitudes and perspectives to life. Thus, the chapter in concluding will argue on the hypothesised impact that the music would have on the young people who are its chief consumers.

8.2   Understanding Urban Music in Malawi As already highlighted in the introduction, the term ‘urban’ in this new genre of Malawi music does not imply that the songs are only associated with urbanites. The music, although mostly produced by urban-dwelling young people owing to their ability to access recording and distribution points, has a following among young people across the country (Gondwe 2017)—with even more appeal to those in rural areas who have little access to other types of music from other sources (e.g. foreign television or radio stations). The observed common characteristics of urban music, apart from the demographics of its producers or consumers, include its borrowing from a ‘Western’ (mostly African American) culture of music and its ability to violate norms as it is beyond or below the reach of censorship; of note, it is also the fact that the producers of urban music trade under stage names. Critics of urban music abound, with people mostly labelling it as ‘bubble-gum’ and ‘noise’ music owing to what would be understood as its irrelevancy (Gondwe 2017; Ndebvu 2017). However, urban music remains a cultural space for young people, and as a popular culture product, it functions within the spaces of young people as other popular culture products. Popular Culture, Malawi Urban Music and the Youth Young people have been shown to represent the biggest producers and consumers of popular culture (Newell et al. 2014; Dolby 2006; Chirwa 2001). This is also applicable to urban music in Malawi, where its main consumers remain young people (Gondwe 2017). Diouf (2003) makes a specific case regarding the youth of Africa, analysing their position at the confluence of global and local cultures and how this is reflected in their intimate relationship to popular culture (see also Ansell 2016; Kraftl et al. 2012; Ansell et al. 2011); these global cultures are the ones that birthed urban music in Malawi; thus, also, its appeal to the youth. Newell, Okome and Forster (2014) argue that it is precisely popular culture, with the

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youth as its producers, which symbolises an eclectic response to change by harnessing both conservatism and rebellion at the same time. In relationship to urban music in Malawi, its ability to enthuse local and foreign ­elements, advocate for youth causes while using language that might otherwise not be acceptable within the frame of ‘conservatism’, makes it an attractive genre to young people who are already at the confluence of the ‘local’ and ‘global’ cultures and are having to adjust in a conservative society while challenging it at the same time. It is no wonder that others have suggested that popular culture—urban music, in this case—shares many traits and characteristics with youth culture (Newell et  al. 2014; Dolby 2006). It is nevertheless important to indicate that popular culture, in which urban music is a product, is not simply a product of the youth. It is, as Miller (1998) argues, a formative space that has implications on society. It is a space of struggle and negotiation (Storey 2014), in which youth conceptualisations are created and/or reinforced. As Dolby (2006) asserts, popular culture has the power to affect public spaces and the social fabric of society by influencing the ways youth conceptualise various issues. This, in turn, does not only apply to the youth, but also to the foundational societal structures (Barber 1987; Fabian 1978). Hence, urban music, rather than merely reflecting its consumers, also has the power to shape them, the normative underpinnings of their society and would have a significant impact on the conceptualisations in societies as well as policy reaction to issues—addiction, in this case. It is the power of popular culture to ‘ask questions and create conditions’ (Fabian 1978: 319) that makes it a vehicle through which ‘future alternatives and possibilities are expressed’ (Newell et  al. 2014). These alternatives and possibilities are usually identified and shared by the masses that would otherwise have been excluded from ‘modern elite’ or ‘tribal traditional’ spaces (Fabian 1978: 315). In this context, it is the ability of urban music to point to a future just as it challenges the present that makes it an interesting aspect to study and understand if one is to ably establish a conceptualisation of addictions that is relevant for the current times and, possibly, the future. In Africa, popular culture has been used to relay information as well as maintain or challenge the status quo (Newell et al. 2014; Chirwa 2001). It has been used in political, social, economic and religious contexts, and with manifold motives and agendas (Barber 1987). Some of this is due to what Vail and White (1991) define as the ability of such forms of art to

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violate normal conventions; such are features that are hugely prevalent in urban music. Thus, as an urban musician, one has the ability to challenge the status quo using a platform that would resonate with most people— the youth in this case. In Malawi, Mafo is among those urban musicians with the arguable ability to change the status quo. Popularly known just by his first name, Mafo Kamwendo is training as a primary school teacher at Blantyre Teachers’ Training College. He is one who has attracted some respectable level of attention among music critics and fans—especially of urban music. He came to the limelight in 2013, which is the year that he released his first song. His music releases have generated a considerable attention and controversy in the public space owing to their ‘liberal’ content in a considered ‘conservative’ society, and also his common ability of ‘stealing’ songs from other musicians so that he can redo them, usually replacing the original words with new words that mostly glorifies smoking, sex and beer. Of prominence is the song that led to his fame, Mowa, which, in brief (and as the chapter will later discuss), is a glorification of beer over women—or sex.

8.3   Understanding Addiction Room (2003) highlights that addiction is a social construct. Nevertheless, the DSM Manual V (American Psychiatric Association 2013) indicates that in most societies, there is reference to addiction. Addiction, however, in this sense, is understood as the compulsive and habitual use of substances with consequences coming from such a use. Jacobs (1986), citing the Standard Medical Dictionary, has held that addiction is ‘the state of being given up to some habit, especially strong dependence on a drug’ (p. 18). In this context, the addictive state has been presented to be this four-step process: 1. an overwhelming desire or need (compulsion) to continue use of the drug and to obtain it by any means; 2. a tendency to increase the dosage; 3. a psychological and usually a physical dependence on its effects; 4. a detrimental effect on the individual and on society. In this case, addiction is not just a case of an overreliance on a drug or a substance; it is also the effects that arise from the use of such a substance and the subsequent dependence. This is also the reason why there should be interest in addiction, considering that it ceases being an individual action as it has repercussions that impact on the collective.

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8.4   Representations of Addiction in Popular Culture Literature on popular culture and addiction has mostly focused on visual representations of addiction (see Hilton 2000; Hirschman 1995). Much of it has also been of other contexts, not Africa (see Nichter 2003). A discussion of addiction weighing heavily on addiction, as portrayed in soap operas or video games and music videos, might not accurately depict the Malawian situation, where only few people can access such products. Room (2003) argues about the need for understanding addiction within the cultural context in which it is experienced and described; thus, his argument that addiction is a social and cultural construct presents an opportunity to initiate a discussion on addiction from products situated within a specific culture—the Malawian culture, in this context. In line with understanding addiction experiences within a context in which the addict and the community exists, the chapter will discuss the presentation of addiction in Malawian urban music, specifically focusing on the music of Mafo. The discussion will be on how the music presents addiction of alcohol, marijuana and sex. The Alcohol in Mafo’s Songs Released in 2013, Mowa is arguably the one song that catapulted Mafo to fame. As of July 2018, the song had over 52,000 views on music website, malawi-music.com.3 It is one of the songs that can be sung along by most young people who are his fans—and even those who are not. The title of the song itself betrays the message: the focus on beer. Thus, at the crux of the song is the glorification of beer. Beer consumption, in itself, does not pass for an addiction. However, in the last verse of the song, Mafo sings (Mafo 2013b): Ife bawa timachita kusambila (We actually swim in beer) Tikamayenda daily tikuzandila (Every day we have to stagger after being intoxicated) Mumtima timakhala tikunyadila (Yet that gives us joy) 3  Malawi-music.com is the major website distributing Malawian music. Most of its uploads are of urban music and its major consumers are young people with access to the internet.

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In these words, Mafo does not just sing of a person who occasionally drinks. He sings of one who drinks as a daily routine. Or, in brief, one whose existence centres on beer. Using an imagery of swimming in beer, one can conclude that the way Mafo presents the song subject’s relationship to beer is that which exists between fish and water—the former can hardly survive out of the latter. In this regard, by inference, the subject can hardly survive without taking beer. This, as Herman and Roberto (2015) point out, is the first step in the journey towards addiction which, they call, is the stage of preoccupation in which a user anticipates the consumption of the addictive product and is preoccupied with its use. Room (2003), in arguing on the interpretive framing of addiction, asserts that an addict reaches a stage where the craving for the addictive product is huge such that they disregard some other barriers to accessing the drug just to satisfy this craving. In this regard, a beer addict would get to drink even if their situation and context is one which would discourage an occasional drinker from having to drink. Mafo, in the same song, Mowa, propagates this idea of addiction, glamorising it in a way. In the later lines of the song, his portrayal of drinking is of a subject who, at all costs, has to be drunk—even in bad weather. This is also regardless of the consequences that he later sings about including the failure to care for oneself. As the song goes on, Mafo highlights that even clothes are not something that the subject in the song is bothered with because they are expensive. Underneath this declaration might be a veiled  criticism of the capitalistic economy that would place a higher price on clothes while making beer affordable; nevertheless, it is also a highlight of addiction in which, to the addict, what matters is to satisfy the craving for the addictive product—beer, in this case—even if it is at the expense of his own well-being. This glorification—not just of beer but addiction to it—appears to be a recurring theme across Mafo’s music. In 2017, he did a cover of Nigeria’s P Square song, Bank alert. He titled it Bawa, which is slang language for beer. It is more of the 2013 Mowa story; this time further highlighting that he does not just glorify beer consumption, but an overreliance on beer which, according to the seminal work of Jellinek (1952), is a sign of addiction to beer. In the song, to further highlight that it is addiction the voice romanticises, Mafo sings (Mafo 2017):

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Ine ndi wa ma blunder (I am always making mistakes) N’kona ndimangoyaka (So, I just drink) Kuyenda sober zimanyazi mbwembwembwe (If I try to walk around without drinking, I am anti-social)

In these lines, Mafo portrays a situation in which the subject is one who can hardly function without beer. Thus, the person has internalised that he is one who makes a lot of mistakes and the only way to survive through such a tumultuous lifestyle and struggle with the community he is a member of is to go through life as a drunk. In addition, this person actually says that he is anti-social, yet when he is drunk, he becomes courageous. This might indeed be misconstrued for Dutch courage, but those in need of Dutch courage have to take beer at that very moment they want the courage (Room 2003; Jellinek 1952), not every day—as Mafo is portraying the subject in the song. This beer addiction that has in a way defined Mafo’s career was carried through to a 2018 release of Mafo and a colleague, Gibo Lantos: Okondedwa merchant. As highlighted, Mafo’s career has mostly thrived on having to redo popular songs done by others. This is a remake of prominent musician-cum-politician Lucius Banda’s 1998 song, Kuno zavuta. Whereas in the original song, Banda uses the voice of a young nephew writing to an uncle in the diaspora of the events back home, which include deaths, diseases and hunger, Mafo and Lantos use the song to write to a ‘friend’ who took them out for beer drinking. That Mafo would hijack a song which had commented on disparate socio-political themes just to use it for a commentary on beer drinking habits might also be stretched to highlight further the obsession that Mafo’s art has on beer. Even the following lines further buttress the point (Mafo and Lantos 2018): Sungatitenge ku bawa ndikupezeka watithawila (You can’t bring us over to a beer drinking joint and leave us stranded) ………………………… Apa tili sober mpaka Gibo akufuna kulira (Look, we are sober and my friend is about to have a mental breakdown)

In that unsuspicious manner of singing about beer addiction in a glamorising way, Mafo highlights a person—referring to his colleague Gibo Lantos—who is about to have a break down because ‘enough’ beer has not been made available to them.

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It is so huge an addiction that Mafo glamorises, for beer, that even when he sings a song glorifying a Malawian pastor based in South Africa, Shepherd Bushiri,4 in a 2016 release, Akadipweteka maluzi, Mafo makes references to beer. Thus, he sings (Mafo 2016): Ndimamuganizila Bushiri ndikati ndapsa (I think about Bushiri when I am broke) Koma ndikasanja ndimayaka mpaka thapsya (Yet, when I have money, I get drunk until passing out)

In these lines, the voice narrates of a character notorious for his drinking. Although Room (2003) argues that addiction has to be understood within a cultural context, Malawian society is replete with historical and current examples of people obsessed and renowned for beer drinking, who would be on a similar level with the voice in the earlier lines who are known to be drunkards. Such characters are not just drunkards; they are addicted to beer. The Marijuana in Mafo Songs In 2017, Mafo, together with his friends operating under the group ‘Good shudren’,5 did a song titled Sufuna. It was, as per Mafo’s reputation, a redo of another song; only this time it caught much flak with music columnist Gregory Gondwe (2017) labelling it ‘folly play’. The song, originally a Christian hymn6 and popularised by Christian music singer Elton Kazembe, was remade to celebrate three things: beer, marijuana, women (sex). In the song, the group asks colleagues to join them on the journey to drinking, smoke with them or go looking for ladies. However, it should be highlighted that there are three musicians in the song—all urban music artists—who have a thing each to celebrate of the three: beer, marijuana, women. Thus, the part that celebrates marijuana was not, at least in the 4  Arguably one of the most renowned Malawian pastors, Bushiri is assumed to be the richest pastor in Malawi. He claims to own businesses and personal jets and does a good number of charity works in Malawi and beyond. He is based in South Africa. 5  Together with Legnz boy and Nyasa B, Mafo formed the group which in traditional English would be ironically called ‘Good Children’. They usually sing in a religious choral fashion although the themes they sing of are divorced from religious messages. 6  The original Sufuna song is about a Christian leader asking a colleague/congregation if they want to join him on the journey to Paradise.

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song, done by Mafo. Nevertheless, as this chapter is largely discussing urban music in Malawi while zeroing in on Mafo who also appears in the song, it will have to draw the words not directly sang by Mafo (Good Shudren 2017a, b). Mesa unkati Chamba chimapengetsa (You used to say marijuana causes mental illness) Bwanji ukufuna kusuta nawo (Why do you want to smoke with me?) Ine ndi wa ganja olo Bae amadziwa (I like marijuana, even my lover knows)

In subsequent lines, the musicians mock their friends that they are not smoking because they do not have access to marijuana (perhaps because they do not have money). Thus, to Mafo—and his urban music colleagues—an explanation for one not smoking at that particular moment might be understood through the lens of lack: they do not have marijuana. As Miller (1989) argues, the first critical element of marijuana addiction is the preoccupation with the consumption of marijuana; this is the initial phase of all addictions as well. Thus, one has to be consuming or, if they are not, it is because they do not have it—not because of self-restraint. On the same note, as the earlier lines show, despite being aware of the negative consequences that marijuana might have (i.e. triggering mental illness), they still have to smoke. Citing the 1952 work of Jellinek in discussing addiction, Room (2003) highlights that addiction is manifest through a loss of control. This loss of control might be in the consumption of the addictive drug. Thus, despite knowing the negative effects of the addictive product, an addict will still consume the product. In the song, the subject is one who smokes, regardless of the awareness of the consequences of smoking. In Bawa, Mafo also mentions—mostly in passing—his fondness for marijuana. It is just a line, almost seemingly callously thrown in, but then the line talks of the intensity of the smoking (i.e. every day); this points to that naturalised desire to consume marijuana and the loss of control that the subject has in regards to marijuana. This idea is reinforced in a 2015 release, Tetelitete, in which he features two friends: Zafrey and Nyasa B. In the song, Mafo sings (Good Shudren 2015):

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Anandilodza ndani ine kuti n’zingobanda (Who bewitched me so that I can always be smoking marijuana?) Kuipitsa mbiri ya achinyamata (And in the process, I ruin the reputation of young people)

Invoking witchcraft, Mafo presents the subject as incapable of controlling his desire for smoking. Thus, the subject is convinced that someone cast a spell on him to be consuming marijuana on a daily basis. Room (2003) argues that addiction is a cultural construct. Thus, in some other contexts, what might be construed as addiction in Psychiatry studies might be referred to as other reasons and might be conceptualised differently. This appears to be the line of reasoning in the above lines that evoke witchcraft. However, the lines also project an image of a person feeling guilty about the consumption. The work of Jellinek (1952), using a case of alcohol addiction, argues that when an addict discovers that their consumption of the addictive product is outside of the ordinary, they develop guilty feelings about their behaviour. This appears to be the situation of the subject in the earlier lines. This guilt, in the earlier lines, is being placated by the allusion to witchcraft. Sex Addiction in Mafo As already highlighted, the song that propelled Mafo to fame—Mowa— might appear as if his career has been built around glamorising beer for in the song he touts beer to be a better companion than women. It is as if he is one who is not bothered with sex. Understood within the context of addiction, it is as if the running theme across Mafo’s music is of a subject suffering from the addiction of beer and marijuana such that the person cannot even hold a relationship. However, Mafo’s career has also been built around the objectification of women—and, in the long run, the glamorising of sex. This glamorisation, when understood in context, pinpoints to an obsession that would be understood as sex addiction. His first traceable song to be released to the public which, of course, had less success than Mowa, was titled Zako. It is a song that ‘celebrates’ a woman’s body. It is mostly a sexualisation of a woman’s body—parts mostly—from the eye of a sex addict for, beyond or below anything, the voice does not sing of anything else that would not make sex more pleasurable for the voice. Thus, the words (Mafo 2013a):

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Koma ndimakonda maonekedwe ako (I love the way you look) Basitu, mwina ndi thupi lako (Just the way you look and maybe your body) Kupanda apo panalibe chako (If it wasn’t for these two, there was nothing for you)

Goodman (1998) highlights that frequent occupation with sexual activities would pass for a spectrum of sex addiction. This view is echoed by Zapf et al. (2008), who argue that to understand sexual addiction is to understand preoccupation with sex in the same way one would understand preoccupation with a drug—alcohol, for instance. As it has been argued, addiction to alcohol also implies a preoccupation with it (Jellinek 1952). In the lines referred to, the persona in the song is one whose relationship with a lady revolves around sex; thus, the obsession with the body and the physical outlook of the lady. This can implicitly be understood to be a preoccupation with sex such that the subject in the song cannot look beyond the physical attributes of the lady to be with her. The verse on which Mafo sings in Sufuna is a glorification of sex, albeit couched as an admiration of women and dangerously presented as love. In the lines that he sings, the presentation of the voice in the song is that of one with an uncontrollable desire to ‘love’ every other lady that he comes across. This love, when weighed from the context of Mafo’s presentations of love, pinpoints more to ‘sex’. An understanding of the lines in the song without all the civility that Mafo uses to communicate in the lines would be of one who claims that he has an insatiable appetite to have sex with every other ‘good lady’ that the person comes across. This would pass for what Goodman (1998) argues is sex addiction. Thus, he argues that sexual addiction is characterised by a recurrent failure to resist the impulse to have sex. This sex is not just done with one partner, but a number of partners (Carnes 2001). In what can be equated to a hunter going about in a jungle looking for game, the chorus has the persona inviting friends to follow him on a ‘hunting’ trail for ladies to ‘love’, as per his modus operandi of ‘loving’ any good lady that he comes across. The persona further mocks his friends who are not willing to go with him on the trail of ‘hunting’ for ladies as failing to join him because they are just not good with ladies. Thus, if one is good with ladies then they just have to be going around ‘hunting’ for them.

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As highlighted in the discussion on marijuana, for the addict his understanding of the world largely rests on the addictive product and he is convinced that such is the reality of the world. Thus, to the addict, whoever is not like him in pursuing the addictive product is lacking and is not self-­ restraint. Addiction, in itself, is characterised by the lack of self-control (Jellinek 1952). Specifically arguing on sex addiction, Carnes (2001) claims that sex addicts have a belief system which affects how they perceive reality and leads to an impaired thinking which, in this case, can be argued as how the addicts perceive those who opt to exercise self-reliant. In Okondedwa Merchant, Mafo continues with this portrayal of sex addiction. Thus, weighing it in line with beer, the voice in the song sings (Mafo and Lantos 2018): Wati: ‘ndikubwela kaye, ndapana winawake ndikufuna kuufila’ (You have excused yourself to go and have sex) … Koma yemwe wapanayo (But the lady whom you have left with) Nafe tikufuna titapanako (We also would like to have sex with her)

Regardless that another person has a lady, the voice in the song still wants to get that lady. As an addict, there is no respect of boundaries (Carnes 2001). It is, of course, an objectification of women, portraying them almost as a bus seat: in which when one takes leave, another should come in to replace that person. Addiction to sex, for the male, usually has that point in it: the objectification of women. This makes it easier to ascribe the consequences of the addiction to other factors; so, as Carnes (Ibid.) highlights that a sex addict would dismiss concerns from the conscience or other people with rational justification, he would also dismiss it here by objectifying women. In context, an addict would justify his promiscuity as one who is just ‘dealing with object (s)’ and his actions therefore do not have any consequences. Zapf et al. (2008) have also argued on the nature of sex addicts to be ‘avoidantly-attached’ in relationships; such people are mostly afraid of intimacy and are emotionally cold; such people would feel less guilty by viewing their partners as objects. This objectification is also there in the song, Samalani ma babe anu. This is a song Mafo does with friends under the same banner of Good Shudren. In the song, the voice advises other men to take care of their women because once they

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lose them and are picked up by others, the team (behind the voices in the song) will not give them (the women) back to the rightful owners (the other men). As a property, a woman can be lost and picked up by another and that other person can refuse to give it back to the ‘original owner’—that is the concept of the song. This objectification points more to sex addiction in which the addict is placating self-guilt by appreciating the targets of his addiction, women in this case, as lifeless objects.

8.5   Conclusion Addiction has become a health hazard with a significant impact on global health and the economy of countries as money has to be spent on rehabilitating addicts and there is a loss of manpower. At the worst, addiction also leads to death, leaving a significant cost on families, communities and the state as the number of people in need of state support might go up. There is a need for a holistic approach in dealing with addiction. However, to ably deal with addiction, one needs to understand the nature of it. It is through understanding the communication around addiction that one gets an opportunity to understand the narratives around addiction and can, therefore, devise effective strategies to use in countering the problem. One such communication avenue through which addiction is discussed is music. This chapter has shown that urban music in Malawi is a significant carrier of messages on addiction; however, instead of challenging behaviours that would lead to addiction, there is a celebration and glamorisation of such behaviours. Using Mafo’s songs, the chapter has highlighted how beer, marijuana and sex are glamorised. As the music is widely enjoyed by young people, it might be argued that young people are more likely going to shape their attitudes towards addictive substances/behaviours from songs, and this would pose a huge impact in challenging such attitudes. The field of urban music in Malawi is just developing. Yet, in its development, it is one that carries varying messages and arguably has an impact in shaping realities, mostly of young people. However, there has not been much research on the interaction of the messages with the youth and how young people negotiate with the messages. Hall (1973) and Storey (2014) have argued on the processes of message deconstruction and consumption in popular culture, highlighting that people do not consume popular ­culture mindlessly and passively. It would, thus, be interesting to establish

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how people consume urban music. Of interest would also be the processes of producing urban music and the sources of knowledge for the producers of popular culture; further research can question if producers reflect their societies or challenge their societies. At the same time, pertaining to addiction, a Malawian conceptualisation of addiction is something that is of interest; this might create pathways to managing and rehabilitating addicts using local resources.

References American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing. Ansell, N. 2016. Children, Youth and Development. London: Routledge. Ansell, N., L. van Blerk, F.  Hajdu, et  al. 2011. Spaces, Times, and Critical Moments: A Relational Time-Space Analysis of the Impacts of AIDS on Rural Youth in Malawi and Lesotho. Environment and Planning 43: 525–544. Barber, K. 1987. Popular Arts in Africa. African Studies Review 30 (03): 1–78. Carnes, P. 2001. Out of the Shadows. Minnesota: Hazelden Information & Edu. Chavi, N. 2017. Tay Grin Signs K8 Million Ambassador Deal with Astro. http:// www.manaonline.gov.mw/index.php/entertainment/item/6227-tay-signsk8-million-ambassador-deal-with-astro. Accessed 20 Jun 2018. Chirwa, W. 2001. Dancing Towards Dictatorship: Political Songs and Popular Culture in Malawi. Nordic Journal of African Studies 10 (1): 1–27. Diouf, M. 2003. Engaging Postcolonial Cultures: African Youth and Public Space. African Studies Review 46 (2): 1. Dolby, N. 2006. Popular Culture and Public Space in Africa: The Possibilities of Cultural Citizenship. African Studies Review 49 (3): 31–47. Fabian, J. 1978. Popular Culture in Africa: Findings and Conjectures. Africa 48 (04): 315–334. Gondwe, G. 2017. Turning Hymns into Folly Play. https://gregorygondwe. wordpress.com/2017/08/29/turning-hymns-into-folly-play. Accessed 18 Jun 2018. Goodman, A. 1998. Sexual Addiction: An Integrated Approach. Madison: International Universities Press. Good Shudren. 2015. Tetelitete. https://www.youtube.com/watch?v=S-T9XJs5l0Y. Accessed 11 Jun 2018. ———. 2017a. Samalani ma babie anu. https://www.malawi-music.com/G/756good-shudren-exclusive/3585-samalani-ma-babie-anu/7726-samalani-mababie-anu. Accessed 10 Jun 2018. ———. 2017b. Sufuna. https://store.malawi-music.com/product/good-shudren-choir-sufuna-prod-struktic-rainne. Accessed 10 Jun 2018.

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Hall, S. 1973. Encoding/Decoding. In Culture, Media, Language: Working Papers in Cultural Studies, 1972–1979. London: Centre for Contemporary Cultural Studies. Herman, M., and M.  Roberto. 2015. The Addicted Brain: Understanding the Neurophysiological Mechanisms of Addictive Disorders. Frontiers in Integrative Neuroscience 9: 18. Hilton, M. 2000. Smoking in British Popular Culture 1800–2000. Manchester: Manchester University Press. Hirschman, E. 1995. Professional, Personal, and Popular Culture Perspectives on Addiction. The American Behavioral Scientist 38 (4): 537–552. Jacobs, D. 1986. A General Theory of Addictions: A New Theoretical Model. Journal of Gambling Behaviour 2 (1): 15–31. Jellinek, E. 1952. Phases of Alcohol Addiction. Quarterly Journal of Studies on Alcohol 13 (4): 673–684. Kraftl, P., J. Horton, and F. Tucker. 2012. Critical Geographies of Childhood and Youth: Contemporary Policy and Practice. Bristol: Policy Press. Kumwembe, W. 2017. Fredokiss Is NBS Ambassador. https://www.times.mw/ fredokiss-is-nbs-bank-ambassador. Accessed 20 Jun 2018. Mafo. 2013a. Zako. https://soundcloud.com/myuziki-pusha. Accessed 15 Jun 2018. ———. 2013b. Mowa. https://www.malawi-music.com/M/188-mafo/217mowa. Accessed 10 Jun 2018. ———. 2016. Akandipweteka maluzi. http://www.malawi-music.com/M/188mafo/1598-akandipweteka-maluzi. Accessed 10 Jun 2018. ———. 2017. Bawa. https://m.malawi-music.com/song.php?id=6339. Accessed 10 Jun 2018. Mafo & Lantos. 2018. Okondedwa Merchant. http://m.malawi-music.com/ song.php?id=9503. Accessed 15 Jun 2018. Miller, N. 1989. The Diagnosis of Marijuana (Cannabis) Dependence. Journal of Substance Abuse Treatment 6 (3): 183–192. Miller, T. 1998. Technologies of Truth: Cultural Citizenship and the Popular Media. Minneapolis: University of Minnesota Press. Mughogho, L. 2017. Urban Music Booming in Mzuzu. https://malawi24. com/2017/09/04/urban-music-booming-mzuzu. Accessed 20 Jun 2018. Music in Africa. 2015. Top Artists Promote Safe Sex With ‘Safeguard Young People’ Album. https://www.musicinafrica.net/magazine/top-artists-promote-safe-sex-%E2%80%98safeguard-young-people%E2%80%99-album. Accessed 25 Jul 2018. Ndebvu, H. 2017. Discussion on Urban Music. [WhatsApp Message to Author]. Newell, S., O. Okome, and T. Forster. 2014. Popular Culture in Africa. New York: Routledge.

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Nichter, M. 2003. Smoking: What Does Culture Have to Do With It? Addiction 98: 139–145. Room, R. 2003. The Cultural Framing of Addiction. In Expanding Addiction: Critical Essays, ed. R. Granfield, 1st ed., 42–50. New York: Routledge. Storey, J. 2014. Cultural Theory and Popular Culture: An Introduction. London: Routledge. Vail, L., and L. White. 1991. Power and the Praise Poem. Charlottesville: Virginia University. Zapf, J., J.  Greiner, and J.  Carroll. 2008. Attachment Styles and Male Sex Addiction. Sexual Addiction & Compulsivity 15 (2): 158–175.

CHAPTER 9

Semiotic Creativity and Innovation: Offshoots of Social Media Addiction Hambaba Jimaima and Gabriel Simungala

9.1   Introduction: The Internet and Social Media The Internet World Stats (2018) reports that the past decade has witnessed an exponential growth in Internet usage. Accentuated by supersonic speed, Out (2015) notes that the internet has become widely accessible and is being harnessed for its full potential by commercial houses, institutions of learning and also by individuals, students included. Globalization and the advent of the technological advancements in all spheres of human development are, according to Blommaert (2011: 1), responsible for the creation of a “sociolinguistic world made up of dynamic, mobile, unstable, yet ordered processes and phenomena, messy and unpredictable at the surface but understandable at a deeper level.” As a consequence, a disengagement and disintegration of the traditional outlook on communities now exists as mobility, complexity and superdiversity rise to prominence being key issues of the modern age (Blommaert 2010). The advent of the Internet as an emblem of the modern age has equally led to the emergence and popularization of social networking

H. Jimaima (*) • G. Simungala University of Zambia, Lusaka, Zambia e-mail: [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_9

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sites, coincidentally, initiating an online community that transcends the physical and traditional notions of speech community. Chou reminds that the Internet, in many ways, is not only an information super highway, but is also a powerful social domain that connects its users around the world. Rightly so, Out (2015) observes that social networking sites such as Facebook, Twitter, Instagram, LinkedIn and mobile instant messaging services (IM) such as WhatsApp, Viber and IMO and video calling services such as Skype, which are all occasioned by the Internet, have become a popular means of communication. In this regard, Veronica and Samuel (2017) note an increasing need for people to find ways to be connected with friends, family members, co-workers, classmates and those they have just met on online platforms. In the quest to remain in touch, creativity and innovation are rife as social actors communicate and represent through a variety of means—usually using the best way they know how (cf Blommaert 2010, 2011). The form of communication being witnessed is what has come to be known as multimodal in nature (see Kress for a detailed discussion on multimodality). The complexity of communication visible on the Internet and social media on the one hand, and the factors that trigger the same, extending to the flow of information between and across spaces on the other, are features of the globalized world whose baseline is a system of global villages (cf Blommaert 2010). While the Internet and social media have been hailed for their potentialities and indispensability for our times, themes of addictions have emerged in literature, consequently opening up a rich terrain of enquiry. Yet, a cursory look at these early theorizations seem to suggest a concentration on Western subjects, with the rest of the world receiving little or no attention. Thus, in this chapter, an attempt to sketch the results of addiction to the Internet, as seen in the eyes of Zambia’s online platforms such as Facebook and WhatsApp, as it relates and extends to communication and representation is made. The instances of semiotic creativity and innovation in communication and representation are theorized as offshoots necessitated by addiction to the virtual-scape, or indeed, the online linguistic landscape.

9.2   Internet and Social Media in Zambia: Perspectives on Addiction An international website that features up-to-date world internet usage, population statistics, social media stats and internet market research data, called The Internet World Stats, reports using data from the Zambia Information and Communications Authority (ZICTA) that Zambia had

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about 7,248,773 Internet users as of December 2017, translating into 41.2% of the population. They project 1,600,000 Facebook subscribers for the same period, with a 9.1% penetration rate. ZICTA (2015), in their assessment, primarily aimed at measuring progress in access and usage of ICTs by households and individuals in Zambia, revealed that 63% of Zambians Internet users spend their time online on social networking sites. Specifically, they noted that about 71% of individuals that own smartphones use the devices to access Over The Top (OTT) applications such as WhatsApp, Viber, Facebook, Skype and Twitter for communication using instant messaging or voice calling. These figures bring to the fore several assumptions—the first being that the exposure to the Internet is growing at an exponential rate, with the potential for addictions, and the second being that Zambia, as a country, is moving with the times in regard to the advancement of technology, which again breeds addiction. Addiction, as described by the American Psychological Association, refers to a compulsive behaviour that leads to negative effects. The concept of addiction, though traditionally used to describe a physical dependence on a substance (Holden 2001 cited in Barnstone 2000), has been applied to excessive use of the Internet. Thus, a newly proposed construct— Internet Addiction—is an individual’s inability to control their Internet use, which in turn, leads to feelings of distress and functional impairment of daily activities. Young locates five different types of Internet addiction— namely, computer addiction (i.e., computer game addiction), information overload (i.e., web surfing addiction), net compulsions (i.e., online gambling or online shopping addiction), cyber sexual addiction (i.e., online pornography or online sex addiction), and cyber relationship addiction (i.e., an addiction to online relationships) (in Out 2015). However, Li and Chung (2006) are of the view that the “Internet in itself is not addictive; instead, the social functions, self-expression, communication, and building of personal ties on the Internet are what is addictive.” From Internet addiction, another construct of social media addiction has been proposed. Walker looks upon social media addiction as a term used to describe a situation where a user spends too much time on social media (e.g., Facebook, Twitter, Instagram) such that it negatively affects other aspects of his or her daily life such as school, work or relationship with others (in Out 2015). Writing on technology as addiction, Barnstone (2000) locates himself as a case in point of an individual who can’t do without technology. Out (2015) reveals that active actors on social platforms feel bound to particular activities such that they become harmful

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habits, which then obstructs other important activities in their lives, and this can be said of people who use social media excessively. Copoeru (2014) argues in favour of defining addiction without making reference to a form of failure, psycho-somatic or existential. On the contrary, he concludes that there is a need to adopt a definition of addiction which holds at its core the idea of empowering addicted persons, as the view this chapter takes, where good offshoots in the name of creativity and innovation are bred.

9.3   Theoretical and Methodological Appraisal Psychology Tools introduces the Internet Addiction Test (IAT) as the first validated instrument for the assessment of Internet and computer addiction. It is a 20-item scale that measures the presence and severity of Internet dependency among adults. Dr. Kimberly Young, a professor at St. Bonaventure University and director of the Centre for Internet Addiction Recovery, developed the IAT to assess symptoms of Internet addiction and compulsivity in a variety of test settings. Using the IAT as a point of departure, the paper has leanings on multimodality and the sociolinguistics of globalization. While the sociolinguistics of globalization breaks down old notions about language, multimodality is an interdisciplinary approach that understands communication and representation to be more than about language (Jewitt et  al. 2012). Blommaert and Rampton (2011: 6) expand on this when they argue that “meaning is multi-modal, communicated in much more than language alone. People apprehend meaning in gestures, postures, faces, bodies, movements, physical arrangements and the material environment.” As a theoretical toolkits, multimodality and the sociolinguistics of globalization have been developed over the past decade to systematically address much-debated questions about changes in society—for instance, in relation to new media and technologies such as the social media and the addictions thereof, which the present chapter addresses (cf Blommaert 2010; Jewitt et al. 2012). The sociolinguistics of globalization, a paradigmatic shift away from an older linguistic and sociolinguistic tradition in which language was analysed primarily as a local, resident and stable complex of signs attached to an equally local, resident and stable community of speakers, has risen to prominence (Blommaert 2010). The pioneering work

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by Makoni and Pennycook, which brought into question the nature of language, its conceptualization, as well as its production and consumption, should be seen to the larger extent as the bedrock of the sociolinguistics of globalization. The narratives we subject to analysis were collected from three WhatsApp groups—namely, University of Zambia Postgraduate Students Association, abbreviated as UNZAPOGRASA 2016/18; the Master of Arts in Linguistic Science, abbreviated as MA Linguistic Sci 2016/18; and the University of Zambia Postgraduate Students Association Social Platform, abbreviated as UNZAPOGRASA SOCIAL. The first two are for academic announcements, and the second, a social platform. For Facebook, data were collected from the University of Zambia and The Voice of Zambia Facebook groups, which count 113,940 and 336,976 members, respectively. Using insights from the IAT, we gleaned the actors’ behavioural patterns as sufficient and tantamount to addiction. Thereafter, on the two platforms of Facebook and WhatsApp, we observe narratives and purposively collected samples with instances of creativity and innovation in them.

9.4   Conceptualizing Social Media In conceptualizing social media, Akar (2010: 17) refers to it as websites that are based on web 2.0 technologies, which enable deeper social interaction, community formation and preparation of and success in cooperation projects. Boyd and Ellison (2007) look upon social media as “a public web-based service that permits users to create a personal profile, identify other users with whom they can relate to or have a connection with, read and react to posts made by other users on the site, and send and receive messages either privately or publicly.” Kuss and Griffiths (2011), using another synonym of social media, which is Social Networking Sites (SNS henceforth), conceive of social media as virtual communities where users can create individual public profiles, interact with real-life friends and meet other people based on shared interests. Further still, they argue that they (SNS) are seen as a ‘global consumer phenomenon’ with an exponential rise in usage within the last few years (Kuss and Griffiths 2011). SNS are thus responsible for the global flow of information between and among spaces by both trans-local and transnational mobility, either physically or on the virtual space.

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Enabled by the Internet, social media has become popular among the young and the old alike. Among the many social media platforms, Facebook and WhatsApp seems to top the list. Veronica and Samuel (2017) advance that Facebook is particularly popular with young people, especially those in college or university, perhaps as reflective of its roots in the student community. This is particularly so even as Kirik et al. (2015) remind that through Facebook, users are able to express themselves freely, establish new friendships and relationships, and follow and engage in dialogues with people or groups they are interested in. Added to list of the online platform, Out (2015) mentions Twitter, Instagram, LinkedIn and mobile instant messaging services (IM) such as Viber and IMO and video calling services such as Skype, which seem to operate in a similar fashion and have become a popular means of communication of the modern age. Besides easy, cheap and fast access to information on the Internet, Kirik et al. (2015) argue that the expansion of the communication network is one of the factors that lead individuals to use social media, and they are, thus, prone to innovate and creatively communicate. Social media is a very fluid, flexible and unstable domain. The emergence of codes for communication—we have called them social semiotic codes being oriented after Kress—owe their existence beyond pedagogical approaches, yet they flourish extensively. As a social practice, language on social media, and indeed, everywhere else ought to be theorized for what is and not what it is thought to be (see Mambwe 2014 for a discussion on language as a social practice in Zambia). Makoni and Pennycook were on point when they brought into question the nature of language, its conceptualization, as well as its production and consumption. Its influences are visible in physical interactions of social actors extending to social media as a medium of full expression of these sociolinguistic resources. As a construct of rising social media addiction, we see it as giving rise to emerging lexicons of social semiotic codes for communication and representation, which come to bear on various social media platforms as meaning-making is occasioned by multiple modes.

9.5   Semiotic Creativity and Innovation Modern-day communication is occasioned by a variety of means and meaning-making has always been multimodal. The long hours spent on the virtual spaces have compelled social media actors to innovatively and creatively devise a form of ­communicating, a new lexicon, a language if you

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like, a form of writing system on WhatsApp and Facebook, the influences of which are far reaching. Essentially, the emergence of this new lexicon abides within the frame of what Blommaert and Rampton (2011: 3) refers to as “rather than working with homogeneity, stability and boundedness as the starting assumptions, mobility, mixing, political dynamics and historical embedding are now central concerns in the study of languages, language groups and communication.” Globalization has not only destabilized the homogeneity of communities, but also the dynamics of communication; hence, the emergence, and by extension, the acceptance and popularization of these social semiotic codes we discuss as the new lexicon on the online landscape. Blommaert (2010) locates these happenings by placing them at the centre of a new order that has been birthed in which the description of the conditions under which communication occurs in contemporary setting has changed. The results of social media addiction for a field such as linguistics are a transformed level and depth of communication, which efficiently and effectively serves the needs of actors. In this lies the idea of creativity and innovation in communication as actors traverse the online landscape. The motivation for actors lies in the instance of the moment, to economically communicate, with fewer words—that is, faster and efficiently. We argue that for linguistics and communication studies, addiction to social media— particularly to Facebook and WhatsApp—has revolutionized communication in the modern era. Below, we present the first corpus of codes. We also adapt Blommaert’s (2011) codes, which he refers to as ‘supervernacular,’ as a descriptor for new forms of semiotic codes emerging in the context of technology-driven globalization processes with reference to mobile texting codes, popularly known as Short Messaging Systems (SMS). Ours here, however, is on the online platform and we specifically address the instant messaging platform of WhatsApp and Facebook. The use of the various codes shown here have become such a norm that it is rare to find uploads with full and ‘correctly’ spelt words. The data reveals that instances where language is used in totality, without following the codes shown here, are the ones uploaded for academic purposes as announcements to the student populace. This is a generation that would be amusingly referred to as the BBC generation—Born Before Computers generation. Noticeably, for the younger generation, the use of these social semiotic codes is the norm. It has rules and is strictly normative, yet operates in an unstable and flexible domain.

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Table 9.1 Semiotic nature of the codes

@ 2 4 8 B C U Thxs Msg Tmrw/2mrw Nth Sth Grz Bck/Bk Btr Wry Fwd/4wd G9 t

At To, too For -eight, -ate, -ait Be See You Thanks Message Tomorrow Nothing Something Greetings Back Better Worry Forward Goodnight

Blommaert (2011: 6) attributes the emergence of these codes as following “the pace of the technological and ergonomic development of the mobile phones themselves as well as of the economy that carries their use along.” The semiotic nature of the codes is brought to life as we look at Table 9.1 above. The semiotic potential of the codes is inherent in them, hence their selection. Kress and van Leeuwen would have us note that all these codes are signs, bearing attributes that all the shared parties in the communication process can relate to. Take, for instance, the codes @, 2, 4, 8, B, C, U—these are deployed for their phonological attributes on the one hand and for their graphic representation on the other. The sound produced when they are uttered is tapped into during the creation of meaningful utterances. Graphically, they serve significant amount of space for social media actors. Of essence to the actors is space and economy. The motivation then lies in creatively blending the graphic and the phonological aspects of the codes to privilege meaning-making on these spaces. Thus, space—or place, as Scollon and Scollon (2003) refers to it—is important for how these codes are interpreted within the field of geosemiotics. These signs, whose influences transcend the online space, are indeed space-based semiotics, which express social meanings in discourses in the material virtual space. Further still, as Table 9.1 illustrates, the codes appear in different forms than one would expect to find in a formal grammatical text appearing in a

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single sentence. The blend of the codes as they are deployed in the construction of meaningful and complete discourses is one which the grammatical normative practices of the English language, for instance, would decline to endorse. Yet, as they are, they are a semiotic resource, a means for making meaning in instances that have now gone beyond the environs of social media. Codes such as Msg, Nth, Thxs only have consonants as the vowels are omitted. It is safe then to conclude that the vowels are the basis upon which these codes, in particular, are creatively crafted. Even when the morphological rules and indeed syntactic rules are flouted, what is crafted in the deployment is sufficient for meaning-making. Noticeably, even when there exists no pedagogical approach in the deployment and usage of the social semiotic codes we bring to the fore, these online productive spaces still flourish permeating even the very spaces that were a sore preserve of standardized pedagogical approaches. Chandler and Kress advance that signs are constantly made anew in communicative instances as they come in different forms of words, images, sounds, gestures and objects. The signs or codes cited earlier are always in constant creation. Thus, in the (re)creation of codes which, of essence, are signs, there is no limit as to what counts as signs and/or semiotic resources, given these are always social culturally newly made through the constant social work of actors in their quest to make meaning. Take, for instance, the codes used for their sound-2 and 4-, they are sometimes blended to create other codes such as ‘2moro’ for the word ‘tomorrow’ and ‘4wd’ for the word ‘forward.’ This constant re(creation) of codes follows Scollon and Scollon (2003); Jimaima (2016); Glenn (2012), Kress and van Leeuwen, who suggest that there is no limit to what a social actor will use as a sign as semiotic resources are limitless and dependent on a social actor’s orientation which, in this regard, is the shared online culture. In fact, what is brought to life on the Zambian Online Landscape is an observation Blommaert, Kloon and Jie put across—that meaning is inevitably based on shared recognition of signs as being meaningful for the parties engaged in interaction. Jimaima, Simwinga and Nkata (2016) conclude as they reflect on the morphological and lexical aspects of the social media discourse and self-­ asserting narratives on the Zambian online media that even though most social media users may not be fully informed about the word formation processes which morphologists put forth, the shared sociocultural knowledge (cf Scollon and Scollon 2003) with which these actors come to these virtual spaces is sufficient to productively transform the

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virtual-scape linguistically, and more so, semiotically. Further still, the data reveals what  Scollon and Scollon (2003) theorized on the motivated sign that the social cultural orientation of actors is key to understanding present-day communication and representation on social media. Interesting though, these meaning-making instances which deploy the new lexicon, the social semiotic codes, defy classical theorizations that call for a shared speech community of speakers. The feature of the motivated sign is inherent in these social semiotic codes, while a physical community of speakers encapsulated in a particular space is missing, there exists virtual-­scape, an online community whose speakers stay online for hours on end, as a result of addiction, and thus share these unstated normative practices in the deployment of the codes. Blommaert (2011) advances how we are witnessing a distribution of sociolinguistic resources adopted by communities of users that share none of the traditional attributes of speech communities, such as territorial fixedness and physical proximity. The only insight they share as they constantly (re)work on the codes is the sociocultural and common backgrounds of the online platform. We argue here that, in themselves, the platforms of Facebook and WhatsApp are virtual cultures that actors tap into. As part of an actor’s orientation to the codes, we noted that due to the long hours spent on these platforms, which ultimately accounts for addiction, the better an actor becomes acquitted to the usage and deployment of the signs. Table 9.2, which is representative of both WhatsApp Table 9.2  WhatsApp and Facebook abbreviations

Abbreviation

Meaning

LOL OMG ILY IDK TBH BTW THX SMH IMO IDC TGIF IRL BFF IKR AMA

Laugh Out Loud Oh My God I Love You I Don’t Know To Be Honest Between Thanks Shaking My Head In My Opinion I Don’t Care Thank God Its Friday In Real Life Best Friends Forever I Know Right Ask Me Anything

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and Facebook comments as well as posts, shows abbreviations and acronyms constantly in use. Blommaert (2010) is of the view that these abbreviations and acronyms whose emergence characterize the new order originally reflect “the clumsy, multi-punch keyboard writing practices required for forming letters and symbols, as well as the relatively high cost of sending long messages.” What the codes shows is a creation through abbreviation. This also is a constant social work as most used words are adopted, abbreviated, then popularized through constant (re)deployment either as status updates, comments or chats on Facebook Messenger.

9.6   Globalization and the Production of Locality In the deployment and subsequent consumption of the new lexicon presented here, the power of the global into the local is realized in the Zambian online landscape. In other words, the global phenomenon is replicated in  local sociolinguistic contexts. As Blommaert, Kloon and Jie argue, in between global circulation, there always lies a local deployment. Thus, as part of the local realization of social semiotic codes, an indigenous lexicon—one that responds to the local social cultural environment—has been birthed. The multilingual tenets of actors are seen in the constant (re)creation of codes in the indigenous languages. The examples in Table  9.2 show that the local environs are equally productive in the adaptation and subsequent (re)circulation of the codes of the indigenous forms. There is then no difference between what the English language can achieve on social media and what abbreviated local languages can achieve. Even the blend of the English semiotic codes and the local ones in narratives is now a common feature as all these are semiotic resources whose deployment can now be seen as the local in the global. The global in the local is captured well by Appadurai, who reveals that global influences become part of the context-generative aspect of the production of locality. He explains that they become part of the ways in which local communities construct a social, cultural, political and economic environment for themselves (in Blommaert 2010). Examples in Table 9.3, represented with the English lexicon first, followed by the local equivalent right below, are in two widely spoken languages of Nyanja—mainly spoken in the capital city with traces of it in most spaces of Zambia—and Bemba, a highly represented language in most provinces. These are the local renderings of the widely accepted global codes, yet, in their local production, they have retained the English

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Table 9.3  WhatsApp and Facebook abbreviations and language Abbreviation

Meaning

Language

LOL NSS OMG YTL WTF NVI

Laugh Out Loud Na Seka Saana Oh My God Yangu Tata Lesa What the Fuck Nanga Vaupuba Ivo

English Bemba English Bemba English Nyanja

stress and impact. They are indigenous but pronounced the English way. In this regard, Blommaert et al. (2011) notes, “we can now see actually occurring semiotic forms as locally deployed resources, ordered in relation to an ideological target – the ‘standard’, the ‘accentless’ variety.” Regardless of the ethnic and cultural background of social media actors, it is now common social practice to locate the deployment of NSS in place of LOL and YTL in place of OMG. However, Blommaert (2010: 24) is quick to put a caveat when he reminds that “even if similar features occur all over the globe, the local histories which they enter can be fundamentally different and so create very different effects, meanings and functions.” Yet, Johnson adds that the fact that the social meanings of linguistic forms can change means that forms that once sounded non-local can be preserved if they come to function as part of the local semiotic repertoire.

9.7   Conclusion Addiction has always been looked upon with negative undertones. As Tart argued, for the majority of researchers, addiction is seen as pathological or at least problematic, both from a personal and a social point of view; for some, it is rather normal, beneficial or even desired (Copoeru 2014). For us, with expertise in linguistics, and indeed, communication studies, the idea that this sort of addiction has birthed a creative and innovative way to communicate is of interest to us. The chapter has shown that even without territorial fixedness and physical proximity, sociolinguistic resources such as the said social semiotic codes can productively flourish all because of social media addiction. This is particularly so as social media enables actors to enter into (often intense) contact with interlocutors they will never physically encounter and whose cultural, social and linguistic backgrounds may be literally worlds apart (Blommaert 2011).

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However, even with creativity and innovation at play, the new lexicon faces a challenge of whether it is a transformation or distortion. In particular, Blommaert (2011) argues that semiotic codes are seen as an anti-­ orthography, especially by teachers and parents of young intensive users of the code. The chapter has however shown that even when we can’t place these conventions in known word formation processes, meaning-making is evident in them. Thus, whereas Jimaima et al. would point out that most of these processes used to create the social media lexicon are to be treated as ‘pseudo’ word formation processes that have potential to transform or distort the language practices of the late modern Zambia, our view responds to the idea that the social semiotic codes in question are strongly normative, seeing as they all use a semiotic baseline and do not, in any way, distort but do transform positively. Like Blommaert (2010/2011), we conclude that these codes are like any other form of language use, a system that operates on the basis of rigorously applied rules, deviation of which is possible but never unlimited and always comes with a price.

References Akar, E. 2010. Sosyal Medya Pazarlaması. Ankara: Efil Publications. Barnstone, T. 2000. Technology as Addiction. Technology and Culture 41 (1): 190–193. Blommaert, J. 2010. The Sociolinguistics of Globalization. Cambridge: Cambridge University Press. ———. 2011. Supervernaculars and Their Dialects, Tilburg Papers in Culture Studies No. 9. Tilburg: Babylon. Blommaert, J., and B. Rampton. 2011. Language and Superdiversities. Diversities 13 (2): 1–36. Boyd, D.M., and N.B. Ellison. 2007. Social Network Sites: Definition, History, and Scholarship. Journal of Computer Mediated Communication 13 (2007): 210–230. Copoeru, I. 2014. Understanding Addiction: A Threefold Phenomenological Approach. Human Studies 37 (3 Fall 2014): 335–349. Glenn, M. 2012. Wayfinding in Pacific Linguascapes: Negotiating Tokelau Linguistic Identities in Hawai‘i’. PhD Thesis, University of the Western Cape, University of Hawaii. Jewitt, C. et  al. 2012. Using a Social Semiotic Approach to Multimodality: Researching Learning in Schools, Museums and Hospitals. London: NCRM, Working Paper 01/12.

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Jimaima, H. 2016. Social Structuring of Language and the Mobility of Semiotic Resources Across Linguistic Landscapes in Zambia. PhD Thesis, University of the Western Cape. Kirik, A., A. Arslan, A. Çetinkaya, and K. Gül. 2015. A Quantitative Research on the Level of Social Media Addiction Among Young People in Turkey. International Journal of Science Culture and Sport (IntJSCS) 3 (3): 108–122. Kuss, D.J., and M.D. Griffiths. 2011. Online Social Networking and Addiction—A Review of the Psychological Literature. International Journal of Environmental Research and Public Health 8 (9): 3528–3552. Li, S.M., and T.M.  Chung. 2006. Internet Function and Internet Addictive Behavior. Computers in Human Behavior 22 (6): 1067–1071. Mambwe, K. 2014. Mobility, Identity and Localization of Language in Multilingual Contexts of Urban Lusaka. PhD Thesis, University of the Western Cape. Out, A. 2015. Social Media Addiction Among Students of the University of Ghana. Masters Dissertation, University of Ghana. Scollon, R., and S. Scollon. 2003. Discourses in Place: Language in the Material World. London: Routledge. The Internet World Stats. 2018. https://www.internetworldstats.com/africa. htm#zm. Accessed on 10 May 2018. Veronica, S., and A. Samuel. 2017. Social Media Addiction Among Adolescents with Special Reference to Facebook Addiction. IOSR Journal of Humanities and Social Science: 72–76. Zambia Information and Communications Technology Authority. 2015. Ict Survey Report – Households and Individuals. Survey on Access and Usage of Information and Communication Technology by Households and Individuals in Zambia.

CHAPTER 10

Macho Rhetoric in Alcohol Addiction: The Narratives of Masculinities among Malawian Youths Anthony Mavuto Gunde

10.1   Introduction Research on alcohol use and related problems in college students is lacking in many regions of the world, more in particular from non-Western cultures (Karam et al. 2007; Adewuya et al. 2007). This chapter examines traditional sources of masculine rhetoric employed by Malawian college students to glorify alcohol addiction, their implications on social and behavioural change. Through a case study drawn from individual interviews with male college students from the University of Malawi, the chapter addresses three specific questions: What do young male college students make of the consumption of alcohol? What are the factors that influence the students to consume alcohol? To what extent does macho rhetoric among drinking college students contribute to alcohol dependency?

A. M. Gunde (*) Journalism Department, Stellenbosch University, Stellenbosch, South Africa Chancellor College, University of Malawi, Zomba, Malawi e-mail: [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_10

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Through thematic analysis of semi-structured interviews from college students, the chapter finds that male college students utilise macho rhetorical metaphors rooted in the Malawian culture effectively to venerate alcohol consumption, which has a huge bearing on an addictive culture. Consequently, the aim of this chapter is to provide an overview of how macho rhetoric has been employed by Malawian male college youths through history and its implications on social and behavioural change with regard to addiction from an African perspective. The chapter draws from the theory of masculinities to examine the recurrent themes emanating from the interviews, with respect to problem drinking among college students in Malawi. This chapter is presented in four sections. The first section offers the existing literature on problem drinking among the young males, specifically focussing on college students across the globe. The second section is about the theoretical framework employed in the case study. In the third section, the chapter discusses the research design and methodology. In the final part of the chapter, a thematic analysis applied to the responses from the University of Malawi male students with respect to their drinking culture will be provided. Excessive Drinking among College Students In the view of Karam et al. (2007), college students in many countries are at elevated risk for heavy drinking, with serious immediate health risks, such as drink-driving and other substance use, and longer term risks, such as alcohol dependence. The prevalence of hazardous drinking in Australasia, Europe and South America appears similar to that in North America, but is lower in Africa and Asia (ibid.). By the same token, Slutske (2005) posits that binge drinking among college students in the United States has become a major public health problem, and this is even more so with men than women. The US Surgeon General and the US Department of Health and Human Services have identified binge drinking among college students as a major public health problem, and some experts have concluded that binge drinking is the most serious public health problem facing US colleges. A recent report commissioned by the National Institute on Alcohol Abuse and Alcoholism estimated that alcohol is involved in approximately 1400 student deaths, 500,000 injuries, 600,000 assaults and 70,000 sexual assaults each year on college campuses (Slutske 2005: 321).

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According to Strauss (2013), drinking at college has become a ritual that students often see as an integral part of their higher education experience. Strauss further argues that many students come to college with established drinking habits, and the college environment can exacerbate the problem. In China, Cheng-Ye et  al. (2012) found out that alcohol abuse among university students was prevalent and that 80.8% were lifetime drinkers, 49.3% were current drinkers (drank alcohol in the past 30 days) and 23.5% were binge drinkers (drank five or more drinks in a period of 2 hours). Problem drinking among college students appears to be a growing trend not only in the West, but in many institutions of higher learning in sub-Saharan Africa. In Nigeria, a 12-month study aimed to estimate the prevalence and examine the socio-demographic of alcohol use disorders among students in six Nigerian colleges in Osun State revealed that the population of male students who were alcohol dependents were more than that of females by over 50% (Adewuya et al. 2007). “Factors independently associated with a diagnosis of alcohol use disorder include parental drinking, male gender, higher economic status and being non-religious” (Adewuya et al. 2007: 5). These findings illustrate that the masculine gender is of great interest with regard to studies on the drinking problem culture among college students. In the same vein, a study by Adeyemo et al. (2016), which sought to determine the prevalence of drug abuse amongst university students in Benin City, Nigeria, found out that alcohol was one of the most commonly abused drug and that students have difficulties in stopping the habitual use of it. The aforementioned study further revealed that a higher proportion of compulsive drug users, including alcoholics, were of the male gender and this was attributed to the foundations of involvement in drinking at early age. In the view of the National Authority for the Campaign Against Alcohol and Drug Abuse (NACADA), a Kenyan government institution, the practice of alcohol abuse has developed to a cultural view and tradition rooted in every level of university environment, and that practice is handed down through cohorts of alcohol abusers to strengthen students’ expectation that alcohol is a necessary factor for social success (2007). Results from a related study conducted at Moi and Eldoret public universities in Kenya (Mahugu et  al. 2016), showed that amongst the students who drink, males made up 68% of them while female constituted 32%. “The results indicated that significantly more male than female students drink alcohol” (Mahugu et al. 2016: 873). Studies conducted at two Ethiopian universities, Addis Ababa and Axum, indicate that the prevalence rate of alcohol

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consumption among students is 34.5% and 31.4%, respectively, and it remains a growing problem in the country as it is in many other ­developing countries (ibid). The concern over alcohol abuse among college students has also been revealed in some studies in Southern African countries. In a South African study to determine the prevalence and distribution of safe, hazardous, harmful and dependent drinking amongst students of Rhodes University by Young and De Klerk (2008), male university students exhibited significantly higher levels of hazardous, harmful and dependent drinking patterns while females reported higher levels of safe alcohol consumption. “Male students, in particular, appear to be at risk of alcohol abuse” (Young and De Klerk 2008: 109). Generally, men consume alcohol more frequently and in larger quantities than women and are more likely to engage in binge drinking, hazardous drinking and harmful drinking (Lategan et  al. 2017: 95). By the same token, Young and De Clerk (2008: 103) further argue: In South Africa, the media and advertising undoubtedly promote the idea that drinking is ‘cool’. Combined with the sudden freedom from prohibitions on drinking which supposedly prevail at schools and at home, many first-year students are vulnerable to the strong peer pressure that is encountered at University.

The repercussions of binge-drinking behaviour among male students from Malawian institutions of higher learning are well documented. In 2012, a second-year male Bachelor of Education student from the University of Malawi’s Chancellor College died after binge drinking on campus and a post-mortem examination revealed he had died of alcohol poisoning (Nyasatimes 2014). A similar incident occurred at a Presbyterian church-funded Livingstonia University in 2018 and also involved a male problem drinker (Phimbi 2018). However, although such and even more occurrences are on the increase, there is little academic research about the drinking behaviour of Malawian college students—more in particular, focusing on males. It is against this background that this study sought to explore the factors behind the prevalent problem drinking culture among male college students in Malawi through a case study of University of Malawi students. This study employed masculinities as a guiding conceptual framework.

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Conceptualizing Masculinities Research and critical studies into men and masculinity has originated as one of the most emerging areas of sociological investigation (Abumere 2013). In the view of Kerfoot and Knights (1996), masculinity is the socially generated consensus of what it means to be a man, to be manly or to display such behaviour at any one time. According to Edwards (2006), scholars of masculinity discuss men and masculinity as socially constructed. In the view of Edwards (ibid), while biological maleness varies very little, the roles, behaviours, bodies and identities that are thought of as “masculine” vary enormously, and as such, this variation allows scholars to argue that masculinity is socially constructed. In the same vein, Kimmel and Bridges (2014) underline that “masculinity” refers to the behaviours, social roles and relations of men within a given society as well as the meanings attributed to them and it is a feminist-inspired, interdisciplinary field that emerged in the last few decades of the twentieth century as a topic of study. According to Kimmel (2000), masculinity emphasises gender, not biological sex, and the diversity of identities among different groups of men. Although gender is perceived to be an internal facet of identity, the concept of masculinity is produced within the institutions of society and through our daily interactions, Kimmel (ibid) further contends. This is in tandem with Connell’s argument that gender is a manner in which social practices are organised and masculinity intersects with other power relations systems, such as race and ethnicity. In this respect, the meanings of masculinity vary across disciplines and societal structures. In light of this, Connel (2005) contends that one should not talk about masculinity, but rather, about ‘masculinities’. Nevertheless, Reeser (2011) argues that it is imperative to think of masculinity as an ideology and linked to power. One way to understand the concept of masculinity as not created by any one person or by any single group is to consider masculinity as an ideology, a series of beliefs that a group of people buy into and that influences how they go about their lives. The concept of ideology is more traditionally associated with class and with politics (we talk about a “bourgeois ideology” or a “communist ideology”), but it is possible to think about masculinity as an ideology too. One reason to think in these terms is that ideology as a concept is often aligned with those in power: we talk about a “dominant ideology” as the political ideology that prevails in a given context. To consider

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masculinity as an ideology makes sense since it often is, or is often perceived of as, a subjectivity linked to power (Reeser 2011: 20). Reeser (2011) further postulates that although a single origin to an ideology cannot be located, ideologies are often assumed to be created and propagated through various social forms, especially through images, myths, discourses and practices. One way in which masculinity is propagated as ideology is through practices (Reeser, ibid.). When men perform various actions on a regular basis, they may be held within an ideology of masculinity (Reeser 2011: 24). As noted earlier, the issue of masculinities is multi-disciplinary, and as such, multiple scholars have employed the concept variedly. For example, in the wake of the 2008 financial crisis that shook the world, Knights and Tullberg (2011) explored the link between masculinity and mismanaging corporations leading to government bailouts for banks and a near collapse of Western economies. Through an analysis of masculine discourses and identities at some Western corporations and media accounts, Knights and Tullberg (2011: 400) found out that men and some women pursued an ever-increasing spiral of material rewards since high salaries and bonuses can serve as a proxy for social recognition that is so elusive and precarious. Insofar as masculine identities are a product of performance, they are necessarily precarious since there is no “inevitability, universality or constancy in ‘what it means to be a man’ . . . Consequently, managers are perpetually and competitively driven to achieve higher and higher salaries and bonuses to secure their status as men. In these contexts, masculinity can be threatened by the mere awareness that others are paid more” (Knights and Tullberg 2011: 400). Addis and Mahalik (2003) investigated how masculinity norms, stereotypes and ideologies play a role in men’s help-seeking behaviours with regard to health problems. The study found out that traditional masculine roles emphasising self-reliance, emotional control and power have a huge bearing on men’s difficulties in seeking health services. The study concluded that traditional helping services are underutilised by many men experiencing a wide range of problems in living. “It is also likely that a variety of masculinity ideologies, norms, and gender roles play a part in discouraging men’s help seeking” (Addis and Mahalik 2003: 12). By the same token, Mahalik et al. (2006) examined masculinity’s relationship to harmful health behaviours through a case study of three universities in Nairobi, Kenya. The research study concluded that for Kenyan men, an acceptance of fate or health conditions and carrying on without help from

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the medical community is associated with being masculine. The aforementioned case studies illustrate that masculinities is a concept that is imperative in the exploration of men’s problem drinking behaviours in college campuses; more, in particular, within the context of the focus of this chapter.

10.2   Research Design and Methodology The purpose of this study was to seek understandings of factors that lead to college students’ risky alcohol drinking behaviours, specifically focusing on males. Although multiple studies have been conducted around the world with respect to drinking behaviours among college students, they have been inclusive of both men and women. This, however, is against the background of research studies over the years, which have revealed that men die younger than women in most countries around the world (Barua 2009; Courtenay 2003; Meinecke 1981). Although a variety of factors influence health and longevity such as biology, health education, and access to health care, many health scientists believe that health behaviours are the most important of these factors (Mahalik et al. 2006). These gender differences and the repercussion emanating from risky drinking behaviours, as highlighted in multiple research studies in the previous section, motivated the sampling population of this study. This study employed a qualitative research methodology using two qualitative approaches: personal interviews and thematic analysis. Nachmias and Nachmias (1987) observe that qualitative researchers attempt to understand behaviour and institutions by getting to know well the persons involved in their values, rituals and symbols, beliefs and their emotions. In the view of Burns (2000), a qualitative research methodology is “naturalistic” in that social reality is regarded as a creation of individual consciousness, with “meaning and evaluation of events” seen as a personal and subjective construction. In other words, it is a method that Strauss and Corbin (1998) refer to as a way to elicit the “lived in experiences, behaviours, emotions, and feelings” as well as about the functioning of an organisation from the research participants’ genuine realities in their natural settings. In this regard, a qualitative research methodology was deemed appropriate to undertake this research study.

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Sample Population Twenty-six final-year undergraduate students, aged between 17 and 24, were sampled for this study through a snowballing technique. Only final-­ year male students were selected having lived through college longer than the rest of the student body. It has to be noted that the issue of sample representativeness in this study was not central. Snowballing is applied when members of a special population are difficult to locate. The researcher identifies a few members of the target population and then asks them to locate other potential individuals befitting the sampling unit (Babbie et al. 2001). Initially, one male student was selected, and he then identified a few more colleagues who consume alcohol. In the view of the foregoing, this study employed the semi-structured (focused) interview technique. This was further informed by the assertions put forward by Nachmias and Nachmias (1987) that among other characteristics, such a technique involves respondents known to have been involved in a particular experience and the interviewer follows an interview guide that set the areas of inquiry. In addition, Merton et al. (1956) note that this type of interview is focused on the subjective experiences of the persons exposed to the pre-analysed situation in an effort to ascertain their definitions of the situation. For ethical considerations, the respondents were asked of their consent with regard to the nature of the study, but their real names have not been presented in this chapter. Through an interview guide, questions put to the interviewees were similar and this took place in the researcher’s office for two months—April–May 2018. According to Bryman (2001: 315), an interview guide is a brief list of “memory prompts of areas” to be covered during a qualitative unstructured or semi-structured interview. Such a guide features an order of topics that the interviewer expects to be answered pertaining to the research questions, Bryman further observes, adding that it also provides room for further probing. An interview guide does not only provide a logical and plausible progression though the focal areas under discussion, but it also acts as a preliminary scheme for the analysis of transcripts (Gaskell 2000). The researcher used two digital devices to record each individual face-­ to-­face interview and this was necessitated to allow a smooth flow of the discussion. This was after seeking consent from the students, all of whom consented. Participants were promised anonymity; as such, names appearing in this text are just pseudonyms. The model of interpretation of results that served this study was that of thematic analysis.

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Thematic Analysis Thematic analysis is the process of identifying patterns or themes within qualitative data (Maguire and Delahunt 2017). Theme identification is one of the most fundamental tasks in qualitative research (Gerry and Bernard 2003). According to Maguire and Delahunt (2017), the goal of a thematic analysis is to identify themes—that is, patterns in the data that are important or interesting—and use these themes to address the research or say something about an issue. “This is much more than simply summarising the data; a good thematic analysis interprets and makes sense of it” (Maguire and Delahunt 2017: 3353). In the view of Braun and Clarke (2006), there are two levels of thematic analyses: semantic and latent. At the semantic level, the analyst does not look beyond the surface or what the respondent has said. However, at the latent level, the researcher starts to identify or examine the underlying ideas, assumptions and conceptualisations—and ideologies—that are theorised as shaping or informing the semantic content (Braun and Clarke 2006: 84). This study employed the latent analytical approach as the aim was to unearth the underlying meanings, deconstruct and reconstruct responses from the interviewees with regard to problem drinking and the implications on behaviour and health.

10.3   Findings and Discussion As argued earlier, the analysis is based on the interview data over a three-­ month period, with male college students who had been identified through a snowballing technique as alcohol consumers. These section presents themes that emerged from these interviews and analyses them simultaneously. There were three main questions aimed at ascertaining the following: What do young male college students make of the consumption of alcohol? What are the factors that influence the students to consume alcohol? To what extent does macho rhetoric among drinking college students contribute to alcohol dependency? However, some questions were further presented to the respondents through further probing. Some of these included: How do you feel when you get too drunk? Have you ever thought heavy or binge drinking is risky in any way? Heavy drinking and binge drinking were used interchangeably in this study.

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Binge Drinking Is Part of College Experience One the key recurrent themes that emerged from the interviews was that of linking alcohol consumption to being part of college life. Heavy use of alcohol among students—in particular, in males—is considered to be usual and part of college life. Analysis from individual interviews with the 26 students overall illustrated that drinking alcohol is part of college experience. Consider Chimwemwe (23), who said: Those who do not drink are still living in the past. They are still like secondary school [high school] boys. To be in college you need to chill sometimes over a drink. I started drinking when I joined the university because I did not want to be left out of the group.

A similar observation was noted from respondent Lusungu (24), who argued that when he was in secondary school, family and peers had regularly commented that he could not drink then “until he gets to college”. This then illustrates that repercussion of alcohol use and misuse in college are rooted in the cultures and institutionalised by family and friends ahead of college. When asked about the perceptions of drinking in college and the consequences, Harry (22) argued that he started drinking, but only occasionally, before joining college, but “when am at home my mother controls me, when am here I can drink as much as I can without anyone controlling me”. This lack of parental control, in this context, exacerbates the problem drinking culture, which this study found contributes to alcohol dependency among many college students. This was further revealed by Harry: There are times that that you do not want to take alcohol . . . you just want to chill with friends that day but then they are taking alcohol. So you can’t be with them while you alone are not drinking yourself

The preceding interviews and subsequent ones are in tandem with an argument advanced by Iconis (2014) that many college students consider heavy drinking to be a natural part of the college experience. By the same token, Sher and Rutledge (2007) argue that the perception that heavy drinking is an integral part of the college experience has been found to be a strong predictor of heavy alcohol use among college students. It was quite clear from the interviews with the male college students from the University of Malawi’s Chancellor College that college experience and

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binge drinking featured frequently as a recurring theme. Along similar lines, a respondent in this study, George (21) described himself as an occasional drinker, but noted that male students who drink excessively are those who start from college and they label that as “ku riser”. This according to Harry is a slang among college students in Malawi which means “graduating to another level”. George further revealed that this form of graduation also has to do with the type of alcohol; “When one comes to college he may learn to consume beer but then you are expected to graduate to stronger stuff like Malawi Gin”, observed George. Coping with Stress and Problem Drinking Another noticeable aspect from the respondents was the linking of heavy drinking to the coping with stress. A recurring feature from the 26 interviews was that of justifying heavy drinking as a way of coping with stress. Majority of the respondents said heavy college workload necessitated them to drink excessively. The attribution of heavy drinking to stress level featured prominently—for example, in an interview with Andrew (24), who observed: We have too many assignments to work on for different lecturers. Sometimes you cannot cope with the results when they don’t come your way and what do you? . . . Get yourself drunk to forget about it.

When asked to elucidate on the issue of stress, some of the respondents said not only does this stem from college workload but it may also stem from family and personal issues such as loneliness, distance and lack of enough financial support. Mphatso (23) revealed there were many instances when he would go with his peers to purchase cheap liquor, but of high percentage volume with the aim of “getting drunk” to relieve stress. It was further noted through further probing that alcohol, in the form of spirits and not beer, was the popular choice among college male students due to the ability to induce intoxication at a quicker, and thereby, cheaper rate. The findings from the interviews resonate with an argument put forward by Bulandr (2015) that stressed individuals, particularly college students, are more easily influenced by other people’s drinking, but this method of coping with stress potentially leads to an increased risk of alcohol abuse disorders.

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Problem Drinking and Masculinities in College A recurrent striking theme that was revealed from the 26 interviews with the University of Malawi students was that of machoism—a strong sense of masculine pride. It was evident from the interviews that male students engage in heavy and risky drinking behaviours as a sense of belongingness. All respondents expressed similar sentiments that alcohol makes them feel like “real men”. Stuart (22) recalled that: I remember on two occasions when we had group discussions and one male student said that he does not drink beer . . . Some members of the group looked puzzled, especially the boys. One even said ‘Mnyamata wabwinobwino ngati iwe sumwa mowa!’ A well-structured boy like you . . . You don’t drink for real!

Alcohol use is thus a form of symbolic expression for masculinity among many male college students. This form expression was also revealed among majority of the respondents that drinking alcohol enhances confidence levels among male students when they want to approach or date female students. For Chris (22), this is even more so when the female student is from a higher economic status that the male. Chris underlined that: It is not just about the confidence to approach girls but the type of girls. You have to know that at this institution there are students who come from different backgrounds, some from well to do families – the suburbs – others from the ghetto. The boys from the suburbs have a better position that those of us from the ghetto to date the girls from the well to do families. Those of from the ghetto need to boost our confidence with alcohol so that we can compete with the suburb boys.

The revelations here illustrate the norms within the context of machoism and masculinity in that some students may resort to alcohol consumption for social motives; however, this may lead to alcohol dependency. This is tandem with masculinities’ scholars Mahalik et al. (2006: 102) positing that men’s traditional constructions of masculinity may contribute to problematic health behaviours. Mahalik et al. (ibid) further underline that masculinities and problematic health behaviours are related. In like manner, this study is also in tandem with the concept of masculinities that alcohol may be used to avoid stigmatisation and to conform to specific gender norms (Peralta 2007).

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It was also noted that an occurrence that takes place once every semester and sponsored by alcoholic beverage companies has a huge bearing on problem drinking behaviours, especially among males. The all-weekend event, named Social Weekend, includes multiple forms of entertainment such as sports, disco and drinking. It is also open to students from other regional colleges. In some cases, the event has been sponsored by Carlsberg Breweries (Malawi) and this is what one respondent attributed to the glorification of alcohol as part of being part of a college culture— in particular, among males. Talumba (21) was of the view that: Social weekend is misunderstood by most students because most males think it is about drinking and having sexual encounters with girls. We also have special promotions and subsidised alcohol from beer companies.

In line with the concept of masculinities, “drinking and heavy drinking is understood to be a form of ‘macho’ or masculine behaviour” (Peralta 2007: 247). This was revealed in interviews with the 26 University of Malawi students in this study.

10.4   Conclusion The chapter expands upon the existing research on college students’ drinking behaviours by focussing on male students and their construction of masculinities. In the study, male college students, to a huge extent, expressed similar reasons from engaging in heavy drinking. These include looking at alcohol consumption as being part of the college experience, coping with stress and a symbolic expression of masculinities—machoism. The findings in the study resonate with Peralta (2007), who argues that the process of drinking and, in particular, heavy drinking for college men is a form of embodied masculinity construction. “Ideological assumptions about masculinity are expressed through drinking behaviour in a social location where such expressions are accepted, legitimized, and often expected” (Peralta 2007: 752). This study was not aimed at making any recommendations or suggesting health interventions but rather to get an in-depth meaning of how male college students make sense of alcohol use or misuse. In other words, the chapter was aimed at exploring male college students’ construction of heavy drinking. While other themes emerged from the findings, machoism was one theme that was recurrently outstanding.

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References Abumere, F.I. 2013. Understanding Men and Masculinity in Modern Society. Open Journal of Social Science Research 1 (2): 42–45. Addis, M.E., and J.R. Mahalik. 2003. Men, Masculinity, and the Contexts of Help Seeking. American Psychologist 58 (1): 5–14. Adewuya, A.O., B.A.  Oba, O.O.  Aloba, B.M.  Mapayi, O.I.  Ibigbami, and T.A.  Adewomi. 2007. Alcohol Use Disorders among Nigerian University Students: Prevalence and Socio-Demographic Correlates. Nigerian Journal of Psychiatry 5 (1): 5–9. Adeyemo, F.O., B.  Ohaeri, P.U.  Okpala, and O.  Oghale. 2016. Prevalence of Drug Abuse Amongst University Students in Benin City, Nigeria. Public Health Research 6 (2): 31–37. Babbie, E., J. Mouton, P. Vorster, and B. Prozesky. 2001. The Practice of Social Research. Oxford: Cape Town. Barua, K. 2009. Why Men Die Earlier Than Women. Journal of Men’s Health 6 (3): 241.1. Braun, V., and V. Clarke. 2006. Using Thematic Analysis in Psychology. Qualitative Research in Psychology 3 (2): 77–101. Bryman, A. 2001. Social Research Methods. Oxford: Oxford University Press. Bulandr, K.V. 2015. Anxiety Sensitivity, Stress, and Problematic Drinking Behaviors Among College Students. Honors Projects, Paper 170. Burns, R.B. 2000. Introduction to Research Methods. London: Sage. Cheng-Ye, J., H.  Pei-Jin, and S.  Yi. 2012. The Epidemiology of Alcohol Consumption and Misuse Among Chinese College Students. Alcohol and Alcoholism 47 (4): 467–472. Connel, R.W. 2005. Masculinities. 2nd ed. Cambridge: Polity. Courtenay, W.H. 2003. Key Determinants of the Health and the Well-Being of Men and Boys. International Journal of Men’s Health 2 (1): 1–27. Edwards, T. 2006. Cultures of Masculinity. London: Routledge. Gaskell, G. 2000. Individual and Group Interviewing. In Qualitative Researching with Text, Image and Sound: A practical Handbook, ed. M.W.  Bauer and G. Gaskell, 38–56. London: Sage. Gerry, R., and H.R. Bernard. 2003. Techniques to Identify Themes. Field Methods 15 (1): 85–109. Iconis, R. 2014. Understanding Alcohol Abuse Among College Students: Contributing Factors and Strategies for Intervention. Contemporary Issues in Education Research 7 (3): 243–248. Karam, E., K. Kypri, and M. Salamoun. 2007. Alcohol Use among College Students: An International Perspective. Current Opinion in Psychiatry 20 (3): 213–221. Kerfoot, D., and D.  Knights. 1996. The Best Is Yet to Come?: Searching for Embodiment in Management. In Masculinity and Management, ed. David Collinson and Jeff Hearn. London: Sage.

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PART III

Neurobiology and Neurochemistry of Addiction

CHAPTER 11

Neurochemistry and Pharmacology of Addictions: An African Perspective Andrew G. Mtewa, Serawit Deyno, Emmanuel L. Peter, Annu Amanjot, Lucrèce Y. Ahovegbe, and Duncan C. Sesaazi

11.1   Introduction Neurochemistry deals with the chemistry of nervous system molecules such as neurotransmitters, autacoids, hormones and neuropeptides that direct functions of neurons. These chemicals modulate the central and peripheral nervous systems. Neurochemistry provides a platform for pharmacological and psychological understanding of addictions—their ­

A. G. Mtewa (*) Malawi University of Science and Technology, Blantyre, Malawi PHARMBIOTRAC, Mbarara University of Science and Technology, Mbarara, Uganda e-mail: [email protected] E. L. Peter National Institute for Medical Research (NIMR), Dar es Salaam, Tanzania PHARMBIOTRAC, Mbarara University of Science and Technology, Mbarara, Uganda e-mail: [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_11

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pro-­genesis, prognoses, progressions and remediations. Neurochemistry interfaces with pharmacology, which is basically the study of uses, effects and mechanisms of drug actions. Addictions are loosely repeated exposure episodes to substances or behaviours that modify the nervous system chemistry and physiology to the point of loss of control (Nestler 2013). These exposures are stimuli that work on the receptors of the nervous system at a microscopic scale, which, with time, completely alter the response system of the mechanism, leading to a bio-psychological condition called addiction (Bettinardi-­ Angres and Angres 2010). To understand the occurrence and treatment of addictions, there is a need to get familiar with the neuroscience of addictions, which involves at least three disciplines of chemistry, biology and pharmacology. This field encompasses both neurological and neuropsychiatric disorders (George-Carey et  al. 2012). Africa and persons of African descent have been reported to be more vulnerable to addiction, for various reasons, which will be discussed in the next sections. Research shows that Africa had its own ways of dealing with the disease, mainly through the use of spiritual interventions and herbal therapy. This chapter outlines historical perspectives of the study of neuroscience, with a focus on addictions in the African community, scientific mechanisms involved in addictions, African interventions and research on addictions.

11.2   Neurochemistry in Africa, a Brief Historical Perspective Neuroscience has been practised in Africa, dating back to the Middle Ages, particularly in the northern part (El-Khamlichi 1996). It particularly began in the form of neurosurgery and neuro-anatomy some 5000 years ago in ancient Egypt (Russell 2017). Imhotep, a physician and a high priest of the Sun God Ra, is believed to have authored the earliest records on neuroscience around 2620 BC (Elhadi et al. 2012). Significant advances in the science was observed from around 332 BC, after Egypt was conquered by Alexander the Great (Elhadi et al. 2012). It was being taught

S. Deyno • A. Amanjot • L. Y. Ahovegbe • D. C. Sesaazi PHARMBIOTRAC, Mbarara University of Science and Technology, Mbarara, Uganda e-mail: [email protected]; [email protected]; [email protected]

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and practised by traditional healers from various tribes, leading to different specializations and focus, such as neurosurgery, among others. In eastern Africa, neuroscience was already being studied in the 1940s (Qureshi and Oluoch-Olunya 2010). The practice and knowledge of neuroscience in Africa and the Arabic region contributed much to the development of medicine during the European renaissance period (El-Khamlichi 1996).

11.3   Addiction amongst People of the African Descent Incidences of substance abuse are well reported for Africa; however, the epidemiology of neurological and neuropsychiatric disorders, including addictions, has not been widely explored on the African continent (Quansah and Karikari 2016). Although persons of all races are prone to getting addicted to some stimuli, studies have shown that there is a genetic basis in the vulnerability to some neurotic disorders between African and non-Africans (Blanckenberg et  al. 2013; Karikari and Aleksic 2015). Research shows that those of African descent are more susceptible to addictions due to proximity to factors that drive them towards addictions. It is reported that addiction, mainly to drugs, is rampant on the African continent (Sevenzo 2015). These include easy access to stimuli (e.g. drugs, pornography, gambling, etc.), mental illnesses, discrimination and racism, poverty, violence, crime and traumatic experiences (Gibbons et al. 2004; Wallace and Muroff 2002; Van-Niekerk 2011). This proximity could be by choice but with a large influence from daily life experiences. The factors associated with addictions, according to some literature (UNODC 2004; Bettinardi-Angres and Angres 2010), have been outlined below. Genetic Predisposition Research shows that there is a group of people who are more vulnerable to getting addicted from minor exposures to environmental factors than others under the same conditions. Despite the whole African race being relatively genetically vulnerable, there are some within the group who are more prone to getting addicted. This is the reason that proper institutionalization, management and research on the continent, spearheaded by Africans themselves, are highly recommended. If not well managed, addictions may cripple the development of the continent in one way or another.

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Access to Stimuli Largely, a society with rampant subjection to various substances and habits is more likely to have its young members, as well as the old, experiment with the same at various levels than societies with less of those stimulants. The society could be as small as a family unit, a small chat group or a ­community at large. Uncontrolled circulation of drugs of abuse, pornographic content and sniffing chemicals in the African continent can produce addictive stimuli to the society. Lack of employment may be one of the factors that subject individuals, who mostly have nothing to do on any particular day, to experiment and engage themselves with addictive substances and behaviour. Mental Illness These illnesses manifest in a variety of ways, including anxiety, depression and bipolar disorders. Traumatic experiences in the physical and emotional sense often lead to post-traumatic stress disorders (PTSD), which when untreated, remain a persistent source of stress. As indicated by the Right Addiction Recovery centre (Guarnotta 2018), there are none to limited treatment options in African communities for most of these illnesses, which force the patients to resort to addictive substances and behaviour in order to cope with illness challenges. Seemingly simple matters such as marital cheating to more complex experiences and natural mental disorders are rampant on the African continent, with almost no proper structures to monitor and check their ramifications on consequent human behaviour. In the end, an unfortunate outcome, where the victim is forced to get solace in addictive stimuli, is taken as a normal thing in most communities and not as a matter of urgency. Discrimination and Racism Discrimination and racism are one of the leading causes of low selfesteem and inferiority amongst a community that believes that life draws a line for opportunities based on race and other descriptive characteristics. Those who are regarded inferior are likely to seek redress from drugs and repetitive habits that will see them off on an addictive path requiring recovery.

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Poverty Sometimes, addicted individuals or those who think they are getting addicted to things and behaviour would wish to get treatment, but lack of community or national facilities and/or personal finances may hinder them from accessing appropriate treatment. They therefore continue on the road of addiction as part of their normal lives. This situation continues to push individuals deep into poverty. Repetitive behaviour and use of substances to cope with mental challenges naturally affect the neuro-response system. This, in effect, heavily loads the nervous system to the point that it becomes laden, causing abnormal physiological responses due to changes in the chemical imbalance of the system. The next section discusses the general chemistry and physiology that occurs during addiction and while on the path to recovery.

11.4   Chemical and Pharmacological Descriptions of Addiction Episodes in Neurosciences For convenience, this section will discuss drugs as an example of various stimuli that come the way of the neurosystem. Drugs, commonly abused substances, are structurally diverse and produce different behavioural effects in the user. Yet, all share the common feature that they can modulate the brain reward system that is fundamental to initiating and maintaining behaviours that are important for survival. It was first proposed that specific neural circuits within the brain were involved in the regulation of reward processes when studies demonstrated that reinforcing effects of commonly abused prescription opioids in rats are diminished following nerve injury and alleviation of mechanical allodynia with non-­ opioid analgesics do not appear to stimulate limbic dopamine pathways originating from the ventral tegmental area (VTA) (Ewan and Martin 2011). The medial forebrain bundle (MFB), which connects the VTA to the nucleus accumbens (NAc), was the site first identified in this way. Other neurotransmitter pathways projecting from the VTA and the NAc that innervate additional limbic system—for example, the amygdale and cortical areas of the brain, which are important for the expression of emotions, reactivity to conditioned cues, planning and judgement—have also been associated in reward. The dopaminergic projection has been most closely associated with reward, though the MFB consists of neurons that contain dopamine, noradrenaline and 5-hyrdoxytryptamine (5-HT).

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Natural and artificial rewards (food, sex, drugs of abuse) have been shown to activate this dopaminergic pathway, also known as the mesolimbic dopamine pathway, causing an increase in dopamine levels within the NAcc (Nutt et al. 2015). Drugs of abuse exert influence over the brain reward pathway, either by directly influencing the action of dopamine within the system or by altering the activity of other neurotransmitters that exert a modulatory influence over the mesolimbic dopaminergic pathway (Lewis 2011). γ-aminobutyric acid (GABA), opioid, serotonergic, cholinergic and noradrenergic neurotransmitter pathways have all been shown to interact at various points along the mesolimbic dopaminergic pathway and to modulate its activity. The major neurotransmitters involved in addiction are thus dopamine, serotonin, norepinephrine and opioids (Tomkins and Sellers 2001). These neurotransmitters are discussed below. Dopamine in Addiction Dopamine is majorly a neurotransmitter and also a hormone involved in the regulation of body functions such as behaviour, mood, weight, temperature, reproduction, sex and movement, among others. One scientific writer described dopamine as “love, lust, adultery, motivation, attention, feminism and in general dopamine is addiction” (Brookshire 2013) emphasizing its greater influence on behaviour. Dopamine is synthesized from tyrosine, which enters the neuron by active transport. In the neuronal cytosol, tyrosine hydroxylase converts tyrosine to dihydroxyphenylalanine (dopa). The enzyme aromatic L–amino acid decarboxylase, sometimes termed dopadecarboxylase, finally converts to dopamine. Dopamine is also actively transported into storage vesicles, where it is converted to norepinephrine by dopamine-hydroxylase (Gnegy 2012). Although research on African gene make up is concerned with dopamine, little research has been conducted, which is not enough for a better understanding to direct any robust interventions in the modulation of dopamine response. Dopamine was originally considered merely a precursor to norepinephrine; however, latter studies revealed distinct regions of the CNS for dopamine and norepinephrine distribution (Gnegy 2012). Indeed, more than half the CNS content of catecholamine is dopamine and extremely large amounts are found in the basal ganglia in the caudate nucleus, the nucleus accumbens, the olfactory tubercle, the central nucleus of the amygdala,

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the median eminence and restricted fields of the frontal cortex. Of these connections, projections between the major dopamine-containing nuclei in the substantia nigra and ventral tegmentum and their targets in the striatum, in the limbic zones of the cerebral cortex, and in other major limbic regions have received greater attention. At the cellular level, the actions of dopamine depend on receptor subtype expression and the convergent actions of other transmitters to the same target neurons (Volkow et al. 2012). As it appears, the African race must have a significant level of dopamine activity in various environmental subjections. The dopaminergic system is highly involved in neural reward processes and substance abuse (Nutt et al. 2015). Dopamine is released in the NAc from neurons originating in the VTA (Small et al. 2003). Neural changes results from repeated dopamine enhancement; addiction and abstention are not choices made freely and flexibly. Momentary states of dopamine enhancement, triggered by a narrow range of cues, shut down intertemporal flexibility. Brain changes that accumulate with the recurrence of this cycle send it further out of reach. Yet, addiction is not one monolithic brain state; rather, it is a sequence of transitory states underlying impulse, reflection and emotions that include embarrassment and repentance. The recursive nature of this sequence provides windows of opportunity for the present self to influence future decisions—such as the decision to quit based on fluctuations in brain state, emotion, and cognitive functioning. Addiction comprises a recurrent series of brain states underlying a recurrent set of choices, whereby habit is interspersed with unexpected opportunities for change (Lewis 2011). In the addiction stage, the dopaminergic system recruits specific neural networks and corresponds to the level of adaptation of molecular and cellular mechanisms and environmental associations made with drug use. Drug addiction involves the ascription of distorted weights onto key elements of the neurocircuitry underlying the processing of motivationally relevant events. First, the recruitment of the mesolimbic dopamine system, which originates in the VTA and projects to extended amygdala, is required to produce the acute reinforcing properties of drugs of abuse. In contrast, the symptoms of acute withdrawal, such as negative affect and increased anxiety, are related to decreases in function of the extended amygdala system and the recruitment of brain stress circuits (Everitt and Robbins 2005).

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Norepinephrine in Addiction Norepinephrine is synthesized from dopamine by dopamine-hydroxylase, where dopamine is actively transported into storage vesicles and converted by the enzyme within the storage vesicle (Gnegy 2012). In noradrenergic neurons, the end product is norepinephrine, while in the adrenal medulla, the synthesis is carried one step further by the enzyme phenylethanolamine N-methyltransferase, which converts norepinephrine to epinephrine. The human adrenal medulla contains 80% epinephrine and 20% norepinephrine. The absence of this enzyme in noradrenergic neurons accounts for the absence of significant amounts of epinephrine in noradrenergic neurons (Rush and Geffen 1980). Two types of adrenergic receptors (α and β) and their subtypes have been described in the CNS; all are G-protein coupled receptors (GPCRs). The β adrenergic receptors are coupled to stimulation of adenylyl cyclase activity. The α1 adrenergic receptors are associated predominantly with neurons, while a2 adrenergic receptors are more characteristic of glial and vascular elements. The a1 receptors couple to Gq to stimulate phospholipase C. The a1 receptors on noradrenergic target neurons of the neocortex and thalamus respond to norepinephrine with prazosin-sensitive, depolarizing responses due to decreases in K+ conductances (Gnegy 2012). There is need for in-depth studies towards understanding the nature and response rate of norepinephrine among Africans from different regions of the continent and the world as exposure to different environmental and social factors would have a contribution. Serotonin in Addiction Serotonin (5-hydroxytryptamine or 5HT) is present in the brain as well as in the periphery. Brain serotonin has been implicated as a potential neurotransmitter in the mediation of a wide variety of phenomena in several aspects of behaviour, including sleep, pain perception, depression, sexual activity, aggressiveness, mood, behaviour, satiety and addiction. Serotonin also may be involved in temperature regulation and in the hypothalamic control of the release of pituitary hormones. Most of the serotonin in the brain is in the brainstem, specifically in the raphe nuclei; considerable amounts also are present in areas of the hypothalamus, the limbic system and the pituitary gland (Jorgensen 2007).

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Dietary tryptophan is initially hydroxylated to form 5-­hydroxytryptophan by tryptophan hydroxylase to form 5-hydroxytryptophan. Decarboxylation of 5-hydroxytryptophan by L-amino acid decarboxylase results in the formation of serotonin. Much of the serotonin released in the brain at synapses is taken back into the initial neuron by an active reuptake mechanism, to be released again (Ren et al. 2017). The serotonergic (5-HT) system is involved in the establishment of drug use–associated behaviours and the transition and maintenance of addiction to drugs such as cocaine, amphetamine, methamphetamine, MDMA (ecstasy), morphine/heroin, cannabis, alcohol and nicotine. There is a crucial and distinct involvement of the 5-HT system in both processes with considerable overlap between psychostimulant, opioids and alcohol. Functional model suggests specific adaptations in the 5-HT system, which coincides with the establishment of controlled drug use–associated behaviours. These serotonergic adaptations render the nervous system susceptible to the transition to compulsive drug use behaviours and often overlap with genetic risk factors for addiction, a  new trajectory by which serotonergic neuro-adaptations induced by first drug exposure pave the way for the establishment of addiction (Muller and Homberg 2015). The serotonin (5-HT) neurotransmitter system provides fundamental modulatory regulation of the limbic-corticostriatal circuitry known to be vital in the development of addiction as well as the aspects of addiction that hinder recovery and contribute to relapse (Jorgensen 2007). Most of the research on serotonin in Africans is limited only to African Americans, which makes it difficult to understand its activities and responses in Africans on the African continent. Opioid Peptides in Addiction Opioid peptides are the most common neurotransmitters in the hypothalamus. They are far more potent than any other neurotransmitters. Three distinct families of classical opioid peptides have been identified: the enkephalins, endorphins and dynorphins (Beaumont 1983). Each family derives from a distinct precursor protein and has a characteristic anatomical distribution. These precursors—prepro-opiomelanocortin (POMC), preproenkephalin and preprodynorphin—are encoded by three corresponding genes. Each precursor is subject to complex cleavages and post-­ translational modifications, resulting in the synthesis of multiple active peptides (Ozaki 2016). The opioid peptides share the common amino-­ terminal sequence of Tyr-Gly-Gly-Phe-(Met or Leu), which has been

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called the opioid motif. This motif is followed by various C-terminal extensions, yielding peptides ranging from 5 to 31 residues. Endogenous opioid peptides appear to function as neurotransmitters, modulators of neurotransmission or neurohormones; the full extent of their physiological role is not completely explored. The elucidation of the physiological roles of the opioid peptides has been made more difficult by their frequent coexistence with other putative neurotransmitters within a given neuron (Mosberg et al. 1988). The genetic basis of addiction in Africa can be connected to the changes in these receptors and signal transduction system. Future studies characterizing receptors in African population is highly needed. There is a dire need among Africans living on different parts of the continent to understand how peptides of opioid nature interact with other peptides, especially over addiction episodes.

11.5   Withdrawal Symptoms in Drug Addiction Withdrawal is a vital manifestation of dependence and motivates relapse. It is a cohesive collection of symptoms that emerge during drug deprivation and decline with either the passage of time or reinstatement of drug use, may be inadequate to explain scientific findings or fit with modern theories of addiction (Piper 2015). Withdrawal symptoms include depression, increased appetite, abdominal cramping, diarrhoea and headache. Withdrawal syndrome occurs in non-availability of the abused drug. The symptoms of withdrawals, such as craving for drugs and increased anxiety, are related to decreases in function of the extended amygdala system and the recruitment of brain stress circuits (Everitt and Robbins 2005). Coping with withdrawal symptoms is often the most challenging part of addiction cessation.

11.6   Treatment Approaches to Addictions Pharmacological Approaches African governments are conscious about addiction as a serious issue, right at policy formulation level. The governments of South Africa and Tanzania are just a few of many other examples that have guidelines for the treatment of addictions (URT 2013). Pharmacological approaches to addiction treatment are focused on the underlying neurotransmitters affected by addictions and are aimed at reducing drug reward or alleviating withdrawal states (Forray and Sofuoglu 2014). The components of the 5-HT system

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had been researched for novel targets for the development of pharmacological treatments for psychostimulant dependence, which is associated with significant deviations in dopamine neurotransmission. Two key modulators of dopamine signalling within the limbic-corticostriatal circuit are the 5-HT(2A) receptor (5-HT(2A)R) and the 5-HT(2C)R. These receptors are known to control the neurochemical and behavioural effects of psychostimulants, and in particular, the in vivo effects of cocaine (Bubar and Cunningham 2008). Agonist replacement therapy in the treatment of drug addiction, either in a low-dose or slow-release formulation, alleviates craving and blocks the reward effects while having little or no abuse potential of its own. D-amphetamine is used as an agonist-like medication in the treatment of amphetamine addiction. Methadone (Robertson and Daniels 2012) and nicotine (Stead et al. 2012) replacement therapy are substitution therapies for opioid and nicotine addiction respectively. Different drugs are used to treat different withdrawal symptoms. Some of the drugs include benzodiazepines, antidepressants and clonidine. Benzodiazepines reduce anxiety and irritability. Anxiety is a common symptom of withdrawal from many drugs, including cocaine and opiates such as heroin. Benzodiazepines have a sedative effect, which helps ease alcohol withdrawals (Perry 2014). Caution should be taken as they are addictive themselves. Antidepressants help relieve depression feelings until the brain is able to produce biogenic amines. Clonidine is used to treat alcohol and opiate withdrawals; reduces sweating, cramps, muscle aches, anxiety and also stops tremors and seizures (Fresquez-Chavez and Fogger 2015). Community-Based Approaches National responsible gambling programme supported by industry and the community is used to achieve redress to addictions (Collins et al. 2011) by getting input from various sectors of the communities. Partnership between the academic and the industry is also another approach that is being used in some parts of Africa, including South Africa (Stein 2015). Spiritualism Religion is reported to be playing a central role among the African population, varying only in extents from region to region due to cultural differences (Mattis and Jagers 2001). Its role is in both treatment and preventive purposes. Religion has, for a long time, been documented to be instrumental in

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dealing with substance abuse pattern treatments (Chitwood et al. 2008). It has also been shown by research to play a protective role against addiction (Hodge et al. 2001; Rote and Starks 2010). Phytotherapy The use of herbs to treat addiction and its withdrawal symptoms has been practised in African communities for some time. A Congolese and Gabon plant called Tabernanthe iboga was reported to contain an alkaloid, ibogaine, which is effective against addictions (Schenberg et al. 2014; Lavaud and Massiot 2017). Most chemical dependencies are treatable with ibogaine by body cleansing and the resetting of the neurochemistry of the brain. Prolonged use of ibogaine induces serious adverse effects, including irregular cardiac rhythms (Alper et al. 2008) and sleep repression (González et  al. 2018). Other plants from which ibogaine is found include Catharanthus roseus, which has two alkaloids of the iboga group, catharanthine and coronaridine (Lavaud and Massiot 2017). In West Africa, a plant, Voacanga Africana is also one of the plants with extracts used against psychoactivities of Indian hemp principally (Kitajima et al. 2011).

11.7   Neuroscience Research and Training in Modern-Day Africa Modern-day neuroscience studies are considered to have been introduced and developed around 1960 in African countries, with teaching in many universities in the continent starting between the years 1960 and 1970 (El-Khamlichi 1996). Folk medicine practice and African physiotherapy against addictions has so much informed modern research and studies on plant-based chemical compounds to come up with conventionally optimized drugs. Despite research being carried out to find treatment agents against addictions, gaps still remain, particularly in the synthesis of derivatives of previously known active molecules. For example, catharanthine and coronaridine are yet to be biosynthesized (Lavaud and Massiot 2017; Kries and O’Connor 2016). The active principle in Voacanga Africana of West Africa was found to be voacangalactone, which acts as an antagonist to cannabinoid receptor CB1 in hemp addictions (Kitajima et al. 2011). African research in neurosciences, including addictions to substance abuse, has been very low. A systematic review of research in the field for two decades (1995–2015) (Quansah and Karikari 2016) reported a lack of

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clinical and experimental research data, which shows that most of the research being conducted in Africa in neurosciences are survey-based. About 60% of the articles retrieved in the same research were reported to have been published between 2008 and 2015, which is a good indicator of the development and growing interest in more recent times. There is generally both a lack of interest and low training opportunities in Africa in the field of neurosciences (Karikari et al. 2016) which significantly limits proper ways of handling addictions and other neuro-diseases. Strides being made in Ghana are still crippled by lack of trained neuroscientists (Quansah and Karikari 2016). Currently, various disciplines in neurosciences have been bundled up together with the facilitation of professional networks in the field such as the Society of Neuroscientists of Africa (SONA) and the Southern African Neuroscience Society (SANS) (Howells and Womersley 2018). Neuroscience studies in Africa are envisaged to sustainably progress well in future with proper engagement and communication amongst stakeholders amidst various challenges (Karikari et al. 2016). The use of implants to counter addictions in South Africa, for example, indicates the positive direction in which African science is heading. In Nigeria, animal models and herbal research have been conducted for interventions in various neurological and neuropsychotic disorders (Akinyemi et al. 2018). Africa’s ability to undertake high-impact research in neurosciences is hindered by lack of funding, facilities and technology (Awenva et al. 2010). Today, most of the following countries have registered at least 20 research publications in neurosciences by 2017 from the south to the northern part of Africa: South Africa, Tanzania, Kenya, Cameroon, Nigeria, Morocco, Algeria and Tunisia (Russell 2017). This is a good indication of the interest African researchers have in the topic, but more can be done.

11.8   Conclusion Africa has high cases of neurological and neuropsychiatric disorders, including addictions. The impact that these cases have on the lives and socioeconomic development of individuals and communities is significantly high. Knowing that these disorders are genetic and environment-­dependent, it is tricky to manage them without understanding neuroscience mechanisms of individual genetic sets as well as individual environmental dispositions. Unfortunately, poor resources and governance impede high-­impact

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scientific research, training and policy formulations to make significant contributions towards managing addictions, in particular. In-depth studies are required for customized groups of people and regions of Africa to make meaningful scientific impact. This work recommends deliberate budgetary allocations specifically to develop areas in this field of science through funding various research projects and establishment of graduate academic and industrial study programmes. More collaborative interdisciplinary work in this field is sure to make a difference. The research has to focus on the genetic basis of addiction in Africa. Other ways through which a robust intervention in the field can be achieved in Africa is by deliberate capacitybuilding policies and programmes that should be monitored and reviewed regularly. Early stage scientists can be engaged by professionals and drilled in specific research areas to improve approaches as well as techniques suitable for the context. Early childhood interventions, mainly in the prevention of addictions and determination of early signs and traits towards addictions as alarms for possible interventions, need to be instituted in a formal way. This could be by incorporating the filed-in mainstream early learners’ school curriculum, community engagement and civic education. Community engagement is one of the best ways through which locally effective addiction therapies can be understood and perfected in a professional way for better and sustainable outcomes. In schools, “Watch-buddy” approach could also help detect early traits towards addictions. This is an approach where students can have accountability partners who can be working together with a third party, on mutual consent, to assist one another against addictive paths. Lastly, a formidable multi-disciplinary approach amongst scientists will help in finding customized solutions in both research and direct victim support.

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CHAPTER 12

Neurobiology of Substance of Abuse (Drugs) and Behavioural Addiction in Africa Godfrey S. Bbosa

12.1   Introduction Addictions to psychoactive drugs or substances of abuse and certain behaviours have continued to be a global public health challenge affecting many people worldwide, and it is a major risk factor to mental illnesses (ASAM 2011; UNODC 2018). And in African nations, the situation is similar though limited studies have been conducted to address the burden of the substances of abuse and behaviours as well as their neurobiological effects on the brain. Addiction is a complex mental disorder that is like a tree (addiction tree) with soils and seeds (soils of addiction) that have an origin from any form of abuse like emotional, physical, sexual and spiritual neglect, and once these interact with the genes, they create the unhealthy roots of addiction like rejection, shame, fear, depression, loneliness, anger and grief or sadness (The Recovery Coach 2010; Steve 2017). And as a way to escape from these painful roots of addiction, the affected individuals engage in the

G. S. Bbosa (*) Department of Pharmacology & Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda Harvard Medical School, Boston, MA, USA © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_12

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branches and leaves of addiction such as alcohol and substances of abuse (drug addiction) and behaviours that lead to behavioural addiction. Various theories are involved in the  maintenance of dependence and addiction to substances of abuse, including (1) neurobiological theories that consist of two major pathways, the dopaminergic reward system and endogenous opioid system. But other systems releasing various  neurotransmitters have been linked to the above two systems, their neurocircuitry and the transcription factors, genetics and epigenetics involved in their activity, (2) adaptive theories that explain the psychological factors that act as motivators and reinforce the addictive behaviours and (3) exposure theories that involve the sociocultural interactions that look at the cultural and environmental factors that surround the individual, thus contributing to the addiction (Openlearn 2016; Peele and Alexander 2016).

Key Definitions

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry due to drugs or behaviours; which is characterized by inability to consistently abstain, impairment in behavioural control, craving or increased “hunger” for drugs or rewarding experiences, diminished recognition of significant problems with one’s behaviours and interpersonal relationships and a dysfunctional emotional response (APA 2013; Koob and Volkow 2016). Behavioural addiction is defined as an intense desire to repeat some action that is pleasurable, or perceived to improve well-being, or capable of alleviating some personal distress, despite the awareness that such an action may have negative consequences (Dasgupta 2017). Drug addiction is also known as substance dependence, is a chronically relapsing brain disorder characterized by (1) compulsion to seek and take the drug, (2) loss of control in limiting intake, and (3) emergence of a negative emotional state (e.g., dysphoria, anxiety, irritability) when access to the drug is prevented (Koob 2011; Koob and Volkow 2016). Neurobiology is the study of cells of the nervous system and the organization of these cells into functional circuits that process information and mediate behaviour (Smith 2002). Substance use disorder describes a problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress (APA 2013; Hartney and Gans 2018).

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12.2   Types of Addiction Generally, there are two broad categories of addiction: (1) alcohol and substances of abuse addiction and (2) behavioural addiction. The alcohol and substances of abuse addiction are the oldest and the most common cause of public health problems mainly mental illnesses  globally. While behavioural addiction is relatively new though some of the behaviours have been in existence for centuries such as sex addiction, eating, gambling disorders and many others. Substance (Drug) Abuse Addiction and Their Classification Drug addiction is a chronic relapsing disorder characterized by (1) compulsion to seek and take the drug, (2) loss of control in limiting intake and (3) emergence of a negative emotional state such as dysphoria, anxiety, irritability, thus leading to a motivational withdrawal syndrome when access to the drug is prevented (Koob and Volkow 2010). There are various classes of psychoactive drugs that are abused worldwide, and the degree of their use varies in different countries depending on accessibility and the pharmacological effects they cause. These drugs are grouped into four major classes, including (1) stimulants, (2) hallucinogens, (3) depressants and (4) anti-psychotics (Wikipedia 2018). However, according to the US Drug Enforcement Administration (DEA), these drugs are classified into five schedules (classes) depending on their acceptable medical use, abuse and dependence potential (Dasgupta 2017; Anderson 2018; DEA 2018). (1) Schedule I (Class A) are drugs with no currently accepted medical use and with high potential for abuse. They include heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-­ methylenedioxymethamphetamine (ecstasy), methadone, methaqualone, cocaine, cathinone in Khat, peyote and magic mushrooms (DEA 2018; Kaur 2012; McGonigle 2014). (2) Schedule II (Class B) are drugs with high potential of abuse c­ ausing severe psychological or physical dependence. They include amphetamines like methamphetamine, dextroamphetamine, dextroamphetamine-­ amphetamine, and methylphenidate and their combinations, cocaine, methadone, hydromorphone, meperidine, oxycodone, codeine, fentanyl, cannabis, cathinones, mephedrone and synthetic cannabinoids. (3) Schedule III (Class C) drugs have less potential of abuse and dependence, and they include benzodiazepines (tranquilizers), barbi-

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turates, ketamine, anabolic steroids, anabolic steroids such testosterone, gamma hydroxybutyric acid (GHB), γ-Butyrolactone (GBL) and benzylpiperazines (BZP) and combination of paracetamol (acetaminophen) and codeine (TSO 2016; WHO 2016; DEA 2018). (4) Schedule IV are drugs with low potential for abuse and risk of dependence, and they include some benzodiazepines like  diazepam, lorazepam, alprazolam, zolpidem; acetaminophen/propoxyphene (Darvocet), tramadol, carisoprodol, pentazocine, propoxyphene, cathine in Khat and many others. (5) Schedule V drugs have low potential of abuse than Schedule IV drugs but with reduced amount of narcotics in the drug combination, and they are commonly used clinically as antidiarrheal, antitussive and analgesic (WHO 2016; DEA 2018). However, these substances have varying levels of causing harm and dependence with heroin ranked as the most harmful drug with high potential of dependence (Kaur 2012; McGonigle 2014). Substance Abuse in Africa In Africa, substance abuse has persistently remained a regional problem and studies show that drug use problem is twice that reported globally and about 2 million people in Africa, out of the 33 million people have drug use problem (Asuni and Pela 1986; UN-ODCCP 1999; Acuda et  al. 2011; ANA 2018). According to the study conducted in ten sub-Saharan African countries, the findings showed that 22 countries were among the highest with rapid increase in per capita alcohol consumption, and there was increasing trend in use of cannabis, tobacco, khat, cocaine, stimulants and heroin (UN-ODCCP 1999; Acuda et  al. 2011; WHO 2017). The findings also show that there is an increase in drug abuse-related mental illnesses in African population, especially in the sub-Saharan Africa countries  (Vancampfort et  al. 2017; Charlson  et  al. 2014;  Baingana et  al. 2006).  However, race and ethnicity as well as tribal differences among whites, Blacks, Asians, Japanese and Chinese have been reported to play a role in individual responses to alcohol and other substances/drugs of abuse, and behavioural addictions and their effects on the brain. And the differences are mainly due to the pharmacokinetics (PK), pharmacodynamics (PD) and pharmacogenetics (PG), and transporters of the substances/drugs in the body (Yasuda et al. 2008).

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Behavioural Addiction Several behavioural addictions like psychoactive drugs have been documented to share many similarities in terms of natural history, phenomenology, tolerance, comorbidity, overlapping genetic contribution, neurobiological mechanisms and response to treatment (Geller 2008; Grant 2008; Grant et al. 2010; Schreiber et al. 2011). Behavioural addiction is defined as an intense desire to repeat some action that is pleasurable, or perceived to improve the well-being or alleviating some personal distress, despite the awareness that such an action may have negative consequences (Deleuze et al. 2015; Dasgupta 2017). These behaviours have continued to be a global problem  even in many African communities, especially among the youth. Among the commonest behaviours encountered in most communities globally are (1) gambling (2) internet, social media and video games (3) shopping (4) work (5) love (6) sex and pornography (7) shopping (8) debit (9) food and eating disorders (10) co-dependency (11) physical exercise (12) religious beliefs (Fong 2006; Villella et  al. 2010; Bridges-of-Hope 2018; Kraus et al. 2018). However, some of these addictions have been around since man’s existence and even the Bible mention sexual immoral that can be a form of addiction like masturbation and pornography: Marriage should be honoured by all, and the marriage bed kept pure, for God will judge the adulterer and the sexually immoral. Hebrews 13:4 (NIV) (Miller 2018). Other forms of behavioural addiction reported include: (1) Impulse control disorders (ICDs) (Schreiber et  al. 2011), (2) Kleptomania, (3) Trichotillomania, (4) Intermittent explosive disorder, (5) Pyromania, (6) Pathological skin picking (Schreiber 2011; Cuzen and Stein 2014), (7) Compulsive buying (Schreiber 2011), (8) Exercise addiction (Berczik et al. 2014). However, though exercise addiction is regarded as an addiction, it was excluded in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) (APA 2013; Cuzen and Stein 2014). Behavioural Addiction in Africa In Africa, a number of behavioural addictions have been reported in different countries, and these include Internet and online video games, gambling, sports betting, sex and pornography, shopping, corruption and eating disorder(Mukasa 2012; Nath et  al. 2013; Ssewanyana and Bitanihirwe 2018). Also, legal casinos have been reported and currently

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operate in many African countries, including Angola, Botswana, Democratic Republic of Congo, Gabon, Gambia, Kenya, Ghana, Lesotho, Liberia, Namibia, Nigeria, Rwanda, Senegal, South Africa, Swaziland, Tanzania, Uganda, Zimbabwe and South Africa (Ssewanyana and Bitanihirwe 2018).

12.3   Neurobiology of Addiction Neurobiology of addiction involves the exposure effects of psychoactive drugs and behaviours on the brain cells, their functional circuits and signal transduction mechanisms, especially in the reward system to modulate behaviours (Smith 2002). Reward System The reward system, also called the dopaminergic mesolimbic system or incentive salience pathways or salience attribution, is physiologically responsible for individual happiness as a form of survival. There are two forms of rewarding stimuli to the system, including (1) natural reward stimuli such as food, water, sex and nurturing (NIDA 2007) and (2) Artificial reward stimuli such as psychoactive drugs and behaviours; these mimic the natural reward stimuli, and, in most cases, they usually provide a stronger activating effect on the reward system (NIDA 2007; AwareMed 2014). Neurocircuitry in Addiction Psychoactive drugs and behaviours affect the reward system (dopaminergic mesolimbic system) that connects to two important nuclei—the ventral tegmental area (VTA) and nucleus accumbens (NAc or NAcc) and to the prefrontal cortex (Koob and Volkow 2010; Volkow et  al. 2011). However, the system is linked to many other brain structures, including the anterior cingulate cortex, the ventral striatum, the ventral pallidum, substantia nigra pars compacta, amygdala, hippocampus, thalamus, lateral habenular nucleus, specific brainstem structures like the pedunculopontine nucleus and the raphe nucleus where they influence the behaviours (Haber 2009). The Ventral Tegmental Area (VTA) is found in the midbrain and it releases dopamine in the brain. It is commonly targeted by drugs such as nicotine, alcohol and opioids like heroin. The VTA nucleus sends ­projection neurons into the medial forebrain connecting to the Nucleus

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accumbens which is involved in motivation. It also projects to amygdala that mediates association of reward with cues and negative reinforcement. It projects to ventral pallidum which is a meeting centre for limbic reward signals and intermediate centre for a number of cognitive, affective and motor processes, and it is also involved in the coding and enhancement of reward learning, hedonics and motivation (Smith et al. 2009). Its projection to hippocampus is associated with the processing of memory and learning and to the pre frontal cortex (PFC) that form the mesocorticolimbic dopaminergic pathway that is strongly involved in learning reinforcement. However, the acute psychoactive drugs exposure leads to increased extracellular dopamine levels in NAc, its projection sites, and the dopamine levels are drug-specific dependent. The Nucleus accumbens (NAc or NAcc) is a small region in the forebrain with ancient evolutionary origins. It plays a key role in the regulation of various survival drives including the food and thirst. The output from this area projects to other brain regions such as the PFC regions especially the medial prefrontal cortex (MPFC) and ventrolateral prefrontal cortex (VLPFC), basal ganglia, amygdala, hypothalamus, anterior cingulate cortex (ACC) and precuneus, and these areas modulate the reward system and emotion circuitry (Pavuluri et al. 2017). The NAc is commonly targeted by different drugs such as cocaine, amphetamine, cannabinoids like cannabis, opioids like heroin and behaviours like gambling, and all of which causes the release of dopamine (DA) into the NAc, where in turn acts as an incentive to continue using these drugs thus influencing behaviours (Nestler 2005; PinsDaddy 2018). The prefrontal cortex (PFC) is part of the frontal lobe, and it is physiologically important in the regulation of many cognitive functions such as memory, language and decision-making and can be influenced by psychoactive drugs and behaviours. The Amygdala is an almond-shape integrative centre or nucleus found in the medial temporal lobe. It is responsible for processing of emotions, emotional behaviour, motivation, survival instincts and memory. And the activation of the VTA, NA, amygdala and PFC nuclei by the psychoactive drugs and certain behaviours collectively produce pleasure/happiness and the reinforcement of that behaviour. And the increased excess dopamine release in these areas causes desensitization (up regulation) of the dopamine receptors and in order to compensate for this desensitization process, individuals will engage in addictive behaviour where they become tolerant and hence return to the same level of ­“dopamine high” (Koob and Kreek 2007). The long-term exposure to these substances

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causes down-regulation of dopamine receptors, thus leading to reduced activity of the reward pathway and hence the withdrawal symptoms (negative symptoms) (Koob and Kreek 2007). The negative withdrawal symptoms include anxiety, depression, irritability and mood swings, anhedonia (difficulty experiencing pleasure), insomnia or somnolence and social withdrawal, and in this state the individual is not getting positive reinforcement but the purpose is to stop the bad feelings and hence the process of craving (preoccupation/anticipation) (Koob and Volkow 2010). Role of Habenula as an Anti-Reward Centre in the Brain The habenula is part of the diencephalon that appears as a small pair of nuclei located above the thalamus at its posterior end, close to the midline, and together with pineal gland, they form the epithalamus. And in vertebrates, it is divided into medial habenula (MHb) that responds to the effects of nicotine and the lateral habenula (LHb) that is responsible for the modulation of the brain’s response to reward stimuli (Beretta et  al. 2012; Velasquez et  al. 2014; Batallaa et  al. 2017). Physiologically, the LHb neurons send aversive and negative reward signals through potent indirect inhibition of dopaminergic neurons in the VTA, and at the same time, the VTA dopaminergic neurons project to the LHb but they release GABA neurotransmitter to inhibit LHb neurons and promote the reward activity in the VTA. This complex interplay makes the LHb play key neuroanatomical role in the regulation of midbrain reward circuitry (Volkow and Morales 2015; Stamatakis et al. 2016). The centre receives input from limbic system and basal ganglia and the fasciculus retroflexus that form major projection to the midbrain and controls the release of glutamate onto gabaergic cells on VTA nucleus. This then inactivates dopaminergic neurons in the ventral tegmental area/substantia nigra compacta and hence controls dopamine levels in the striatum thus acting as an “anti-­ reward”, “negative reward” or “punishment” centre as well as playing a key role in reward-associated learning (Bromberg-Martin et  al. 2010; Volkow and Morales 2015). And through LHb, it also modulates serotonin levels and norepinephrine release while the MHb modulates acetylcholine release (Bromberg-Martin et al. 2010; Velasquez et al. 2014). The habenula influences the brain’s response to pain, stress, anxiety, sleep and reward, addiction and other behaviours. Its functional impairment is ­associated with various neurological conditions and diseases like depression, schizophrenia and drugs of abuse- related disorders (BrombergMartin et al. 2010; Velasquez et al. 2014).

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12.4   Neurotransmitters Involved in Addiction Exposure to psychoactive drugs and behaviours influences many neurotransmitters release by the neurons in the neurocircuitry of the reward system and its interlinked nuclei. These drugs causes the release of DA in the NAc, thus stimulating D1 receptors (D1R) and the firing in the area (Esch and Stefano 2004; Castro et al. 2015; Volkow and Morales 2015; DiScala et  al. 2018). Many other neurotransmitters are released by the different nuclei that are linked to the reward system including dopamine and GABA released at the NAc and amygdala, and their release is influenced by the cocaine and amphetamines exposure (Esch and Stefano 2004; Volkow and Morales 2015; DiScala et al. 2018). Opioids exposure influence the release of many neurotransmitters, such as opioid peptides like β-endorphin, γ-endorphin, enkephalins, dynorphins, nociception; dopamine and endocannabinoids neurotransmitters in both the VTA and NAc; nicotine and other active compounds in the tobacco products influence the release of the dopamine, GABA and opioids peptides neurotransmitters in the NAc, VTA and amygdala (Esch and Stefano 2004; Volkow and Morales 2015; DiScala et al. 2018). The delta-9-­tetrahydrocannabinol (d-9-THC) and cannabidiol (CBD) from Cannabis (Marijuana) influence the release of dopamine, endocannabinoids and opioid peptides in the VTA and NAc. While alcohol exposure influences a number of neurotransmitters in the neurocircuitry of the reward system, such as dopamine, opioids peptides, GABA, glutamate, endocannabinoids as well as the ion channels (GABAA-stimulated chloride ion channels and inhibits voltage-dependent calcium and sodium ion channels) in the NAc, VTA and amygdala (Table 12.1) (Esch and Stefano 2004; Volkow and Morales 2015; DiScala et al. 2018).

12.5   Addictive Drug Targets and Their Main Mechanisms of Action in the Reward System Psychoactive drugs have various mechanism of action, and they are grouped into four classes depending on their target in the reward system. In the VTA, Class 1 drugs including opioids, cannabinoids, γ-hydroxy butyrate (GHB) work through G-protein-coupled receptors (GPCRs) mechanism by targeting GABA neurons; Class 2 drugs target the ion channels on both the GABA and dopaminergic neurons, and they include benzodiazepines, nicotine, Phencyclidine  (PCP), ketamine and ethanol

PCP, ketamine (dissociative anesthetic)

Psilocybin Class II: Drugs that Nicotine bind to ionotropic receptors and ion channels (Lüscher and Ungless 2006; Volkow et al. 2011; Rupp 2017) Benzodiazepines Alcohol Inhalants

γ-Hydroxybutyric acid (GHB) LSD and mescaline

GABAAR Multiple targets such as GABA and glutamateReceptors (GABAAR, 5-HT3R, AChR, NMDAR, Kir3 channels) NMDAR

5-HT2AR (Gq) Nicotinic receptors (Nicotinic neuronal) (predominantly α4β2 subtype), nAChR (α4β2)

5-HT2AR (Gq)

GABABR (Gi/o)

Activates mainly 5HT2A serotonin receptors and less of other 5HT receptor subtypes (5-HT1, 5-HT2, 5-HT6, and 5-HT7 receptors and partly on dopamine (DA) receptors D1 and D2 and the adrenergicα2 receptors Activates mainly 5HT2A serotonin receptors Directly activates VTA DA neurons by stimulating their nicotine receptors and indirectly activates them by stimulating the nicotine receptors in glutamatergic terminals to VTA DA neurons (excitation, disinhibition, modulates release) Positive modulator, disinhibition Facilitates GABAergic neurotransmission, which may disinhibit VTA DA neurons from GABA interneurons or may inhibit glutamate terminals that regulate DA release in Nac (excitation) Antagonist, disinhibition – inhibits NMDA glutamate receptors

Disinhibits VTA DA neurons by inhibiting GABA interneurons that contain MOR in the VTA or directly activates NAc neurons that contain μ-opioid receptor Regulates dopaminergic signaling through CB1R in NAc neurons and in GABA and glutamate terminals to NAc Disinhibition

μ-opioid receptor (MOR), MOR (Gi/o)

Class I: Drugs that Opioids (heroin, opioid activate G protein– analgesics) coupled receptors (GPCR) (Lüscher and Ungless 2006; Volkow Cannabinoids et al. 2011; Rupp 2017) Cannabinoid CB1 receptor, CB1R (Gi/o)

Mechanism for DA increase

Molecular target

Mechanistic classification Drug name

Table 12.1  Main classes of drugs of abuse, their main molecular targets, and some of the mechanism(s) by which they increase DA in NAc

Dopamine & 5HTOthers are norepinephrine, opioid and glutamate

Gambling and others

Addictive behaviours (Clark et al. 2013; Potenza 2013; Bates 2015)

SERT > DAT, NET

Methylenedioxymethamphetamine (MDMA, Ecstasy) (Empathogen)

Cathine, cathinone and NET and SERT, synaptic vesicles norephedrine; Cathine is up to 10 times less potent than cathinone

DAT, SERT, and NET DAT, NET and SERT, VMT

Cocaine Amphetamines Methamphetamine

Khat (Patel 2000; Colzato et al. 2011; Lemieux et al. 2015; Caulfield 2016)

Class III: Drugs that bind to transporters of biogenic amines or promote the release of dopamine from synaptic vesicles (Lüscher and Ungless 2006; Volkow et al. 2011; Rupp 2017)

Blocks dopamine transporter (DAT) on the terminals of DA projecting neurons from VTA to NAc (cocaine) or releases DA from the vesicles of DA terminals (methamphetamine, amphetamine) Increases mainly the extracellular concentration of serotonin and less of dopamine and norepinephrine by 2 mechanisms (1) increase their release from the synaptic vesicles and (2) by blocking their re-uptake system. Similar to amphetamines but it stimulate the release of dopamine and inhibit the reuptake of epinephrine, norepinephrine and serotonin in the central nervous system (CNS), NAc, striatum and dysfunctions in prefrontal cortex (PFC) and orbitofrontal cortex (OFC) Reward pathway: (VTA & NAc), amygdala, striatum, ventromedial PFCCognitive control pathway: Lateral PFCbilateral insula and ventral striatum

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(Lüscher and Ungless 2006; Volkow et  al. 2011; Rupp 2017). In the nucleus accumbens, all the addictive drugs increase dopamine neurotransmitter levels in the dopaminergic neuronal synapse. However, in both the VTA and NAc, Class 3 drugs target dopamine transporter (DAT) in the dopaminergic mesolimbic system (reward pathway), and these drugs include cocaine, amphetamines and ecstasy (Lüscher and Ungless 2006; Volkow et al. 2011; Rupp 2017). Then Class 4 drugs that have low potential of abuse and commonly used clinically in the management of various conditions include antiepileptics, appetite suppressants, anxiolytics, sedatives, as well as benzodiazepines that also appear in Class 2; also included under Class 4 are some opioids like tramadol and dextropropoxyphene, fenfluramine, lorcaserin, fenproporex, mazindol, amfepramone and diethylpropion (DEA 2018). There are also solvents such as jet fuel and toluene (paint thinner) that target the mesolimbic dopamine system and medial prefrontal cortex (mPFC), acetone (nail polish remover)  and others (Beckley and Woodward 2013), which are commonly sniffed and also targets the neuronal membrane bi-lipid layers (Table  12.1), thus causing behavioural changes as well as “sudden sniffing death’’.

12.6   Behavioural Addiction Targets and Their Main Mechanisms of Action in the Reward System Like the psychoactive drugs, addictive behaviours such as gambling, Internet and video games, and many others influence similar various brain regions, especially the reward system, ventral anterior cingulate cortex, ventromedial prefrontal cortex, orbitofrontal cortex, basal ganglia, thalamus, ventral striatum, amygdala, insula, left occipital cortex, left fusiform gyrus, right parahippocampal gyrus, right prefrontal areas and many others (Goudriaan et al. 2010; Potenza 2013). And the various n ­ eurotransmitters influenced by these behaviours in these brain regions include norepinephrine, serotonin, dopamine, opioid and glutamate, and these  have been implicated in gambling and pathological gambling (Goudriaan et al. 2010; Potenza 2013). The adrenergic systems have been hypothesized to contribute to arousal and excitement, serotonin to impulse control, dopamine to rewarding and reinforcing aspects, opioids to pleasure/urges, cortisol to stress responsiveness and glutamate to cognitive functioning including cognitive flexibility (Goudriaan et al. 2010; Potenza 2013).

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Transcription Factors Activated by Psychoactive Drugs and Addictive Behaviours Exposure to psychoactive drugs and addictive behaviours influences the various neurotransmitters activities in the reward centre and its associated nuclei in the brain. The influence occurs by activating various transcription factors that lead to gene expression of (1) the precursor molecules and enzymes involved in the synthesis, storage in the vesicles, release and their degrading enzyme systems at the synapses (2) neurotransmitter transporters at the synapse (re-uptake systems) that are responsible for removing the neurotransmitters at the synapse such as dopamine transporter (DAT), serotonin transporter (SERT) (3) ion channels, receptors and signaling transduction pathways especially the G-protein-coupled receptors  (GPCRs) leading to activation of cyclic adenosine monophosphate (cAMP), cyclic guanosine monophosphate (cGMP), phospholipase C (PLC) cascade leading to production of diacylglycerol (DAG) and inositol triphosphate (IP3) second messenger systems that activate protein kinases which in turn activate various transcription factors involved in these processes (Marinissen and Gutkind 2001; Robison and Nestler 2011; Nestler 2013). The commonest transcription factors involved in gene expression include cAMP response element binding protein (CREB), Fos family transcription factor such as cFos, FosB and ΔFosB and these dimerize with JUN family proteins to form the AP-1 complex that then upregulates transcription processes (Nestler 2008; Wikimedia 2016). Other factors include nuclear factor κB (NFκB); myocyte enhancing factor-2 (MEF2); glucocorticoid receptor, nucleus accumbens 1 transcription factor (NAC1); early growth response factors (EGRs); and signal transducers and activators of transcription (STATs) (Marinissen and Gutkind 2001; Robison and Nestler 2011; Nestler 2013). However, the commonest transcription factors involved in addiction are CREB and Fos family. CREB is highly expressed in the whole brain and commonly targets genes for cFos, brain-derived neurotrophic factor (BDNF), tyrosine hydroxylase and a number of neuropeptides such as corticotropin-releasing factor and dynorphin (opioids) that influences directly or indirectly the dopamine levels, especially in the reward pathway and other areas of the brain involved in addiction like the PFC, VTA, NAc, amygdala, hippocampus and many others (Robison and Nestler 2011; Nestler 2013). The Fos transcription factors have been reported to cause downstream cascade of reactions leading to altered protein expression, structural changes in the neurons in the different brain regions and their functions. For example,

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chronic cocaine self-administration for 4 hours daily for a period of 18 days has been reported to cause expression of cFos, Fos and ΔFosB in NAc, medium spiny neurons  (MSNs), basolateral amygdala and pre-limbic PFC.  Other proteins such as cyclin-dependent kinase-5 (CDK5), Ca2+/ calmodulin-dependent protein kinase II (CaMKII), NFκB, MEF2, CREB, G9a and DNA methyltransferase 3a (DNMT3) (Robison and Nestler 2011; Nestler 2013). However, opioid drugs exposure reduce the medium dendritic spiny density in NAc through CREB and Δ FosB opposite to that of cocaine despite both being stimulant drugs (Nestler 2013). The opioid peptides in the brain such as dynorphin is expressed in NAc neurons through CREB, and its increment in this region causes dynorphin activation of κ opioid receptors on VTA dopamine neurons, in turn suppressing dopaminergic transmission to the NAc, hence reducing the reward response in the brain (Nestler 2013). Also repeated use of cocaine and nicotine have been reported to induce NFκB factor in NAc leading to whole cell and morphological plasticity of the NAc MSN dendritic spines, and this enhances the craving for the drugs (Velasquez et  al. 2014). Also, MEF2 factors are expressed in the brain regions including in the NAc MSNs where they activate or repress gene transcription depending on the type of the recruited proteins. Prolonged use of cocaine has been reported to suppress striatal MEF2 activity via the D1 receptor–cAMP-dependent inhibition of calcineurin, a Ca2+-dependent protein phosphatase as well as in the regulation of CDK5 transcription factors (Robison and Nestler 2011). Another protein factor expressed in the brain and influenced by psychoactive drugs and addictive behaviours is the brain-derived neurotrophic factor (BDNF) that is active at the synapses, and it promotes the survival of neurons or nerve cells by promoting their growth, maturation and their maintenance. However, following chronic cocaine exposure, BDNF1 and BDNF4 expression are reduced in the cerebral cortex and BDNF1 reduced in the cerebellum, VTA, NAc and amygdala but  increases following three months exposure  after withdrawal from cocaine use (Nestler 2013). The BDNF modulates the activity of the various neurotransmitter systems in the brain including noradrenergic, dopaminergic, serotonergic, glutamatergic and cholinergic systems as well as modulating the plasma levels of neurotrophin that control both cognitive and aggressive impulsiveness (Archer et  al. 2012). Therefore, the accumulation of the ΔFosB, together with NFkB, acts as a key control protein that produces neuroplasticity in the brain functions  and they acts as “one of the master control proteins” that produces addiction-related structural neuronal changes at the synapses in the brain leading to the addiction behaviours (Nestler 2008; Wikimedia 2016).

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12.7   Conclusion Drug abuse and addictive behaviours leading to serious health consequences, accidents, diseases, economic loss, addiction and even death have continued to be a serious global challenge in many communities of the different countries, especially among the youth in many African nations. The most commonly abused drugs in African communities include alcoholic beverages, cannabis, khat, caffeine, methamphetamine, ecstasy, phencyclidine, nicotine, solvents, prescription drugs such as benzodiazepines like diazepam, opioids like codeine, pethidine and many others. And the commonly encountered addictive behaviours include gambling, sports betting, sexual, shopping, especially among ladies, co-dependency, overeating, internet and video games, social media and many others. Chronic exposure to these drugs and addictive behaviours greatly influences people’s brains, thus affecting their behaviours and decision-making. They mainly affect the reward dopaminergic system (mesolimbic system) that connects to two important nuclei including ventral tegmental area (VTA) and nucleus accumbens (NAc) as well as to other interlinked nuclei to this system. In the brain, these substances and addictive behaviours also affects various neurotransmitter systems in the different regions of the brain by affecting the enzymes required for their synthesis, release, their degrading mechanisms including their re-uptake mechanisms as well as their signalling transduction mechanisms. They also affect the transcription factors especially CREB, ΔFosB and BDNF that are responsible for the expression of the genes that regulates these neurotransmitters in the ­different brain regions especially in the reward system and its associated nuclei. However, whereas psychoactive drugs use and addictive behaviours have continued to be a serious problem in Africa, there are limited studies done to understand the neurobiology of these substances among the African population on the continent since there is race/ethinicity differences on the pharmacokinetics and pharmacodynamics (pharmacogenetics) of the different drugs and behaviours among different people thus influencing their behaviours. The review has tried to summarize the various studies on the neurobiology of the psychoactive drugs and addictive behaviours in Africa. However, there is limited literature on the various studies done in this area in the different African countries and yet substance abuse use and engagement in various addictive behaviours are rapidly increasing on the continent resulting in addiction, severe health consequences, especially mental

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illnesses and infectious diseases like HIV/AIDS, homeless, poor work output, dropping out of school and poor academic performance and even death. Also, there is limited work done on the effects of psychoactive drugs and addictive behaviours on the various brain neurocircuitry, the neurotransmitters involved among the African population which could differ from the rest of the world population especially in terms of the various transcription factors that would influence the different behaviours in the different people when exposed to these substances especially long term. Therefore, work needs to be done on the neurobiology of psychoactive drugs and addictive behaviours among African population.

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Goudriaan, A.E., M.B. DeRuiter, et al. 2010. Brain Activation Patterns Associated with Cue Reactivity and Craving in Abstinent Problem Gamblers, Heavy Smokers and Healthy Controls: An fMRI Study. Addiction Biology 15: 491–503. Grant, J.E. 2008. Impulse Control Disorders: A Clinician’s Guide to Understanding and Treating Behavioral Addictions. New York: Norton. Grant, J.E., M.N.  Potenza, et  al. 2010. Introduction to Behavioral Addictions. American Journal of Drug and Alcohol Abuse 36 (5): 233–241. Haber, S.N. 2009. Anatomy and Connectivity of the Reward Circuit. In Handbook of Reward and Decision, 3–27. Amsterdam: Academic. Hartney, E., and S. Gans. 2018. A Guide to DSM 5 Criteria for Substance Use Disorders: Symptoms Used to Diagnose Substance Use Disorders. https:// www.verywellmind.com/dsm-5-criteria-for-substance-use-disorders-21926 Kaur, K. 2012. Psychoactive Drugs and What Makes Them So Hazardous. Popular Science (2009): 1–4. Koob, G.F. 2011. Neurobiology of Addiction: Focus. The Journal of Lifelong Learning in Psychiatry IX (1): 55–65. Koob, G., and M.J. Kreek. 2007. Stress, Dysregulation of Drug Reward Pathways, and the Transition to Drug Dependence. American Journal of Psychiatry 164 (8): 1149–1159. Koob, G.F., and N.D.  Volkow. 2010. Neurocircuitry of Addiction. Neuropsychopharmacology 35 (1): 217–238. ———. 2016. Neurobiology of Addiction: A Neurocircuitry Analysis. The Lancet Psychiatry 3 (8): 760–773. Kraus, S.W., R.B. Krueger, et al. 2018. Compulsive Sexual Behaviour Disorder in the ICD-11. World Psychiatry 17 (1): 109–110. Lemieux, A.M., B.  Li, et  al. 2015. Khat Use and Appetite: An Overview and Comparison of Amphetamine, Khat and Cathinone. Journal of Ethnopharmacology 160: 78–85. Lüscher, C., and M.A. Ungless. 2006. The Mechanistic Classification of Addictive Drugs. PLoS Medicine 3 (11): e437. Marinissen, M.J., and J.S.  Gutkind. 2001. G-Protein-Coupled Receptors and Signaling Networks: Emerging Paradigms. Trends in Pharmacological Science 22 (7): P368–P376. McGonigle, I. 2014. Framing British Drug Policy. Science and Technology Studies: The Next 20. http://stsnext20.org/vignettes/2014/2010/2030/ framing-british-drug-policy/ Miller, B. 2018. Exposing Satan’s Devices: What the Bible Says About Masturbation. BibleResources.org. 2012–2018. Christ Unlimited Ministries. Mukasa, M. 2012. Impact of Sports Betting and Corruption, Reflection from Uganda. A Paper Presented at the Plenary Session of the Interpol Global Academic Experts Meeting for Integrity in Sport. Interpol Global Academic Experts, 1–47.

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PART IV

Substance and Non-substance Addiction

CHAPTER 13

Prevalence of Alcohol Addiction in Africa Edith B. Milanzi and Yamikani Ndasauka

13.1   Introduction Alcohol consumption is one of the most important global risk factors for the burden of disease (Lim et  al. 2012; Rehm et  al. 2009). The latest global status report on alcohol and health by the World Health Organization (WHO) found that worldwide, 6% of all deaths and 5% of the burden of disease and injury are attributable to alcohol consumption; it is among the top three leading risk factors for disease burden, just behind high blood pressure and tobacco consumption, including second-hand smoke (World Health Organisation 2014). Alcohol consumption in Africa is expected to rise in the near future, but the fight against consumption of alcohol and consequently addiction and alcohol dependence remain a low priority in public policy and in the general population. Increasing alcohol consumption and public health problems related to alcohol in Africa point to the need for the development of effective national alcohol policies (Bakke and Endal 2010).

E. B. Milanzi (*) Institute for Risk Assessment Sciences (IRAS), Utrecht University, Utrecht, The Netherlands Y. Ndasauka Chancellor College, University of Malawi, Zomba, Malawi e-mail: [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_13

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Alcohol consumption contributes to over 200 types of diseases and injuries, including cancer, cardiovascular disease, liver cirrhosis, motor vehicle accidents and epilepsy (Lim et al. 2012; Rehm et al. 2009; Mallick and Assaf 2015; World Health Organisation 2014), and it has been identified as the leading risk factor for death and disability in sub-Saharan Africa and the leading risk factor for disability-adjusted life-years (DALYs) among African male adolescents aged 15–24 years (Gore et al. 2011). People living in under-resourced countries experience a greater burden of disease due to alcohol consumption compared to those in higher-income countries (Ferreira-Borges et al. 2015). The definition of harmful drinking is somewhat unestablished, but according to the WHO, standard for heavy episodic drinking is six or more drinks on one occasion, at least once monthly (World Health Organisation 2014). Alcohol consumption is largely socially acceptable in many societies, but the substantial effects on the health and well-being of individuals and the community as a whole are increasingly detrimental (Kabwama et al. 2016). Therefore, the estimation of prevalence and correlates of alcohol consumption is a systematic prerequisite step in the direction of planning an effective intervention program for the target drinking population. Trends of Alcohol Consumption in Africa Alcohol per capita consumption (APC) in the WHO African Region accounted for 6 litres of pure alcohol in 2010, with the highest consumption levels in southern Africa. Countries in the Global Burden of Disease (GBD) in sub-Saharan Africa have been reported to have the highest consumption of alcohol per drinker, with 34.0 litres (22.9 litres per female drinker; 38.1 litres per male drinker), while countries in the GBD Eastern Europe region have been reported to have the second highest consumption of alcohol per drinker, with 26.4 litres (16.1 litres per female drinker; 35.3 litres per male drinker) (Shield et al. 2013). Although there has been a trend of decreasing alcohol consumption in most developed countries, in many developing countries, levels of alcohol consumption have also increased in recent years (Gureje 2009). According to the WHO, drinkers in African countries consume 13% more alcohol per capita than the average among drinkers globally (World Health Organisation 2014). In South Africa, the prevalence of alcohol consumption ranged from 82.1% to 48.4% between years 1997 and 2000 (Parry

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et al. 2002). Nigeria reported a prevalence of 57.9% of lifetime alcohol consumption (Lasebikan and Ola 2016) in 2011 while Uganda reported 26.8% of current alcohol consumption from a study conducted in 2014 though the country was previously reported to have one of highest levels of alcohol consumption in the East African region, with an annual per capita alcohol consumption of 23.7 litres (World Health Organisation 2014). Francis et al. (2014) concisely summarized the prevalence of alcohol consumption among young people (aged 15–24) in Eastern Africa in a systematic review and meta-analysis. In this report, Kenya was reported to have high alcohol current consumption prevalence of 69% specifically in male sex workers in 2008. Higher prevalence of current alcohol consumption was also reported in Ethiopia (51%) in 2005 and Rwanda (49%) in 2004; however, studies done in the 1990s generally reported lower current alcohol consumption prevalence. An important analysis on alcohol-­related questions in the Demographic Health Surveys (DHSs) was performed for all African countries with relevant alcohol-related questions. In this report, Rwanda had the highest prevalence of ever alcohol consumption (76%), only slightly higher than in 2000 DHS (74%) specifically in men, but higher alcohol consumption was observed in countries like Madagascar, Namibia, Zambia and Kenya (Mallick and Assaf 2015). Frequency of alcohol consumption has not been extensively studied mainly because of lack of coordinated data in studies to specifically address this question. Alcohol Addiction in Africa Alcoholism is a chronic, relapsing disorder that has a considerable component of genetic susceptibility, is under marked influence of environmental factors, and its onset and course are fundamentally shaped by behavioural choices (Heilig et  al. 2011). The major part of adverse health consequences of alcohol consumption is derived from alcohol dependence. Alcohol addiction, though not widely recognized as such, is a genuine disease as it can cause neurological changes that lead to an individual not being able to control their actions, characterized by the inability to stop using alcohol despite possible physical, psychological and mental consequences (Rehm 2011). Literature on the prevalence of alcohol addiction in specific African countries is rare. The WHO global status report reported 3.3% of alcohol consumption disorders and 1.4% of alcohol dependence for the WHO

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African region as of 2010. So much focus is placed around health and social indicators that are associated with harmful alcohol consumption: however, these are not the only effects that should receive attention. Effects on the people around the drinker are as paramount. Heavy consumption of alcohol will cause individuals to be violent, and domestic abuse has been reported by spouses if their partner becomes violent after consuming alcohol. Interestingly, family history of alcoholism has been associated with an increased risk of developing alcohol consumption disorders. Chartier et al. (2017) showed that the relationship between familial alcoholism and alcohol dependence was stronger with successive generations in the United States. However, evidence is limited of this association in African families. With alcohol consumption rising in Africa, it is also highly likely that alcohol addiction cases are likely to rise. Unfortunately, alcohol addiction has not been systematically quantified in African countries, and consequently, treatment of the same either is given low priority or does not exist at all in some countries. The aim of this study is to quantify the prevalence of alcohol consumption in Africa. Based on the number of days spent consuming alcohol, we also make a case for addiction in African countries.

13.2   Methods We used Demographic Health Survey (DHS) data from 19 African countries with data on alcohol consumption from the year 2000 to 2016. If one country had multiple datasets, the most recent one was used. In brief, DHS surveys are nationally representative household surveys that provide data for a wide range of monitoring and impact evaluation indicators in the areas of population, health and nutrition. The DHS collects, analyses and disseminates accurate and representative data on population, health, HIV and nutrition through more than 300 surveys in over 90 countries worldwide (https://dhsprogram.com/). Questions requiring respondents to state if they drink or have ever had an alcoholic drink were used to determine whether a respondent has ever had alcohol. Using these questions, prevalence of ever drinking among all adults surveyed was assessed using data from 19 countries mostly in sub-­ Saharan Africa. Furthermore, 13 surveys asking the frequency of alcohol intake were further analysed to make a case for alcohol addiction. Since different metrics of frequency were used, we could not determine how many bottles/glasses of alcohol were consumed per specified period as the DHS data extracted does not contain this information (only one survey

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asked how many glasses of alcohol were consumed). Therefore, based on the number of days a respondent had said they had alcohol within a specified time period, we postulated that if half of the specified number of days were spent drinking alcohol then the respondent might be dependent on alcohol and therefore likely addicted. The Diagnostic and Statistical Manual of Mental Disorders was initially compiled to collect statistical information about mental disorders in the United States but has now become global criteria to diagnose disorders mostly psychiatric and neurological disorders. The manual glossary describes diagnostic categories and how to use the manual for making clinical diagnoses and is regularly revised. The most recent manual revised in 2013 describes the following terms to diagnose alcohol dependence and addiction: (1) tolerance; (2) withdrawal or avoidance of withdrawal; (3) persistent desire or unsuccessful attempts to cut down or stop drinking; (4) spending much time drinking, obtaining alcohol or recovering from its effects; (5) giving up or reducing occupational, social or recreational activities in favour of drinking; (6) impaired control over drinking; and (7) continuing to drink despite a physical or psychological problem caused or exacerbated by drinking (American Psychiatric Association 2013).

13.3   Results Alcohol Consumption in Africa Between 2000 and 2016 We were able to extract data from 19 African countries with DHS data on alcohol consumption between 2000 and 2016. Figure 13.1 shows selected demographic characteristics of the study population by country. Majority of the surveyed population were from rural areas, were married and had at least attended primary school education. In countries with data on both men and women, women were highly represented than men. The overall prevalence of alcohol consumption by country is shown in Fig.  13.2. Rwanda survey in 2005 showed the highest consumption of alcohol in the region (76%), followed by Madagascar in 2003, Lesotho in 2009 (54%), and  Uganda in 2000 (53%). The most recent surveys from Ethiopia in 2015 and Burundi in 2016 also showed high alcohol consumption levels (45% and 47%, respectively). Considering that alcohol consumption habits are most likely different between men and women, we also investigated alcohol consumption separately for men and women for countries that had data on both genders (Fig.  13.3). Overall men had higher alcohol ­prevalence than women as expected; however, women in Uganda, Namibia

100 90 80 70 60 50 40 30 20 10 0 Angola

None

Benin*

Benin*

Angola

Burundi Ethiopia

Ethiopia

Kenya

Urban

Lesotho* Madagascar Malawi

Rural

Secondary

Residence

Primary

Malawi

Mozambique* Nigeria Namibia Rwanda*

Rwanda*

Higher

Tanzania*

Highest education

Tanzania* Zambia

Zambia

Uganda

Uganda

100 90 80 70 60 50 40 30 20 10 0

100 90 80 70 60 50 40 30 20 10 0 Burundi

Kenya

Women

Married

Gender

Marital status

Men

a e a a ia na ia bia di la ar awi so bi bw i ny sc er nd l fa run iop ha go Ke ga Ma Nig am Uga Zam ba G An ina Bu Eth a N m rk Zi ad M Bu

Benin* Never married

Fig. 13.1  Selected demographic characteristics of the study population by country

100 90 80 70 60 50 40 30 20 10 0

Frequency (%)

Frequency (%)

Burkina faso

Burkina faso Burundi

Ghana

Ghana Kenya Lesotho* Madagascar Mozambique* Nigeria Namibia

Swaziland*

Swaziland*

Zimbabwe

Zimbabwe

Frequency (%)

Frequency (%)

Angola Burkina faso Ethiopia Ghana Lesotho* Madagascar Malawi Mozambique* Nigeria No longer married

Namibia Rwanda* Swaziland* Tanzania* Uganda Zambia Zimbabwe

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Fig. 13.2  Overall alcohol prevalence by country (* indicates prevalence among one gender only)

Fig. 13.3  Overall alcohol prevalence by country, separately by men and women

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and Madagascar also showed relatively higher alcohol assumption. The maximum alcohol consumption prevalence was observed in Uganda for women (51%) and the minimum was Malawi, with approximately 2%. We were unable to pool a single prevalence for all the available countries because of the different questions used to assess alcohol consumption which introduces heterogeneity between the different surveys and therefore makes the numbers across countries less comparable. Alcohol Addiction in Africa Thirteen countries had data on frequency of alcohol assumption. To make a case for addiction for the different countries, number of days of alcohol consumption within a specified period of time was considered (Table 13.1). Table 13.1  Average number of days spent drinking alcohol within a specified period Country

Description of assessment question

Number of days drank alcohol in last 3 months Burkina Number of days drank alcohol in last Faso 3 months Ethiopia Number of days drank alcohol in last 30 days Ghana Times consumed alcohol in last 7 days Kenya Days drank alcohol in last 2 weeks Number of days drank alcohol in last Lesothoa 3 months Madagascar Number of days drank alcohol in last 3 months Namibia Days drank alcohol in last 2 weeks Nigeria Number of days drank alcohol in last 3 months Rwandaa Number of days drank alcohol in last 3 months Uganda Number of days drank alcohol in last 30 days Zambia Number of days drank alcohol in last week Zimbabwe Number of days had at least 1 drink in last 30 days Benin

a

Data available for only one of the genders

a

Average number of days (95% CI) Men

Women

–

5.9 (5.4; 6.5)

17.9 (16.4; 19.2) 5.3 (4.4; 6.2) 11.5 (10.6; 12.4) 9.4 (8.4; 10.3) 1.6 (1.5; 1.6) 1.0 (0.9; 1.3) 3.8 (3.6; 4.1) 2.02 (1.6; 2.4) 13.6 (12.2; 15.3) – 4.0 (3.3; 4.5)

0.5 (0.4; 0.6)

5.3 (4.5; 6.1) 5.4 (4.5; 6.3)

7.6 (6.3; 8.9) 1.2 (0.8; 1.5)

16.4 (15.4; 17.4)

–

5.1 (4.4; 5.6)

1.2 (0.9; 1.3)

2.3 (2.2; 2.4)

1.3 (1.2; 1.4)

5.7 (5.4; 6.1)

1.0 (0.8; 1.2)

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The average number of days spent drinking alcohol varied between men and women, for example, men in Burkina Faso reported taking alcohol on 18  days on average while women reported 5  days on average within 90 days. In Ethiopia, men spent at least 11 days drinking alcohol in the previous 30  days, 13  days in 3  months in Lesotho, at least 5  days in Namibia within 2 weeks, and 16 days in 3 months in Rwanda. Men generally spent more days drinking than women. Based on the number of days indicated to have had at least a drink in a specified period, the proportion of the population that spent more than half of the days drinking within the specified period was determined and classified as addicted. This was calculated in the population that had stated that they take alcohol. As seen in Fig. 13.4, the highest estimated prevalence of likely addiction was observed in Ethiopia (30%), Rwanda (17.4%), Ghana (14.6%), Zimbabwe (11.5%),

Fig. 13.4  Prevalence of addiction by country (* indicates prevalence among one gender only)

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Burkina Faso (9.7%), and Namibia and Nigeria (9.5%). The lowest addiction prevalence rates were observed in Kenya (1.7%) and Madagascar (0.3%).

13.4   Discussion Alcohol consumption prevalence is on the rise in Africa, and alcohol dependence and addiction are likely to increase too as results of this analysis show. We observed as high as 76% of alcohol consumption in Rwanda and up to 47% for the most recent surveys in Burundi, Madagascar and Ethiopia. Ethiopia, Ghana, and Rwanda, generally had high prevalence of alcohol addiction. Madagascar showed the lowest levels of addiction despite a high prevalence of alcohol consumption. Surveys and mortality studies, particularly from the developed world, suggest that there are more drinkers, more drinking occasions and more drinkers with low-risk drinking patterns in higher socioeconomic groups (World Health Organisation 2014). This could be different for developing countries as there is a substantial amount of alcohol that is produced outside formal commercial channels and highly so in rural areas with low socioeconomic status. Acuda et al. (2011) reported an extensive systematic review on addiction in Africa, but the studies included were conducted in the 1990s. This review reported less drinking in females as also observed in this analysis. However, there is no comprehensive analysis on alcohol addiction arising from alcohol consumption. Research on consumption of alcohol and problems attributed to alcohol have mainly been conducted in South Africa and Nigeria (Gureje 2009; Peltzer et al. 2011; Parry et al. 2002; Morojele et al. 2016), and different rates of alcohol prevalence have been reported with the same countries maintaining high levels of alcohol consumption throughout the years (Mallick and Assaf 2015). The major impediment to quantify both alcohol consumption and addiction in this study but also other related African studies is the lack of systematic assessment of frequency of alcohol consumption. Methodological differences as well as variation in questions used to assess alcohol prevalence and frequency of consumption especially with the DHS datasets restrict comparisons of available data across different countries as also noted by Acuda et al. (2011). Shield et al. (2013), however, report that modelling alcohol consumption using drinking status prevalence survey estimates and per capita consumption data enables comparisons between different countries and populations and also corrects for the underestimation of drinking in survey data, which if left

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uncorrected results in an underestimation of the burden of disease attributable to alcohol. Future studies can employ this approach to facilitate comparisons of available data. However, drinking patterns and study methodology remain different, and therefore, results of such approaches require careful interpretation. Based on the results of the current analysis, it is adequate to say alcohol consumption is a problem in Africa, and alcohol addiction could be an impeding public health problem if it is not promptly addressed. One of the major limitations of the current study design is the use of survey data. Surveys are prone to recall bias—respondents may not recall when and how often they had alcohol and therefore give inaccurate responses to alcohol consumption and frequency questions. In addition, respondents may under report their alcohol consumption because of the awareness of the negative health consequences. As such, this may lead to an underestimation of the true prevalence. We also computed addiction prevalence rates based on number of days spent drinking alcohol instead of number of drink taken within a specific time period because this data was not available with the DHS surveys. Therefore, our results should be interpreted with caution. Effective implementation of policy intervention is the major key to reducing alcohol consumption across the globe. More importantly, policy interventions need to be backed up by evidence from research, hence the need for accurate and up-to-date estimates of the various relevant indicators of alcohol consumption. This is imperative for monitoring and developing cost-effective strategies to control alcohol consumption and in turn addiction. The WHO European Health Network (Ferreira-Borges et al. 2013) reported a number of high cost-effective measures for reducing alcohol consumption, for example, (1) increased alcohol prices, with rise in the price of alcoholic beverages leading to fall in alcohol consumption, and a decrease in prices to a rise in alcohol consumption, (2) limiting the availability of alcohol by enforcing strict age limits, (3) controlling ­business hours and number of alcohol selling outlets and (4) enforcing laws that discourage drunk driving. However, the aforementioned strategies were presented for a European setting. African countries have also adopted some of these strategies to reduce alcohol consumption, but the effectiveness of these policies remains to be seen. While recognizing that there is no single formula to decrease alcohol consumption across Africa, the WHO commissioned a regional strategy on reduction of the harmful consumption of alcohol in 2010 outlining policy

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interventions as follows Ferreira-Borges et al. (2013): (1) information-based public education which includes providing alcohol education to public and religious, community leaders as well as integration into the school curriculum, (2) improvement of the health sector by strengthening approaches of tackling alcohol-related problems in the health system, (3) research and surveillance to monitor alcohol production, consequences of harmful consumption as well as related health and social indicators which helps in establishing relevance of the problem at hand and easily to translate into policy, (4) enforcing drink driving legislation, regulation of alcohol marketing and addressing availability, accessibility and affordability (Ferreira-Borges et al. 2013). The implementation of these policies in Africa was recently investigated in 46 African countries (Ferreira-Borges et al. 2017). Forty-four per cent of the countries were seen to observe strict legislation with the highest score observed in Algeria and the lowest in Sao Tome. However, the implementation of the mentioned policies hinges on several factors, such as economic and political factors, and is also bent towards commercially produced alcohol whose production and selling is formally assessed. The major challenge recently facing Africa is found in rural areas where alcohol is locally brewed and strong alcohol is easily accessible, without legislation and restriction. An example of this includes sachets, a relatively new phenomenon with regard to alcohol-related problems in sub-Saharan Africa in which small plastic bags of approximately 30–100 ml of strong liquor, with an alcohol content ranging from 30%–45%, available in many African countries are easily accessible, especially to children and adolescents (Hoel et al. 2014). Several countries such as Malawi, Ivory Coast, South Africa, Uganda, Zambia and Tanzania have all drawn up policy on bans on sale of alcohol sachets, but data is sparse on whether all of these countries have put the bans into action. The lack of information about the nature and extent of harmful consumption of alcohol, especially in an environment of unrestrained marketing and other industry activities, weakens the ability of policymakers to take appropriate policy measures (Ferreira-Borges et al. 2017).

13.5   Conclusion The overall presentation is that Africa faces a major challenge with the growing burden of harmful alcohol consumption and that there are no proper mechanisms to effectively implement policy interventions that have

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mainly been drawn on paper. Effective and systematic implementation of these policies will lead to dramatic reduction in alcohol consumption across the continent and across the globe.

References Acuda, W., et al. 2011. The Epidemiology of Addiction in Sub-Saharan Africa: A Synthesis of Reports, Reviews, and Original Articles. The American Journal on Addictions 20: 87–99. American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington: American Psychiatric Association. Bakke, O., and D. Endal. 2010. Vested Interests in Addiction Research and Policy Alcohol Policies Out of Context: Drinks Industry Supplanting Government Role in Alcohol Policies in Sub-Saharan Africa. Addiction 105: 22–28. Chartier, K.G., N.S. Thomas, and K.S. Kendler. 2017. Interrelationship Between Family History of Alcoholism and Generational Status in the Prediction of Alcohol Dependence in US Hispanics. Psychological Medicine 47: 137–147. Ferreira-Borges, C., et  al. 2013. Reduction of the Harmful Use of Alcohol: a Strategy for the WHO African Region. African Health Monitor 16: 31–35. ———. 2015. Alcohol Control Policies in 46 African Countries: Opportunities for Improvement. Alcohol 50: 470–476. Ferreira-Borges, C., C.D. Parry, and T.F. Babor. 2017. Harmful Use of Alcohol: A Shadow over Sub-Saharan Africa in Need of Workable Solutions. International Journal of Environmental Research and Public Health 14. Francis, J.M., et  al. 2014. Systematic Review and Meta-Analysis: Prevalence of Alcohol Use Among Young People in Eastern Africa. Tropical Medicine & International Health 19: 476–488. Gore, F.M., et al. 2011. Global Burden of Disease in Young People Aged 10–24 Years: A Systematic Analysis. Lancet 377: 2093–2102. Gureje, O. 2009. Alcohol Problems and Responses: Challenges for Africa. Journal of Substance Use 5: 56–61. Heilig, M., et al. 2011. Pharmacogenetic Approaches to the Treatment of Alcohol Addiction. Nature Reviews Neuroscience 12: 670–684. Hoel, E., et al. 2014. Context and Consequences of Liquor Sachets Use Among Young People in Malawi. African Journal of Drug & Alcohol Studies 13 (2): 97–106. Kabwama, S.N., et  al. 2016. Alcohol Use Among Adults in Uganda: Findings From the Countrywide Non-Communicable Diseases Risk Factor Cross-­ Sectional Survey. Global Health Action 9: 31302. Lasebikan, V.O., and B.A. Ola. 2016. Prevalence and Correlates of Alcohol Use among a Sample of Nigerian Semirural Community Dwellers in Nigeria. Journal of Addiction 2016: 2831594.

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Lim, S.S., et al. 2012. A Comparative Risk Assessment of Burden of Disease and Injury Attributable to 67 Risk Factors and Risk Factor Clusters in 21 Regions, 1990–2010: A Systematic Analysis for the Global Burden of Disease Study 2010. Lancet 380: 2224–2260. Mallick, L., and S. Assaf. 2015. An Inventory of Alcohol-Related Questions in the Demographic and Health Surveys and an Analysis of Alcohol Use and Unsafe Sex in sub-Saharan Africa. DHS Analytical Studies No. 53. Maryland: ICF International. Morojele, N.K., J.S.  Brook, and D.W.  Brook. 2016. Tobacco and Alcohol Use Among Adolescents in South Africa: Shared and Unshared Risks. Journal of Child and Adolescent Mental Health 28: 139–152. Parry, C.D., et al. 2002. Alcohol Use in South Africa: Findings From the South African Community Epidemiology Network on Drug use (SACENDU) Project. Journal of Studies on Alcohol 63: 430–435. Peltzer, K., A. Davids, and P. Njuho. 2011. Alcohol Use and Problem Drinking in South Africa: Findings From a National Population-Based Survey. African Journal of Psychiatry 14: 30–37. Rehm, J. 2011. The Risks Associated with Alcohol Use and Alcoholism. Alcohol Research & Health 34: 135–143. Rehm, J., et al. 2009. Global Burden of Disease and Injury and Economic Cost Attributable to Alcohol Use and Alcohol-Use Disorders. Lancet 373: 2223–2233. Shield, K.D., et al. 2013. Global Alcohol Exposure Estimates by Country, Territory and Region for 2005: A Contribution to the Comparative Risk Assessment for the 2010 Global Burden of Disease Study. Addiction 108: 912–922. World Health Organisation. 2014. Global Status Report on Alcohol and Health. Geneva: World Health Organisation.

CHAPTER 14

Drug Use and Addiction Amongst Women with Disabilities Who Are Commercial Sex Workers in Zimbabwe Tafadzwa Rugoho

14.1   Introduction People use drugs and sell sex in all regions of the world and this has become a global challenge. Rugoho (2019) observed that commercial sex workers are also amongst the main users of drugs. The total population of women who are into commercial sex workers is difficult to ascertain due to the pervasive nature of the profession. In fact, researchers have estimated that female sex workers represent between 0.1% and 7.4% of the general population in different regions. According to the United Nations Office on Drugs and Crime (UNODC), around 230 million people (5% of the global adult population) used an illicit drug in 2010. The latest peer-reviewed estimates indicate that approximately 16 million people inject drugs around the world. The World Health Organization has estimated the attributable burden of disease from substance abuse in established market economies like the U.S. conservatively at greater than 23% from tobacco, from alcohol and from illicit drugs (no mention of prescription drug abuse). Disease burden includes not only additional health care T. Rugoho (*) University of Kwa Zulu Natal, Kwa Zulu Natal, South Africa © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_14

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costs but also lost productivity due to morbidity and mortality. Substance abuse especially limits the potential productivity of affected persons with disabilities, because, as Moore et al. (1994) note in their study of disability and illicit drug use, “Compared to the general population, individuals with disabilities are more likely to encounter problems of personal adjustment and unemployment, as well as the experienced medical and health difficulties.” It seems self-evident that the widely documented physically and mentally debilitating effects of substance abuse must further compromise the already impaired functional capacity of most persons with disabilities. Sex work, popularly known in literary dissertate as prostitution (Rugoho 2019), is perhaps the world’s oldest “profession”. Also referred to as sex-­ for-­hire or commercial sex work in contemporary academic discussion, sex work has existed since time immemorial. Evidence from the earliest times of human existence indicates that men paid women for all kinds of sexual services rendered. Its popular existence is widely documented in various forms throughout the Greco-Roman religion and was referred to as ‘sacred’ or ‘temple’ ‘prostitution’. This form of sex work was a common societal feature many centuries before the Christian era and widely practised in ancient Greece. This form of sex has also been traced to the Far East where it not only thrived but was a highly valued profession from as early as 300 B.C. In some other parts of Europe, the practice also seemed a common feature during the medieval era. Saint Augustine and Saint Thomas Aquinas, some of the leading fathers of the Christian faith, may have acceded, even tolerating the practice, considering it a deterrent measure against rape, seduction and even adultery. Dissenting opinions only emerged later when beliefs in the biblical theory of sin and the condemnation of erotic pleasures derived from the Hebraic Law came under spotlight. Eventually, penalties for sex work meted out included corporal punishment, mutilation of some parts of the body such as hands or legs and even execution. In Zimbabwe commercial sex work is in rampart especially in urban centres. Just like other countries in Africa, the government of Zimbabwe has tried to suppress the profession. Those who are caught in the profession are jailed and harassed by the police. Rugoho (2019) observed that regardless of the challenges in the profession, the sector has managed to attract women with disabilities. Women with disabilities in Zimbabwe who are into the profession have reported several benefits that have made it possible to bear the challenges associated with the profession.

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14.2   Literature Review Abuse is used in connection with consumption of alcohol in inordinate amounts and inappropriate utilisation of prescription medications and ‘use’ to refer to consumption of substances defined as illegal by federal statute; we use ‘substance abuse’ as an umbrella term for all of the above (Glazier and Kling 2013). The term ‘sex worker’ refers to those engaged in prostitution and is the preferred term used throughout the literature on the subject. The term has been adopted as is it free of complicated, derogatory and sexist connotations which are more commonly associated with the term ‘prostitute’ (May et al. 2000). Sex work is a term used to describe a wide range of activities relating to the exchange of money (or its equivalent) for the provision of a sexual service. The term was heavily criticised over the past decades by scholars and women activist who argue that it gives the notion that the industry is entered by people without a choice. The term has lost respect, especially among feminist scholars and female advocates. The name carries the connotations of a woman who has no say over the prostitution process (Flowers 2001). Katsulis (2009) argued for the adoption of the term “sex worker” because it should be regarded as the profession since there are people who are using the trade as a source of income and livelihoods. This argument is further supported by Qayyum et  al. (2013) who noted that the trade provides women or men with employment. Harcourt and Donovan (2005) compiled a long list of the different types of sexual services practised by disabled sex workers around the world. From this list, they grouped types of sexual services into two categories; direct and indirect sex work. Direct sex work refers to services, such as indoor and outdoor prostitution as well as escort services. This type of sex work typically involves the exchange of sex for a fee in which genital contact is common. Indirect sex work refers to services, such as lap dancing, stripping and virtual sex services (over the Internet or phone). Genital contact is less common in this type of sex work; however, a fee is still exchanged for the service. According to Ward et al. (2005), trends over the period 1990–2000 indicate that demand by those willing to pay for sex has increased. In 1990, 5.6% of men reported paying for sex in their lifetime; by 2000, this had increased to 8.8%. Disabled sex workers come from a wide range of socio-economic contexts. Homelessness and drug addiction have been identified as the two most significant factors which prompt engagement in on-street sex work among the disabled women and two of the main barriers to stabilising the lives of

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sex workers (Spice 2007; Davis 2004). In their study into on-street sex workers in Bristol, Jeal and Salisbury (2004) reported a high proportion of on-street sex workers who claimed they were either homeless or living in insecure/temporary accommodation (two-thirds) and all respondents admitted to problems with drug addiction. This type of engagement in sex work is often described as ‘survival sex’, where people engage in sex work as a last resort, to provide shelter and food or to fund severe addictions in a ‘work-score-use’ cycle. The literature suggests that poor education, as well as a lack of training and qualification, impacts on vulnerability, driving entrance into sex work and reducing the chances of finding alternative forms of employment. This depicts that poor education among the disabled prompts them to venture into sex work. In Jeal and Salisbury’s (2004) study, they found one-third of interviewees had left education at the age of 14  years or younger. Similarly, Bindel and Atkins (2008) found 39% of respondents had no training or formal qualifications. Poor education could affect the ability to find mainstream work, meaning opportunities to earn an income are limited. Sanders (2007a) points to educational factors which reduce the vulnerability of sex workers. She claims those who work off-street are more likely to have come from social backgrounds which are not excluded, have participated in mainstream work, have completed full-time education and may have a professional background. One could assume that it is both the more stable nature of off-street sex work which draws these workers to it and also the relatively stable position of the workers which leads to greater stability in the first place. In Africa, earliest evidence of sex work exists from ancient Egypt, where historical accounts show prostitution as ‘sacred’ indulgence during the era of the Pharaohs. There is also evidence of thriving sex work from trading posts, ports and developing cities in pre-­ colonial East and West Africa. In South Africa sex for benefits existed as far back as the voyages of discovery when sex was on offer to early European sailors and travellers who stopped at the refreshment station at the Cape in the seventeenth and eighteenth centuries. Sex for profit, in the case of women, and pleasure for men, dates back to the late 1600s when a white settlement was established at the Cape colony. The development of long-­ distance trading is also associated with the rise to prominence of sex work in East Africa. Previous research has found a much higher proportion of persons with disabilities affected by substance abuse than in the general population, reportedly as great as 87%. Moore et al. (2002) estimated that 1.5 million

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persons with disabilities could be in need of substance abuse treatment. It is asserted, in a recent review of the literature on substance abuse and physical disability, that: “Persons with disabilities are at a disproportionately greater risk for substance abuse problems than members of the general population” (Glazier Kling 2013: 112). There is a robust, if fragmented, literature on the multifaceted relationship between disability and substance abuse. One aspect is substance abuse as a causal factor in disability, for example, intoxication leading to disabling injury, particularly in auto vehicle crashes: “Substance misuse/abuse is also a major contributing factor to many traumatic injuries…alcohol intoxication rates at the time of traumatic brain injury range from 36% to 51%” (Glazier Kling 2013: 112).

14.3   Factors Driving Disabled Women Entrance into Sex Work and Drug Abuse Stigma and Stereotypes Women who are into commercial sex work face discrimination from the community and fellow workers with disabilities. They are called different names and these names inflict emotional and psychological trauma. Deady (2011) in his studies observed that some of these women self-prescribe some medication in an effort to cope with the stress that is associated with the profession. The great majority of women with disabilities face prejudice and stigma in their daily lives and are often seen as being victims to ‘double discrimination’, first from their status as women and second from their disability. This widely held discrimination is common both in the home and in the community and leads to women and young girls with disabilities being denied their basic human rights, including freedom of movement and association, health (in extreme cases, the stigmatisation can lead to withholding or delaying of critical care and, in turn, lead to death), education, pursuit of livelihood and more. Stigma makes it difficult for women with disabilities to exercise their rights, integrate into the community and be self-sufficient. A 36-year-old expressed it as: I am trying to make a living. The government is not helping me. I have tried to get employed but there are no jobs for us. The only option that was left for me was to sell my body. I have more than four children who all need to be fed. They need shelter and many other things. Now when I joined this

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field I am emotionally traumatised. The community laughs at me. The church calls me a sinner. It’s hard for you to survive in this profession. I have been taking illegal drugs which are sold in the street for me to survive. Without these drugs, I can’t survive. I can only engage in prostitution when I am intoxicated. Now I am only taking strong drugs to cope. I consider myself to be an addict.

Discrimination can take many forms, such as racism, stigmatisation and prejudice. It can prevent social inclusion, driving marginalisation and vulnerability. For some disabled women, discrimination can exacerbate feelings of isolation and loneliness. Additionally, it can prevent or obstruct access to services and employment which may drive migrants to use other means of survival, such as sex work (UK NSWP 2008). Additionally, disabled women are more likely to be denied access to nutrition, vocational training, employment and income-generation opportunities. They are routinely excluded from social and community activities and are often denied access to the customary roles of women in their community. Lastly, adequate attention is not given to women with disabilities in self-help organisations, which further denies them the ability to be a part of an advocacy agenda. Stigma can also lead to women with disabilities being ‘hidden’ by their families in some societies. Many families do not want to put in the time or energy necessary to properly care for women with disabilities because they are seen as being non-productive and unable to contribute. Further, women with disabilities are sometimes regarded as ‘bad’ women and are kept hidden so as not to damage the marriage possibilities of their siblings. Marginalisation Women with disabilities are often pushed to the fringes of society. With a strong gender bias present in many countries, there is an even higher chance that a woman living with disability will have all of her rights ignored, as she is seen as a burden, not a contributor. As a result, social support systems (where they exist) are not utilised for or by these women, nor do the same women have a voice in the improvement of these systems. The United Nations Development Programme  International Poverty Centre states: “The concept of social exclusion (SE) describes the processes of marginalization and deprivation that can arise even in rich ­countries with comprehensive welfare provisions. It is a reminder of the multiple faces of deprivation. SE is perhaps the most difficult to interpret

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of the poverty concepts under review. Still, SE is the only approach that focuses intrinsically on the processes and dynamics that allow deprivation to arise and persist” (UNODC 2006). Common social practices such as marriage, social/community activities, access to education, participation in employment and the political sphere are much harder for women with disabilities compared to men with disabilities to access. Money, Debt and Low Level Welfare Benefits Commentators, such as Brents and Sanders (2010), stress the importance of financial drivers which often push disabled women into sex work. With the indoor parlour industry estimated to be worth around 534 million per year (Moffat and Peters 2000), there are obvious financial rewards for some involved in sex work including brothel owners, managers and sex workers. Brents and Sanders claim that with fewer well-paid jobs available, welfare benefits too low to meet the ever-increasing cost of living, in particular, for single mothers and women who are often marginalised from the mainstream employment structure, the financial drive to engage in sex work is very strong. In a separate article, McNaughton and Sanders state that welfare benefits are not generous enough to prevent poverty or marginal lifestyles. Debt plays a significant role in driving entrance into sex work. Low or insufficient income results in worse outcomes in both long-­ term health and life expectancy. As the Marmot Review (2010) recommends, a minimum income for healthy living would ensure appropriate income for all stages of the life course reducing overall levels of poverty, health inequality and improving living standards. Alcohol Use Additionally, research exploring problematic alcohol use amongst female sex workers across England and Wales found that alcohol use, before entry into sex work, was used as a coping mechanism to help overcome or deal with experiences of loneliness and abuse during childhood and/or adolescence (Brown 2013). Mental Health Traumatic experiences, such as physical or sexual abuse during childhood, have negative implications for mental health throughout the life course.

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Although the links between child abuse and engagement in sex work is unclear, in a study by Bindel and Atkins (2008) where 72% of the sex workers interviewed reported experiences of physical, sexual and verbal violence during childhood, past experiences of abuse were said to compound feelings of worthlessness. Furthermore, in a study by Fitzpatrick et al. (2012), which looked at pathways into multiple level exclusion and homelessness in UK cities, they found mental health problems to be prominent amongst people who experience chronic social exclusion. Mental ill-health can cause difficulties with employment, social relationships and dealing with day-to-day life as well as poor physical health, which can lead to social exclusion (Social Exclusion Unit 2004). Low Employment Employment is integral to participation in society and has a great effect on self-sufficiency as well as self-esteem. When denied this opportunity, disabled women remain excluded from the workplace, from society and from economic freedom maintaining many women’s already dependent state. In Tunisia, 85% of persons with disabilities (15–64) are unemployed, and women with disabilities are four times less likely than men with disabilities to secure employment. Discrimination Discrimination can take many forms, such as racism, stigmatisation and prejudice. It can prevent social inclusion, driving marginalisation and vulnerability. Discrimination can exacerbate feelings of isolation and loneliness where support from family and other social networks may be lacking. Additionally, it can prevent or obstruct access to services and employment which may drive disabled women to use other means of survival, such as sex work (UK NSWP 2008). Sex work engagement may occur as a means to find alternative forms of income and survival.

14.4   Drug Addiction and Sex Work Drug addiction amongst sex workers is typified by a ‘work-score-use’ cycle (Jeal et al. 2008). In a study by Jeal and Salisbury (2004) which explored the health of on-street sex workers in Bristol, all interviewees admitted to having a history of alcohol and/or drug use. Over half of respondents

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stated they entered sex work specifically to fund drug addictions and many continued to use drugs whilst pregnant. It is claimed that alcohol use amongst sex workers is used for self-medication: to help mask some of the negative feelings associated with sex work, including distress, anxiety and experiences of selling sex (Brown 2013). Drug and alcohol addiction can cause serious damage to people’s health. Many drug addicts are undernourished and homeless. Some of the most prominent health concerns facing sex workers as a group are communicable diseases, such as HIV and other blood-borne viruses. In addition, common health complaints by this group have included abscesses, as a result of intravenous drug, poor dental care and premature death through overdose (Ward and Day 2006). In popular consciousness, sex work is often blamed on drug use. One common view is that the drug dealer who approaches a young and innocent girl makes her addicted to drugs and pushes her into sex work. Another stereotype is that drugs bear the responsibility for making women vulnerable to the sex-work industry. Most people tend to think that one of the strongest reasons why women start sex-working is because they want to fund their drug habits, once they become addicted. According to various research studies, conducted in an international level and based on a detailed selection of quantitative and qualitative data, including interviews of women involved in drugs and sex work, there seems to be a clear interdependence between sex work and drugs. According to a report on prostitution and drugs in Portland, produced by the Multnomah County Sheriff’s Office, the interdependence of those two practices is attributed to different factors and it is not at all clear or evident that drugs are usually the cause of prostitution. Drug-using sex workers might have been firstly introduced to drugs before going into sex work but equally might have started using drugs as a consequence of their involvement with sex work.

14.5   Conclusion A review of the literature revealed that there are multiple social exclusions which drive entrance into sex work and result in negative consequences, such as poor physical and mental health, homelessness and stigmatisation, as a result of sex work. In many cases, there is an overlap between sex work, homelessness and other forms of social exclusion, such as disability, impoverishment, violence, family breakdown and untreated mental health problems. Disabled women venture into commercial sex work as a means to earn a living and also fulfil their sexual desires. They finally end up in drug addiction so as to boost their confidence and morale in this job.

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References Bindel, J., and H. Atkins. 2008. Big Brothel: A Study of the Off-Street Sex Industry in London. London: POPPY Project, EAVES Housing for Women. Brents, B.G., and T. Sanders. 2010. Mainstreaming the Sex Industry: Economic Inclusion and Social Ambivalence. Journal of Law and Society 37 (1): 40–60. Brown, L. 2013. Cycle of Harm: Problematic Alcohol Use Amongst Women Involved in Prostitution. Liverpool: Alcohol Research UK and Eaves. Davis, J. 2004. Off the streets: Tackling homelessness among female streetbased sex workers. First published in October 2004 by Shelter, 88 Old Street, London EC1V 9HU, Report. Deady, G.M. 2011. The girl next door: a comparative approach to prostitution laws and sex trafficking victim identification within the prostitution industry. Washington and Lee Journal of Civil Rights and Social Justice 3 (2): 66–79. Flowers, R.B. 2001. Runaway Kids and Teenage Prostitution: America’s Lost, Abandoned and Sexually Exploited Children. Vol. 14. Westport: Praeger. Fitzpatrick, S., G.  Bramley, and S.  Johnsen. 2012. Pathways into Multiple Exclusion Homelessness in Seven UK Cities. Urban Studies 50 (1): 148–168. Glazier, R., and R.  Kling. 2013. Recent Trends in Substance Abuse Among Persons with Disabilities Compared to That of Persons Without Disabilities. Disability and Health Journal 6 (2): 107–115. Harcourt, C., and B.  Donovan. 2005. The Many Faces of Sex Work. Sexually Transmitted Infections 81: 201–206. Jeal, N., and C.  Salisbury. 2004. A Health Needs Assessment of Street-Based Prostitutes: Cross-Sectional Survey. Journal of Public Health 26 (2): 147–151. Jeal, N., C. Salisbury, and K. Turner. 2008. The Multiplicity and Interdependency of Factors Influencing the Health of Street-Based Sex Workers: A Qualitative Study. Sexually Transmitted Infections 84 (5): 381–385. Katsulis, Y. 2009. Sex Work and the City: The Social Geography of Health and Safety in Tijuana, Mexico. Vol. 22. Texas: University of Texas Press. Marmot Review Team. 2010. Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post-2010. London: The Marmot Review Team. May, T., A. Haracopos, and M. Hough. 2000. For Love or Money: Pimps and the Management of Sex Work. London: Home Office – Research, Development and Statistics Directorate. Moffat, P.G., and S.A. Peters. 2000. Pricing Personal Services: An Empirical Study of Earnings in the UK Prostitution Industry. Scottish Journal of Political Economy 51: 675–690. Moore, D., B.G. Greer, and L. Li. 1994. Alcohol and Other Substance Use/abuse Among People with Disabilities. Journal of Social Behavior & Personality 9 (5): 369–382.

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Moore, D., B. Greer, and L. Li. 2002. Alcohol and Other Substance Use/Abuse Among People with Disabilities. Psychosocial Perspectives on Disabilities 1994 (9): 369–382. Qayyum, S., M.M.A. Iqbal, A. Akhtar, A. Hayat, I.M. Janjua, and S. Tabassum. 2013. Causes and Decision of Women’s Involvement Into Prostitution and Its Consequences in Punjab, Pakistan. Academic Research International 4 (5): 398–411. Rugoho, T. 2019. Experiences of Disabled Commercial Sex Workers in Zimbabwe. In Diverse Voices of Disabled Sexualities in the Global South, ed. Paul Chappell and Marlene de Beer, 151–165. Cham: Palgrave Macmillan. Chapter 11. Sanders, T. 2007a. The Politics of Sexual Citizenship: Commercial Sex and Disability. Disability & Society 22 (5): 439–455. ———. 2007b. Protecting the Health and Safety of Female Sex Workers: The Responsibility of All. BJOG : An International Journal of Obstetrics and Gynaecology 114 (7): 791–793. Social Exclusion Unit. 2004. Mental Health and Social Exclusion – Social Exclusion Unit Report. London: Office of the Deputy Prime Minister. Spice, W. 2007. Management of Sex Workers and Other High-Risk Groups. Occupational Medicine 57: 322–328. UK Network of Sex Work Projects [UK NSWP]. 2008. Working with Migrant Sex Workers. Good Practice Guidance. London: NSWP. UNODC. 2006. United Nations Office on Drugs and Crime. Poverty in Focus, December. Ward, H., and S. Day. 2006. What Happens to Women Who Sell Sex? Report of a Unique Occupational Cohort. Sexually Transmitted Infections 82 (5): 413–417. Ward, H., C.H.  Mercer, K.  Wellings, K.  Fenton, B.  Erens, A.  Copas, and A.M. Johnson. 2005. Who Pays for Sex? Analysis of the Increasing Prevalence of Female Commercial Sex Contacts Among Men in Britain. Sexually Transmitted Infections 81: 467–471.

CHAPTER 15

Drug Addiction among Youths in Zimbabwe: Social Work Perspective Tatenda Nhapi

15.1   Introduction Social history has documented psychoactive substances usage since ancient times. At modern humans emergence from Africa circa 100,000 Before Common Era (BCE) archaeologists believe existence of knowledge about which fruits and tubers could be fermented at certain times of the year for a naturally occurring cocktail or two (Holtzhausen 2017). Considering high southern African HIV prevalence estimates due to unsafe sexual behaviours, adolescent illicit drug use prevalence and its associated health-­ risky behaviours have attracted growing international recognition (Rudatsikira et al. 2009). Adolescence, as Blum et al. (2014) observes, is divided into early, middle, and late with ages 10–14 years being early adolescence marked by dramatic physical, cognitive and social changes; however, researchers view it as among the most neglected periods of life. Across these five  years, a young person physically develops, progressing from a prepubescent youngster with childlike features to someone with an adult appearance (Blum et al. 2014).

T. Nhapi (*) Erasmus Mundus Masters in Advanced Development Social Work, Lincoln, UK © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_15

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Zimbabwe has an estimated 1.4 million people living with HIV (PLHIV), 1.2 million of whom are between the ages of 15 and 64 (United Nations Development Programme 2018). Adult HIV prevalence has steadily decreased over the last ten years, declining from 18.1% in 2005 to 13.8% in 2015. Prevalence among children (0–14) is estimated at 1.6%. While the epidemic has declined among both men and women (15–49), women continue to bear disproportionate burden with prevalence levels of 16.7% compared to 10.5% among men in 2015. The same gender disparity is true for new infections, where women have an HIV incidence of 0.67%, compared to 0.28% among men (15–49) (United Nations Development Programme 2018). Behaviour is a central aspect of adolescent health and many behaviours known to cause non-communicable disease later in life begin in adolescence (Blum et al. 2014). The United Nations Office on Drugs and Crime (UNODC)’s World Drug Report of 2013 estimates that there are 28 million drug users in Africa (United Nations Office on Drugs and Crime 2013). Moreover, the AU Plan of Action on Drug Control (2013–2017) was adopted by the 5th Session of African Union (AU) Conference of Ministers (African Union 2013). The Plan of Action aimed at improved health, security and socio-­ economic well-being of African people by reduced illicit drug use, trafficking and associated crimes. Over 60% of Africa’s 960 million people are under 24 years and 75% is under the age of 35 years, and in 2015, the continent’s 226 million youth aged 15–24 years accounted for nearly 20% of the world’s youth population (FAO). FAO notes that by 2050 those aged 15–35 years are expected to number 840 million. Africa is left vulnerable to organised crime fuelling drug addiction due to high income inequality, high youth populations, high urbanisation rates, low levels of criminal justice resources, firearms proliferation, wars and civil conflicts, and weak controls over criminal activities (African Union 2013). Prescription drugs and pills abuse continues to be on the increase among youths amid revelations that cross-border traders are smuggling the substances into Zimbabwe (Chipunza and Razemba 2017). The Department of Mental Health in the Ministry of Health and Child Care indicated in 2014 that 135 drug-induced psychosis admissions were recorded at Harare Hospital in 2013 with 865 outpatients documented in the same year (Chipunza and Razemba 2017). Alcohol, cannabis, heroin, glue and cough mixtures such as histalix and Broncleer are commonly used substances in Zimbabwe. Cannabis (mbanje) remains the most popular illicit drug mainly because it is grown locally or smuggled in from neighbouring countries like Malawi and Mozambique (Global Drug Policy

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Observatory 2014). In some societies along the Zambezi River, mbanje is grown and consumed in large quantities as a way of life and therefore the drug finds their way into other parts of the country (Global Drug Policy Observatory 2014). Year 2017 was devoted by African Heads of State and Government as a year of “Harnessing the Demographic Dividend through Investments in Youth”. The decade 2018–2027 was declared as the “African Decade for Technical, Professional and Entrepreneurial Training and Youth Employment” by the 29th ordinary Summit of the AU held in July 2017. For Kanengoni (2017), policy actors’ apparent desire to ‘engage youth’ is often viewed by youths as not necessarily driven by the need to allow them to define their polity. Kanengoni (2017) notes this is co-opting them and getting them to behave, be cultured and maintain the traditions set for them by others. Furthermore, the youth concept has been categorised by anthropological, sociological and psychological studies as a developmental or life stage, but childhood to adulthood transition should not be considered fixed and stable (Christiansen et al. 2006). Commitment to work with and for youths is reflected in section 20 of Zimbabwe’s new Constitution and the National Youth Policy framework. Section 20 is a component of Chapter 1 of the Constitution of Zimbabwe Amendment (No.20) Act 2013 on Founding Provisions (Zimbabwe Human Rights Commission n.d.). Section 20 sets the youth’s rights agenda in Zimbabwe through state, its institutions and agencies at every level taking reasonable measures, including affirmative action. This is to ensure that youths: • have access to education and training, • have opportunity to associate and to be represented and participate in political, social, economic and other spheres of life, • afforded opportunities for employment and other avenues to economic empowerment, • have opportunities for recreational activities and access to recreational facilities and • be free from harmful cultural practices and all forms of abuse or exploitation (Zimbabwe Human Rights Commission n.d). Young people are numerically dominant in Africa but have few materials or social resources to meet poverty threats in African cities (Bourdillion 2012). According to Bourdillion (2012), adults control most material resources, and youths’ social networks rarely include those in positions of

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power. This chapter explores the theoretical and policy gaps preventing greater integration between youths’ psychoactive substances abuse prevention and social development in Zimbabwe. The chapter’s aim is to understand strategies towards development of a more complete and robust evidence base to be drawn on for addiction-free life worlds for African youths. This book chapter examines various paths taken by youths, state and non-state actors in safeguarding against drug misuse. Two interrelated questions are addressed: (1) to what extent is socio-economic turbulence a key driver for drug misuse amongst Zimbabwean youths? (2) What has been the experience of drug addiction prevention programmes that have been implemented? Firstly, mental health and addictive substances concepts are defined. Secondly, approaches to drug misuse prevention are outlined from health and from social development perspectives, respectively. This book chapter thus seeks to move away from the deterministic ways of looking at youth drug misuse and is anchored on the premise that viewing youth substance and drugs addiction in Zimbabwe as a mono-crisis is plainly simplistic. Such an approach does not allow enough space to get at the diverse everyday experiences arising out of the different and immediate constituent. Theoretically, this chapter demonstrates compatibility between socio-­economic turbulence and drug and substance addiction paradigms. The methodology used is a rigorous, evidence-focused literature review based on the core principles of a systematic review. It allows for innovation and reflexivity, particularly regarding policy implications. The study methodology entailed a review of books, technical papers, tacit information and websites to find material on drug abuse in Zimbabwe published between 2010 and 2018 to understand the current state of knowledge. Conceptually, this study relies on Merton’s sociological theory of anomie. In his 1957 theory of anomie, Merton offered a typology of adaptations based on the individual’s acceptance or rejection of cultural goals and institutionalised means (Montgomery 2004). Merton’s theory remains influential in subfields such as crime and deviance (Montgomery 2004). Merton perceived anomie as a state of dissatisfaction arising from a sense of discrepancy between the aspirations of an individual and the available means that the person has to realise these ambitions. According to Montgomery (2004), money attainment through socially approved means work is the key societal goal. Nearly everyone internalises the culturally approved goal of “getting ahead”,

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that is, making money, accumulating material possessions and achieving high social status based on money and occupation. Thus, youths become rebellious or enter retreatism mode when these goals are not achieved through the escape mechanism of substances addiction (Montgomery 2004). The major aim of this study was to gather knowledge on the situation of lived realities embedded in youths becoming addicted to drug and substance misuse. This chapter is structured as follows. In the following section, reflections are made on dynamics, key drivers, and channels of drugs distribution and trends of drug addiction amongst African youths. After providing some concrete and current examples of addiction and substance misuse, the latter part of the chapter draws on a variety of literatures and programme experience that enables laying out a range of conditions under which youth drug addiction reduction outcomes can be achieved. Chapter concludes by highlighting some basic considerations that need to be taken into account in future drug misuse and youth development programming.

15.2   Types of Addictive Substances Substances like marijuana (cannabis) are used by some for deeply spiritual experiences and are culturally entrenched with the Rastafari movement since it began in the 1930s. Marijuana—or ganja, as Rastas commonly call it, is considered sacred and referred to as the wisdom weed or holy herb. Rastas believe that the Tree of Life mentioned in the Bible is the marijuana plant and that several other biblical passages further promote its use (Holtzhausen 2017). Also, another abused substance that has become the drug of choice for Zimbabwe’s urban youth and local music stars is Broncleer. Broncleer is meant to alleviate colds, coughs and allergies, but some people are finding pleasure in downing 50 ml–100 ml at once instead of the prescribed dosage of 10  ml cough syrup at a time for adults. Broncleer contains codeine that treats bronchitis, although the thick, bitter syrup a teaspoon is considered the recommended dosage for use. However, users swig it straight from the bottle together with other drugs or alcohol, to achieve a sensational high. In Zimbabwe the sugary drug can only be sold to individuals in possession of a medical prescription. Alcoholic beverages have changed from home-brewed mahewu and “opaque beer” to bottled “clear beer” and stronger alcoholic drinks (World Health Organisation 2004). Opaque beer is a pulpy-looking drink

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served in brown plastic 3-l “scuds” (named after the scud missile) that are typically passed around to others who share a drink. In rural Zimbabwe, fermented beverages are commonly prepared at home from locally grown grains and produced for use during special cultural events as weddings, funerals and spirit-appeasing ceremonies (World Health Organisation 2004). Presently traditional beers are still used in traditional ceremonies, but also sold to fellow community members as part of regular social gatherings. The commonest types of traditional beer are a seven-day beverage called doro rematanda, and by-products of this seven-day beer  are muchaiwa, and a one-day beverage called chikokiyana (World Health Organisation 2004). The following below enumerates legislation related to alcohol use: • The Liquor Act [chap. 14:12] is the main law regulating alcohol in Zimbabwe. • Other legislation related to alcohol includes: • The Traditional Beer Act [chap. 14:24], • The Road Traffic Act, • The Shop Licences Act, • The Child Protection Act, • The Finance Act (ZIMRA Licenses and Approval), • Food and Food Standards (Alcoholic Beverages) Regulations 2001 (Southern African Alcohol Policy Alliance 2014) In 2008, initial discussions about the Zimbabwean National Alcohol Policy began. From six consultative meetings, six drafts policies were made until a final draft was agreed on at end of 2011 and it awaits cabinet approval (Southern African Alcohol Policy Alliance 2014). However, Southern African Alcohol Policy Alliance notes despite the sincerity on the part of government, the alcohol industry played a significant role draft alcohol policy in its formulation.

15.3   Conceptual Framework As a group of actors, youth form an especially sharp lens through which social forces are focused in Africa, as in much of the world (Durham 2000). The United Nations (UN) refers ‘youth’ as those in the 15–24 age group, whereas many African countries and institutions (including the African Union Youth Charter) define youth as people aged 15–35

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(Oosterom 2018). Initiation rites rather than a specific age symbolise transition from childhood to adulthood in many African societies (Bourdillion 2012). Youth is an internally and externally shaped social position and constructed by larger societal and generational process (Christiansen et  al. 2006). Although less visible than pubertal maturation, adolescence age period is marked by equally profound brain development that fundamentally alters how young people think and engage the world. Geyer et  al. (2015), further observe adolescents’ interest is in risk taking and boundaries pushing. Compared to other life stages, adolescence is a period characterised by an increased likelihood for behaviours that could have potentially harmful outcomes, such as substance use (Geyer et al. 2015). In the same vein, educationalists have long realised that children do not learn by passively receiving information and instructions passed on to them by teachers and other adults but learn reading, writing, and numeracy by practice (Bourdillion 2012). Culturally embedded ideals place many of the caring roles within the collective space of kin and community networks—particularly those facilitating young people’s entry into adulthood (UNICEF 2016). Bourdillion (2012) notes children observe what others do and imitate what works: learning is a kind of apprenticeship in life. Children experiment to see the effect of different responses to the situation they are in and constantly produce their own responses to the environment they face, and normally they learn to take control of their lives through successful responses (Bourdillion 2012). Kanengoni (2017) notes the contested place of young people in African socio-political and economic processes and how media shaped and constructed narratives. Lately, Kanengoni (2017) argues youth themselves are constructing new and multiple other narratives fanned by many factors. Social media and other creative spaces have opened up opportunities for youth to not only challenge dominant narratives but to create counter-­ narratives painting a different picture about their lives and role in global and local politics (Kanengoni 2017). Finally, addiction specialists argue that an addict’s drug-seeking behaviour results from physiological brain changes caused by chronic drug usage. According to Holtzhausen (2017), the Disease View states that there is some “normal” process of motivation in the brain a process somehow changed or perverted by brain damage or adaptation caused by chronic drug use. On this theory of addiction, the addict is no longer rational; she uses drugs as a result of a fundamentally non-voluntary process (Holtzhausen 2017).

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Furthermore, Masunda and Muzarurwi observe applicability of the reflexivity concept of purposive action to drug addiction. They note the concept is framed on notion that people have as reasons for doing certain things or acting in a certain way is applicable to drug abuse. When the reflexivity concept of purposive action is applied in understanding, prescription drug abusers are of the view that prescription drugs help them to forget their social problems (Masunda and Muzarurwi 2016). Drugs, as Chirisa (2017) notes, cause an above normal dopamine release increase causing a person to experience pleasure and look for more of the drug for that pleasure level outside the natural pleasurable activities. Dopamine at high levels causes psychotic symptoms: hallucination delusion, disorganisation and violent behaviour, resulting in the user ending up in a psychiatric unit (Chirisa 2017). Mbembe (1992)’s critique of African postcolonial societies aids framing of African and specifically Zimbabwean key youth addiction drivers. According to Mbembe, the post-colony is characterised by a distinctive style of political improvisation, by a tendency to excess and a lack of proportion as well as by distinctive ways in which identities are multiplied, transformed and put into circulation. Mbembe further notes post-colony concerns with the ways in which state power through its administrative and bureaucratic practices creates an own world of meanings master code. This becomes the society’s primary central code which ends up g ­ overning— perhaps paradoxically—the various logics that underlie all other meanings within that society. Finally, Honwana (2014)’s waithood concept contends globally youths face the same crisis of joblessness and restricted futures. The ‘waithood generation’ possesses a tremendous transformative potential, as young people understand that the struggle to attain freedom from want requires radical social and political change (Honwana 2014). Majority of African youths grapple with a lack of jobs and deficient education, inability to obtain work and become independent—to build, buy or rent a house for themselves, support their relatives, get married, establish families and gain social recognition as adults (Honwana 2014). These attributes of adulthood are becoming increasingly unattainable by the majority of young people in Africa. Honwana uses the waithood notion, a meaning waiting for adulthood, to refer to this period of suspension between childhood and adulthood. On the one hand, young people are no longer children in need of care, but on the other, they are still unable to become independent adults.

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15.4   Socio-economic Context Scholars have differed on the endemic and historical causes of the Zimbabwe crises, but have converged on the point that it hardly began in 2000, as popular and contemporary literature would seem to suggest (Chiumbu and Musemwa 2012). According to the 2012 National Census, 48% of Zimbabwe’s population of 13.2 comprises children the age of 18. These adolescents are entering adulthood under conditions of limited livelihood opportunities and pervasive poverty, especially in rural areas, where 80% of children in poor households reside (UNICEF 2016). According to World Poverty Clock (2018), over five million people in Zimbabwe are living in extreme poverty, throwing into doubt the country’s capacity to meet the United Nations Sustainable Development Goal to end extreme poverty by 2030. Around five million people in Zimbabwe were living in extreme poverty, with a target escape rate at 51.8% and a current escape rate at 11.1% (World Poverty Clock 2018). According to the World Bank (2018), Zimbabwe’s recovery from decades of economic contraction has largely been shaped by agriculture growth and investment patterns. Zimbabwe had double-digit growth rates shortly after dollarisation in 2009, but growth started to decline in 2012 as confidence started to diminish and the investment-to-gross domestic product (GDP) ratio declined sharply. It is projected to slow to 2.7% in 2018 partly due to liquidity shortages. Zimbabwe’s expansionary fiscal policy that started in 2016 has resulted in unsustainable fiscal deficits that widened from 8.5% in 2016 to 11.1% in 2017. The expansionary fiscal policy spilled over into the financial sector and resulted in cash shortages that weigh negatively on economic growth (World Bank Zimbabwe 2018). After experiencing record hyperinflation in 2008, the country adopted in 2009 a multicurrency regime that ushered in macroeconomic stability and positive economic growth. Inflation stabilised; revenues and bank deposits recovered sharply. Zimbabwe’s fundamentals for economic growth and poverty reduction remain strong, and will continue to yield results, provided there is consensus around inclusive and competitive investment policies (World Bank Zimbabwe 2018). Nhunzvi (2014)’s study pointed to “unemployment, and economic frustration” experienced by youths as the chief driver of drug addiction related mental cases. According to Nhunzvi, the situation is worsened by Zimbabwe’s inadequate rehabilitation structures, where drug abusers go through therapy in the country’s health institutions, but are released back

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into the environment encouraging a relapse. Hospital statistics showed that as many as 60% of all re-admissions during the period from January 2010 to December 2011 were secondary (not new) to substance-induced disorders, and that less than 3% of these service users moved into long-­ term recovery with follow-up (Nhunzvi 2014). The long political and economic crisis that plagued Zimbabwe since 2000 is when youth unemployment peaked. Throughout these myriad of crises, Zimbabweans have creatively devised a repertoire of strategies to survive (Chiumbu and Musemwa 2012). The unstable economic environment during this period led to the proliferation of the informal sector and parallel (black) market which absorbed most young people as agents and  dealers (Zinhumwe 2012). According to African Capacity Building Foundation (2016), many young people have little or no skills and are therefore largely excluded from a productive economic and social life. Those that have some education often exhibit skills irrelevant to the labour market, where education and skill requirements are increasing, resulting in millions of un- and underemployed youth.

15.5   Key Drivers of Substance Abuse Behavioural scientists regard drug addiction as a behavioural disorder resulting from drug reinforcers assuming control over a substantial portion of an individual’s behavioural repertoire (Holtzhausen 2017). Psychiatrists and clinical psychologists, as Holtzhausen further notes, attend more to the drug abuser’s individual characteristics and consider cognitive co-morbidities as anxiety or depression, which contribute to development and maintenance of drug abuse and addiction. Increased drug use has been due to rapid socio-economic changes as a growing youth urban population, poverty, instability, exposure to violence, difficult job conditions, work overload, post-traumatic stress disorders, and neglect and abuse (African Union 2013). Socio-economic Status Increased substance abuse risk amongst adolescents results from adverse environmental conditions, such as socio-economic challenges, poverty and family instability (Geyer et al. 2015). Pufall et al. (2017) investigated education, substance use and sexual risk behaviour linkages in 3274 Zimbabwean young adults aged 15–19 years. Pufall et al. (2017)’s study

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aimed at characterising substance use amongst rural Zimbabwe adolescents and to investigate whether reductions in substance use might be one pathway through which school enrolment reduces HIV risk in vulnerable and orphaned children. The study aims (1) to describe levels and patterns of substance abuse in adolescents in Eastern Zimbabwe; (2) to test the hypothesis that substance abuse lies on the causal pathway between parental loss and increased HIV risk behaviour for orphaned adolescents by: (i) investigating whether orphaned adolescents have higher levels of substance abuse, and (ii) whether those practicing substance abuse have greater HIV risk behaviour; and (3) to test the hypothesis that substance abuse is reduced in orphaned adolescents who are enrolled in school (Pufall et  al. 2017). Fifty-one per cent of the study population were females, and demographic characteristics were generally evenly distributed between the genders. Study concluded that substance use is associated with early sexual debut, number of sexual partners and transactional sex, while school enrolment was associated with lower substance use in males. Pufall et al.’s study recommended education access may reduce sexual risk behaviours and HIV infection rates among male adolescents in sub-­ Saharan Africa by reducing substance abuse. Moreover, a study by Bandason and Rusakaniko (2010) showed that there is substantial burden of experimental smoking among secondary school children in Harare, Zimbabwe. In an average class of 40 pupils (which is the standard class size in Zimbabwe), we would expect that at least 25% of them have experimented with smoking and 7% are daily smokers (Bandason and Rusakaniko 2010). Some societies believe that moderate alcohol consumption does not have adverse effects, tobacco cessation could lead to weight gain and cannabis is a social and religious blessing of gods (Jiloha 2009). These beliefs permit the adolescents to use drugs without hesitation or guilt as positive attitude towards the drugs is likely to initiate drug use among the adolescents (Jiloha 2009). Cognitive and Neuro-Behavioural Consequences of Drug and Substance Addiction All drugs abuse, from nicotine to heroin, cause a particularly powerful surge of dopamine in the nucleus accumbens (Holtzhausen 2017). The likelihood of drug usage or participation in a rewarding activity will lead to addiction is directly linked to the speed with which it promotes dopamine

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release intensity and reliability (Holtzhausen 2017). Substance abuse amongst adolescents is associated with numerous social problems such as crime and other antisocial activities, high risk sexual behaviour, impairment of academic performance and an increased risk of suicide, accidents, contagious diseases and psychological distress (Geyer et al. 2015). According to the Ministry of Health and Child Care, 45% of all mental cases are triggered by drug and alcohol abuse, and statistics show that 57% of all admissions in psychiatric institutions are due to drug and alcohol abuse. Addiction is a disease, not a moral failing, characterised not necessarily by physical dependence or withdrawal but by compulsive repetition of an activity despite life-damaging consequences. This view has led many scientists to accept the once heretical idea that addiction is medical condition requiring treatment, not incarceration (Towo 2018).

15.6   Addiction Mitigation Strategies The following section of the chapter explores state and non-state actors programmatic interventions which when implemented can have the desired outcomes of reduced youths’ addiction. The international drug control system comprises three drug control treaties which recognise the “health and welfare of mankind” as its overarching concern (UNDP 2015). It establishes a “dual drug control obligation: to ensure adequate availability of narcotic drugs, including opiates, for medical and scientific purposes, while at the same time preventing illicit production of, trafficking in and use of such drugs” (UNDP 2015). Several organisations and institutions have intervened in the dire situation. Organisations such as Anti-Drug Abuse Association of Zimbabwe, the First Step with Addiction Recovery Trust, Alcoholics Anonymous in Zimbabwe, Highlands Halfway House in Harare, have been adding to the over-subscribed Government psychiatric units in managing and rehabilitating some of the drug users (Chirisa 2017). Awareness activities are carried out in schools during annual International Day against Drug Abuse and Illicit Trafficking commemorations and through different media outlets. Zimbabwe’s longstanding mental health policy and recent efforts to build mental health research and teaching capacity makes officials and clinicians more likely to approach mental health at a systems level than in other settings (Hendler et  al. 2016). Empirical studies aiming at providing evidence to specifically open up social spaces for dialogue to come out with Draft Zimbabwe National

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Illicit Drug Control Master Plan are required. Furthermore, scientific research should be used to validate and discuss the implications of illicit drug research findings, and to develop next steps for advocacy, policy and services provision for Zimbabwe (Towo 2018). Zimbabwean drug laws do not adequately address issues surrounding prevention and treatment. The Dangerous Drugs Act (chap. 15) in conjunction with the Criminal and Codification Act has not kept up-to-date with current thinking on how to tackle drug-related issues (Global Drug Policy Observatory 2014). Recently, there have been other signs that Zimbabwe is starting to wake up to the dangers of smoking. In March 2015, Zimbabwe became the 180th country to ratify the WHO’s Framework Convention on Tobacco Control. The treaty regulates tobacco production, sales, advertising and taxation and aims to increase public awareness on the dangers of smoking (Deutsche Welle n.d.). However, UNDP notes the relationship between drug control policy and human development is complex and multifaceted; both share a common objective to reduce drug-related harms (UNDP 2015). Policies aimed at prohibiting and punishing the cultivation, sale and use of certain drugs, as UNDP notes, have disproportionately shaped the international drug control approaches irrespective of countries’ development goals (UNDP 2015). A multi-sectoral approach encompassing social workers’ led strategies and interventions that tackle drivers of youth drug addiction are required. Promotion of mental health and prevention of mental disorder is more pronounced on World Health Commemoration Days (Epilepsy Day, World Autism Awareness Day, World No Tobacco Day, International Day Against Drug Abuse &Illicit Trafficking, World Mental Health Day). This is done through electro and print media (Zimbabwe Broadcasting Corporation TV, Newspapers), road shows, expos, exhibitions and IEC materials (Ministry of Health and Child Care n.d.). Furthermore, government should consider a holistic evidence-based drug policy, grounded in science, public health and human rights (Masunda and Muzarurwi 2016). Stakeholders in youths related fields must take measures to expose youths to information on how prescription drug abuse affects their social, physical, psychological well-being and future life prospects (Masunda and Muzarurwi 2016). Linked to this parenting programmes roll out at schools, community centres or churches to equip parents/care-givers on drug addiction and substance abuse risks guide youths’ responses to drug addiction risks (Geyer et al. 2015).

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Youth Dividend The youth bulge in Zimbabwe’s population structure, whereby 35.7% are youth (15–34  years) and 13% are young adolescents (between the age 10–14 years), can result in strategic investments targeting youths survival and development, delaying early marriages and child bearing, preventing unintended pregnancies. Advocacy is widely recognised as a tool for generating local and global support for health issues, and WHO mental health advocacy conceptualisation subsumes “various actions aimed at changing the major structural and attitudinal barriers for positive mental health outcomes” (Ngoma 2016). One important thread in mental health advocacy responds to the stigma people with mental disorders face by promoting human rights and respecting service users’ autonomy as advocates for themselves and each other (Hendler et al. 2016). Research has found that preventing adolescence use of drugs could be the best primary strategy aimed at preventing drug addiction. Early drugs use during this critical period of development increases a person’s chances of developing an addiction. Drug addiction prevention must aim at blocking young adolescent boys and girls from experimenting with drugs (Chirisa 2017). Teenagers will still be developing judgement and decision-making skills and would not have reached maturity to accurately assess the risks of all of these forms of drug use. Furthermore, using drugs at this age can disrupt brain function in areas critical to motivation, memory, learning, judgement and behaviour control (Chirisa 2017). In many Global South countries, attention to mental illness remains compartmentalised and consigned as a matter for specialist policy. Despite great advances in global mental health, mental health policy and practice dovetail only to a limited degree with social development efforts (Plagerson 2016). A strong economic base cannot be built without strengthening girls’ and vulnerable youths’ social and economic assets and thereby breaking the chain of intergenerational poverty (UNFPA). Transforming education and skills development and employment and entrepreneurship provision for young women and men will be central to progress towards sustainable peace and development (FAO). The Decent Work Country Programme for Zimbabwe (DWCP) launched in 2013 by the Ministry of Labour and Social Services and the social partners aims to combat the high levels of youth unemployment through initiatives such as the Skills for Youth Employment and Rural Programme (Zimbabwe Human Rights Commission n.d).

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Also, investment in recruiting empathetic and experienced facilitators, on-going support and training for youths is critical. Parenting programmes involve engaging closely with parents on difficult and sensitive challenges. Parents’ roles in encouraging sustained participant attendance and strengthening protective practices in the community should not be underestimated (UNICEF 2016). Zinhumwe (2012) recommends revision of the curriculum (education and training) to make it compatible with the needs of the industry—the world of work. Also, Zinhumwe indicates that establishment of a co-­ ordinated Labour Market Information System necessary to monitor labour market trends and facilitate the designing, planning and monitoring of policies and programmes geared at employment generation. Parenting programmes should be offered at schools, community centres or churches to educate parents/care-givers on the risks related to substance use and to equip them with skills to guide adolescents on how to deal with exposure to drugs (Geyer et al. 2015). A greater synthesis with the socio-economic and political domains for the mental health sector likely accelerates scaled up mental health service provision (Plagerson 2016). This fosters a more effective alignment between treatment and prevention of mental illness and promotion of positive mental health (Plagerson 2016). Therapy The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the so-called American Psychology Association bible of mental disorders, regardless of the particular substance, the diagnosis of a substance use disorder is based upon a pathological set of behaviours related to the use of that substance (Holtzhausen 2017). These behaviours fall into four main categories, namely (1) impaired control, (2) social impairment, (3) risky use, and (4) pharmacological indicators (tolerance and withdrawal) (Holtzhausen 2017). People who interact with adolescents in the home or community need to be alert to changes in an adolescent’s behaviour and appearance that may signal substance abuse (Jiloha 2009). The Ministry of Health and Child Care’s Department of Mental Health Services coordinates provision of comprehensive mental health and psychiatric services (promotive, preventive, curative and rehabilitative) including substance abuse (Alcohol, Drug and Tobacco Control). This includes development, implementation and maintenance of national mental health and psychiatric care programmes, standards and regulations affecting the

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programme. It also provides professional and technical leadership, advice, support and supervision on mental health and psychiatric care areas (Ministry of Health and Child Care n.d.). Also, youths reverting to substance use to cope with life challenges place an onus on local and provincial government to provide opportunities and facilities to address adverse social circumstances. These opportunities and facilities could include sport and recreational activities, services by community-based centres and mentorship programmes (Geyer et  al. 2015). For such initiatives, Department of Social Services employed social workers can take the lead in engaging youth in the social and public spaces.

15.7   Conclusion Modern-day philosopher, icon and youth advocate K. Duckworth believes that drugs are a distraction, introduced to densely populated African neighbourhoods to destroy the talent the youth have and obstruct them from reaching their full potential (Ngoma 2016). Robust state and non-­state actors’ collaborative programmes can holistically tackle youth drug addiction. Youth socio-economic empowerment in context of economic turbulence is one approach the chapter notes as galvanising the fight against youth drugs addiction. Social workers can play a leading role in initiatives towards curtailing addiction. Frontline social workers as professional grounded in a repertoire of community engagement skills can engage with other allied health and economic development programmes for holistic programmes for youths empowerment and addiction reduction. Such initiatives will be for the ultimate aim of youths contributing to African Union’s agenda 2063 for a socially and economically transformed Africa. Future research must invest in robust data, and evidence that will reveal more precisely the magnitude and patterning of youth drug abuse, as well as assess programme impacts, is critical. Evidence-informed programming can contribute to strengthening the effectiveness and efficiency of programming especially in the most resource-constrained contexts. Applied social research by professionals as social workers can contribute to youth development and youth addiction knowledge management. A study of local understandings and practices relating to youths pays attention to differences arising from age, gender, ethnicity, religion or social class. Other youth themes should include household structure and care arrangements, community norms, particularly adolescents’ transition to adulthood, and migration and modernisation impacts (UNICEF 2016).

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Jiloha, R.C. 2009. Social and Cultural Aspects of Drug Abuse in Adolescents. Delhi Review of Psychiatry 12 (2): 167–175. Kanengoni, A. 2017. Youth in Africa: Dominant and Counter Narratives. BUWA! Journal on African Women’s Experience 8: 1–5. Masunda, W., and R.  Muzarurwi. 2016. Prescription Drug Abuse Among the Urban Youth: Case Study of Gazaland Area Highfields Harare. International Journal of Politics and Good Governance 7 (3): 1–10. Mbembe, A. 1992. Provisional Notes on the Postcolony. Journal of International African Institute: 3–37. Ministry of Health and Child Care. n.d. Mental Health. http://www.mohcc.gov. zw/index.php/features/custom-styling/mental-health. Accessed 12 May 2018. Montgomery, J. 2004. Individual Adaptations to Cultural Contradictions: Using Non-Monotonic Logic to Reconstruct Merton’s Theory of Anomie. https://www. ssc.wisc.edu/~jmontgom/anomie.pdf. Accessed 2 May 2018. Ngoma, S. 2016. Youth and Drug Abuse. http://zimyouthcouncil.org/?p=179. Accessed 12 May 2018 Nhunzvi, C. 2014. Recovery from Substance Abuse among Young Adult Zimbabwean Men. Unpublished Masters Dissertation University of Cape Town, Cape Town. Oosterom, M. 2018. YK4D Emerging Issues Report Youth Employment & Citizenship: Problematising Theories of Change. Brighton: Institute of Development Studies. Plagerson, S. 2016. Integrating Mental Health and Social Development in Theory and Practice. Health Policy and Planning 30: 163–170. Pufall, E.L., et  al. 2017. Education, Substance Use, and HIV Risk among Orphaned Adolescents in Eastern Zimbabwe. Vulnerable Children and Youth Studies 12 (7): 360–374. Rudatsikira, E., et al. 2009. Prevalence and Predictors of Illicit Drug Use Among. Annals of African Medicine 8: 215–220. Southern African Alcohol Policy Alliance. 2014. http://saapa.net/countries/ zimbabwe. Accessed 6 Jun 2018. Towo, A. 2018. The Need for Scientific Research in the Fight Against Drug and Substance Abuse in Zimbabwe. https://bulawayo24.com/index-id-opinion-sccolumnist-byo-125597.html. Accessed 1 June 2018. UNDP. 2015. Addressing the Development Dimensions of Drug Policy. New York: UNDP. UNICEF. 2016. Parenting, Family Care and Adolescence in East and Southern Africa: An Evidence-Focused Literature Review, the UNICEF Office of Research – Innocenti. Rome. United Nations Development Programme. 2018. Consultant: Development of Integrated Training & M & E & Case Tracking Tools for SGBV/HIV/TB Management and Referral Path Which are KP/Youth & Gender Friendly. https://jobs.undp.org/cj_view_job.cfm?cur_job_id=79480. Accessed 20 June 2018.

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United Nations Office on Drugs and Crime. 2013. World Drugs 2013. https:// www.unodc.org/unodc/secured/wdr/wdr2013/World_Drug_Report_2013. pdf. Accessed 2 June 2018. World Bank Zimbabwe. 2018. Zimbabwe Country Overview. http://www.worldbank.org/en/country/zimbabwe/overview. Accessed 30 June 2018. World Health Organisation. 2004. Global Status Report on Alcohol 2004 Country Profiles Zimbabwe. www.who.int/substance_abuse/publications/en/zimbabwe.pdf. Accessed 12 Apr 2018. World Poverty Clock. 2018. Zimbabwe. https://worldpoverty.io/. Accessed 27 June 2018. Zimbabwe Human Rights Commission. n.d. OHCHR Study on Youth and Human Rights Youths in Zimbabwe. https://www.ohchr.org/Documents/Issues/ Youth/ZimbabweHRCommission.pdf. Accessed 12 June 2018. Zinhumwe, C. 2012. The Youth and Unemployment in Zimbabwe. Harare, Building a Future with Decent Work for Young People Harare 29 March.

CHAPTER 16

Internet Addiction and Mental Health among College Students in Malawi Tiwonge D. Manda, Edister S. Jamu, Elias P. Mwakilama, and Limbika Maliwichi-Senganimalunje

16.1   Introduction The Internet and related services have become central in human interrelations, shaping how people share their life experiences online, organize political movements, and communicate with family members and peers. For regular users, it could be argued that irreversibility has been reached, making it difficult to comprehend how human interaction would be without the possibilities offered by the Internet and related services such as social media. The centrality of Internet-enabled services in human interaction is also evident in the lives of university students, most of whom are considered digital natives. Among other things, Internet services enable access to distributed educational resources and allow students to communicate with remotely located friends and colleagues. Internet-enabled services

T. D. Manda (*) • E. S. Jamu • E. P. Mwakilama • L. Maliwichi-Senganimalunje Chancellor College, University of Malawi, Zomba, Malawi e-mail: [email protected]; [email protected]; [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_16

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also provide students with low cost means for sharing resources with peers (Mkandawire and Senganimalunje 2011). Despite the aforementioned benefits, previous studies have identified high rates and severe consequences of addiction or pathological Internet and related services use among university students (Li et  al. 2015). Addiction/pathological Internet and related services use refers to problematic Internet and related services and is  use associated with significant social, psychological, and occupational impairment (Li et  al. 2015). Central to the concept of addiction is dependence on a substance or activity, which is characterized by overindulgence, tolerance, withdrawal, craving, and loss of control (Widyanto and McMurran 2004). Over the years, the concept of addiction has been extended beyond its initial linkage to substance use because of growing recognition of behavioural addictions such as Internet and social media use (Widyanto and McMurran 2004). Excessive Internet and related services use has been documented to cause neurological complications, psychological disturbances, and social problems (Li et al. 2015). These may result in disruption of relationships, social isolation (Faraci et al. 2013), episodes of depression, and neglect of school work among students (Li et  al. 2015). Despite a growing acknowledgement of the negative aspects of excessive Internet and related services use, there is still a dearth of studies on the subject, especially in sub-Saharan Africa. This chapter, therefore, explores the phenomenon of addictive/pathological Internet and related services use among university students in Malawi, and how this relates to probable cases of common mental disorders (CMD). The chapter applies a combination of the Internet Addiction Test (IAT) (Young and de Abreu 2011) and the Self-Reporting Questionnaire (SRQ-20) (Beusenberg and Orley 1994). The Internet Addiction Test (IAT), is a 20-item questionnaire that measures key characteristics of pathological online use. The test measures the extent of a person’s use of the Internet and related services, classified in the addictive behaviour in terms of mild, moderate, and severe impairment (Young and de Abreu 2011). The SRQ-20 is a psychiatric disturbance-screening questionnaire developed by the World Health Organisation (WHO). It is a 20-item questionnaire, used to identify probable cases of CMD (Beusenberg and Orley 1994). This screening questionnaire, employs a yes/no answer format which makes it easier to administer (Harding et al. 1980). In 2009, the tool was validated in Malawi on mothers in a rural health centre. The criterion validation was conducted against the Structured Clinical Interview

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for the Diagnostic and Statistical Manual of Mental Disorders 4th edition (SCID) (Stewart et al. 2009). The cut-off point of 7/8 was identified as an acceptable level for detecting CMD. Participants scoring 8 or above were considered as having probable CMD and those scoring 7 or less were classified as having no probable CMD (Stewart et al. 2009; Udedi et al. 2014). In order to establish a relationship between Internet addiction and mental disorder, this chapter analysed data of 977 college/university students who had complete records of the study variables such as age, gender, and levels of study (undergraduate or postgraduate). This represented a 99% response rate out of the 984 randomly sampled participants. Of the 977, a majority (57.2%) were identified to be from the 20 to 24 age group, with more male (64.7%) than female participants (35.3%), and 95.4% were undergraduates (with a majority in their first year of study, 41.5%).

16.2   Literature Review Internet Addiction: The Controversial Addiction In today’s digital world, there seems to be a thin line between technology use and abuse. According to Perdew (2015), some technology users cross that thin line further from use and abuse to addiction. The phrase ‘Internet addiction disorder’ was first used publicly by Ivan Goldberg in 1995, when he posted a humorous entry about Internet addiction on PsyCom.net (Perdew 2015). Since then, Internet addiction has attracted considerable research interest, with Young (1998) arguing that a new disorder was emerging with the new form of technology. She likened Internet addiction to other impulse-control disorders. However, there is still widespread disagreement on whether Internet addiction is a true medical disorder (Nakaya 2015). Controversies around Internet addiction have divided opinion among professionals and professional bodies. The key, seemingly unending, debate on Internet addiction is one of recognition. Many professionals take the stance by Young (1998) that Internet addiction exists. For instance, Griffiths (2000) defines technological addictions as a subset of behavioural addictions which feature the core components of addiction such as salience, mood modification, tolerance, conflict, and relapse. He therefore agrees with Young’s (1998) conclusions on similarities between Internet addiction and other addictive behaviours. In medical terms, addicts crave a substance or experience and get a rush

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from engaging in it to such an extent that their lives become centred on the addictive behaviour, causing health and emotional problems such as ignoring one’s health, family, and finances (Perdew 2015). Such a link is well established and identifies Internet addiction as a legitimate psychological disorder (Paska and Yan 2011). While the above and others insist that Internet addiction is a mental disorder, universal agreement on such classification is lacking (Nakaya 2015; Paska and Yan 2011; Perdew 2015). There are, therefore, no formal criteria for Internet (online) addiction (Parks 2013). Those who oppose such recognition, such as The American Psychiatrist Association (APA), cite a number of challenges facing Internet addiction. One of the challenges is that of definition (Johnson 2009; Nakaya 2015). The difficulty with defining Internet addiction is the ever-shifting baseline of normal usage from lack of a true baseline when the Internet and online activities were gaining ground in the 1990s to an average of eight hours a week ten years later to the time when normal usage kept changing, making it difficult to scientifically classify Internet addiction as a disorder (Young 1998). According to Nakaya (2015), although Internet use is widespread, definitions of what exactly constitutes Internet addiction differ widely. Paska and Yan (2011) hold a similar view when they report that Internet addiction does not have a precise or exact definition. Scepticism that Internet addiction is a real disorder might be rooted in WHO’s 1957 definition of addiction (Parks 2013) which associates addiction with drugs. Other challenges include treatment and estimation of rates of addiction. Parks (2013), while outlining warning signs of online addiction, asserts that it is challenging to treat, largely because people either are in denial of having a problem or do not want to give up their online activities. The controversies in definitions and treatment, may in turn lead to the third challenge that rates of Internet addiction are difficult to determine and estimates vary widely depending on the country being studied and how addiction is defined (Nakaya 2015). These challenges are compounded by the position taken by The American Psychiatrist Association (APA) regarding Internet addiction. The APA does not formally acknowledge Internet addiction as a mental disorder, and, therefore, it is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) due to lack of sufficient evidence (Parks 2013; Perdew 2015). However, the APA encourages further research on Internet addiction. Meanwhile, the closest that Internet addiction has come

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to be included in the DSM is the inclusion of Internet Use Gaming Disorder in the appendix of DSM-V (Nakaya 2015). Regardless of the debates and controversies on Internet addiction, use of the Internet and social media continues to rise and fears of addiction are not unfounded. Certainly, the Internet and social media are a necessary evil in human activity. Internet and Related Services Use: A Necessary Evil The Internet and related services, such as social media, have become an essential part of our social fabric and work life to such an extent that it is difficult to imagine transactions and interactions in modern day societies and organizations without digital platforms. The benefits of the Internet and related services are numerous. For instance, the Internet offers direct benefits to society by allowing users a range of practical applications such as the ability to conduct research, perform business transactions, or access international libraries (Young 1998). Others, such as Reinecke (2009), have pointed out the positive effect of the Internet in facilitating online communication and entertainment, allowing people to escape from negative thoughts about themselves. The multiple benefits of the Internet and related services notwithstanding, problems abound, particularly those associated with misuse or addictive use of the Internet and related services. Familial, academic, and occupational problems have been reported as negative consequences of addictive use of the Internet (Ingram 2016; Li et al. 2015; Young 1998, 1999). Association with depression has also been reported. For example, Young and Rogers (1998) report that moderate to severe rates of depression co-exist with pathological use of the Internet. In the Young and Rogers’ (1998) study, the researchers found that addicts used the Internet an average of 38 hours per week for non-­ academic or non-employment purposes, causing poor grade performance among students, discord among couples, and reduced work performance among employees. There are, therefore, negative familial, employment, and academic negative consequences of pathological Internet usage. In the interpersonal relationship domain, Young (1999) holds that marriages, dating relationships, parent-child relationships, and close relationships have suffered disruption, caused by Internet addiction, as addicts spend less time with people in their lives in exchange for solitary life with computers. According to Young (1999), Internet addicts exhibit similar characteristics as those addicted to intoxicants, thereby breeding distrust

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and hurting the quality of once stable relationships overtime. In extreme cases, parents have abandoned or neglected their real-life children (Perdew 2015). In work settings, Internet misuse among employees is a serious concern for managers, forcing organizations to invest in monitoring devices that allow managers to track Internet usage (Young 1999). Clearly, although the benefits of Internet to organizations are immense, there are genuine concerns that employees are spending more time at work on the Internet for non-job-related tasks. For students, the Internet has been promoted as a very important educational tool. As a result, schools across the world are moving (for those not already there) towards integrating Internet services into the classroom environment (Young 1999). Undoubtedly, the Internet is an ideal research and educational tool. However, there are concerns for student populations regarding utilization as observed by Young (1999), who reports declining study habits, drop in grades, or sheer excessive Internet use. Furthermore, students surf irrelevant websites and engage in other nonproductive- or non-school-related activities on the Internet such as chat room gossip and interactive games. Another study by Li et  al. (2015) reports sleep deprivation, academic under-achievement, failure to exercise and to engage in face-to-face social activities, negative affective states, and decreased ability to concentrate as consequences of intensive Internet use. Realizing the pathological use of the Internet and social media, some scholars argue that students require help on how to exercise self-control and achieve a level of balance when using the Internet and social media (Zaremohzzabieh et al. 2014). For example, some college campuses have initiated Internet addiction support groups (Murphy 1996) akin to substance abuse support groups. Since the main thrust of this chapter is Internet and related services addiction within the context of university/college students, it is important to recognize that university/college students are particularly vulnerable. These students, with most of them still in their teen years, fall within what Griffiths (2000) calls the typical addict: a teenager, usually male, with little or no social life or no self-confidence. In their virtual world of gamers, for instance, the shy, awkward gamers become masters of their own fate, exploring new worlds, staving off monsters, and recovering treasures (Perdew 2015). Such vulnerability could in part be a result of newly found freedom from both time constraints and responsibility observed in college student populations (Ingram 2016); [relative] ease of access to the

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Internet, huge blocks of unstructured time, freedom from parental control, encouragement from faculty, desire to escape college stressors, social intimidation, and alienation (Young 2004). Demographically, larger proportions of younger populations are likely to use the Internet than their older counterparts (Perdew 2015).

16.3   Methodology Data were collected using a combination of online- and paper-based questionnaires, to enhance the response rate. A total of 984 undergraduate and postgraduate students from universities and colleges in Malawi participated in this study. This sample was drawn out based on multistage sampling technique where stratified samples of university/colleges were identified followed by simple random sampling (SRS) of individuals from each stratum. Two strata were identified from the sampling frame of all schools of higher learning in Malawi, namely public and private universities/colleges. From these two strata, an SRS of n = 984 study participants was drawn using the Cochran’s formula;



n=

Z 2σ 2 D2

where sample size n was computed from an assumed normal population with Z = 1.96 at 95% level of confidence with precision level of D = 3 and population standard deviation σ = 48 (computed from a previous related study). Out of 984 interviewed students, 977 had complete records of socio-­ demographic characteristics, with a majority (57.1%) coming from the age group between 20 and 24, seconded by those in between 15 and 19 in proportion (19.9%), see Table 16.1. Socio-demographic characteristics by gender show that of those in the highest reported age group (20–24), there were more males (67.4%, 376/558) than females (32.6%, 182/558) unlike in the 15–19 age group where 112 (57.7%) were females and 82 (42.3%) were males. In addition, most of the females reported to have been studying Science programmes (65.1%) compared to Humanities and Social Sciences (34.3%) though the proportions were different with males (81.9%-Science category, and 18.1%-Humanities and Social Science category).

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Table 16.1  Socio-demographic characteristics of study participants by gender Gender in categories

Total

Female N (%)

Male N (%)

15–19 20–24 25–29 30–34 35–39 40+ Non-responsive

112 (32.5) 182 (52.8) 32 (9.3) 12 (3.5) 6 (1.7) 0 (0.0) 1 (0.3) 345

82 (13.0) 376 (59.5) 114 (18.0) 37 (5.9) 15 (2.4) 8 (1.3) 0 (0.0) 632

194 (19.9) 558 (57.1) 146 (14.9) 49 (5.0) 21 (2.1) 8 (0.8) 1 (0.1) 977

Undergraduate Postgraduate

325 (98.4) 18 (5.2) 343

607 (95.7) 27 (4.3) 634

932 (95.4) 45 (4.6) 977

Year 1 Year 2 Year 3 Year 4+ Non-responsive

145 (41.9) 66 (19.1) 62 (17.9) 54 (15.6) 19 (5.5) 346

243 (38.5) 154 (24.4) 139 (22.0) 73 (11.5) 22 (3.5) 631

388 (41.5) 220 (23.5) 201 (21.5) 127 (13.6) 41 (4.2) 977

Discipline of study Science Humanities and social science Non-responsive Total

222 (65.1) 117 (34.3)

521 (81.9) 115 (18.1)

743 (76.2) 232 (23.8)

2 (0.6) 341

0 (0.0) 636

2 (0.2) 977

Age group

Total Level of study Total Year of study

Total

Data Collection Data was collected through self-administered questionnaires with a set of questions that aimed at exploring the possible link between Internet addiction and common mental disorder (CMD) among student populations. As such, these questionnaires were randomly administered to college/university students from both public and private institutions operating in Malawi. Information collected included demographic characteristics; Internet and social media usage, using the Internet Addiction Test (IAT) (Reinecke 2009); and factors for assessing probable cases of common mental disorders, using the Self-Reporting Questionnaire (SRQ-20) (Beusenberg and Orley 1994).

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The Self-Reporting Questionnaire This study utilized the Self-Reporting Questionnaire (SRQ-20) tool developed by World Health Organization (WHO) (Harding et  al. 1980; Mkandawire and Senganimalunje 2011) to identify probable cases of common mental disorders (CMD). The questionnaire has 20 items and employs a yes/no answer format to detect probable cases of anxiety and depression. CMD refers to the co-occurrence of depressive, anxious, and somatic symptoms (Young and Rogers 1998). CMD meets the nosological criteria of the DSM and International Classification of Diseases, Tenth Revision (ICD 10) for most prevalent disorders such as depressive and anxiety disorders (Perdew 2015). The SRQ-20 has also been validated and applied in Malawi, to identify probable cases of maternal depressive disorders and common mental disorders among primary health care attendees (Stewart et al. 2009; Udedi et al. 2014). Both the cited studies from Malawi, consider the cut-off point of 7/8 to be appropriate for the Malawian context. The cut-off point of 7/8 means that participants scoring 8 or above were considered most likely to have common mental disorders and those scoring 7 or less as unlikely to have mental disorders (Stewart et al. 2009; Udedi et al. 2014). It has been argued that the stated cut-off point allows for balance between sensitivity, specificity, and positive prediction of CMD (Stewart et al. 2009). The cutoff point 7/8 for detecting proportions of individuals with probable mental disorders has also been widely used by a number of research studies in other developing countries (Harding et al. 1980; van der Westhuizen et al. 2016). This chapter, therefore, applies the same cut-off point of ≥8 for a positive screening of CMD as validated in previous studies. The Internet Addiction Test The Internet Addiction Test (IAT) is one of the most widely utilized diagnostic instruments for Internet addiction (Faraci et  al. 2013). It was designed to assess aspects of an individual’s life that might be affected by their excessive Internet use. The IAT is a 20-item questionnaire on which respondents rate items on a six-point Likert scale (from 0—Does not apply, to 5—Always). The Likert scale is used to assess the degree to which Internet use affects the respondent’s daily routine: social life, productivity, sleeping pattern, and feelings (Widyanto and McMurran 2004). Total assessment scores are between 20 and 100, with 20 being the minimum score and 100 being the maximum score. Table 16.2 provides interpretations for ranges of total IAT scores.

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Table 16.2  Description of IAT total score ranges IAT total score range

Interpretation

Less than 20 20–39 40–69 70–100

Non frequent Internet users Average online user and able to control his/her Internet usage Excessive Internet usage Significant problem experience due to Internet usage

Data Analysis IAT total score values were used from 20 items rated in a six-point Likert scale (from 0—Does not apply, to 5—Always). Later the aggregated item IAT scores were considered in ranges as described in Table 16.2 above. Secondly, this study has utilized a Self-Reporting Questionnaire (SRQ-­ 20) tool developed by World Health Organization (WHO) to identify probable cases of common mental disorders. Based on such scale and interpretations, non-parametric tests of correlations (spearman’s rho) and tests of associations (Chi-square test) between variable ‘IAT total score range’ and other variables such as ‘gender’, ‘age group’, ‘level of study’, ‘year of study’, and ‘discipline of study’ were conducted. Where necessary, a t-test method was used to quantify the level of differences in mean reported IAT scores between two groups of a variable. All analyses and interpretation were measured at 5% level of significance using IBM SPSS Statistics version 20. Ethical Considerations Prior to responding to the Self-Reporting Questionnaires which were utilized in this study, respondents were provided with information detailing what the study was about. It was made clear that their participation was voluntary and that consenting to take part was by returning the completed questionnaires to the researchers. Contacts of the lead author were provided to whom queries were to be directed. Anonymity and confidentiality were maintained throughout the study by encrypting participants’ identifying information.

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16.4   Results and Discussion Out of 977 completed questionnaires, the majority (57.1%) came from the 20–24 age group, seconded by those between 15 and 19 (19.9%). There were more male (64.7%) than female participants (35.3%), and 95.4% undergraduates (with a majority in their first year of study, 41.5%). Assessment of Levels of Internet and Social Media Usage According to Fig.  16.1, this study established that the total IAT scores were slightly normal in terms of their distribution with mean reported total IAT score of 39.06 (18.08 SD, 90 Range). Out of the 977 total respondents (34.9% females and 65.1% males) with a majority falling in the age range of 20–24 (57.1%), this study established that 40.44% tend to experience frequent problems because of excessive use of Internet, while just 5.03% experience more significant problems (Fig.  16.2). Average online users, those able to control their usage of the Internet and related services properly, were 39.94%.

Mean = 39.06 Std. dev. = 18.083 N = 994

60

50

Frequency

40

30

20

10

0

-20

0

20

40

60

Total IAT scores

Fig. 16.1  Distribution of IAT total scores

80

100

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5.03% 14.59%

IAT score ranges less than 20 20 to 39

40.44%

40 to 69 70 to 100

39.94%

Fig. 16.2  Proportions of reported IAT score ranges for study participants Table 16.3  Proportions of IAT score ranges by age group IAT score ranges

Less than 20 20–39 40–69 70–100 Total

Gender

Total

Female N (%)

Male N (%)

42 (30) 136 (34.5) 138 (34.5) 29 (58) 345 (35.1)

98 (70) 258 (65.5) 262 (65.5) 21 (42) 639 (64.9)

140 394 400 50 984

Furthermore, results reveal that gender is significantly associated with experiences of problems due to excessive usage of Internet ( X32 = 13.24 p-value = 0.004). As Table 16.3 shows, more females (58%, 29/50) were identified to have significant problems because of usage of Internet, most frequently, than males (42%, 21/50). Nevertheless, males (65.5%, 262/400) were still noted to experience frequent problems because of excessive Internet use than females (34.5%, 138/400). By comparing with other variables, this study found that excessive use of Internet is not significantly associated with age group, year of study, and

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discipline of study in college/university. However, level of study (undergraduate or postgraduate) appears to be highly significantly associated with experiences of problems due to usage of Internet (see Table 16.4). Supporting the same findings are the distributions of IAT total scores appearing on a box-and-whisker plot (Fig.  16.3) where the median Table 16.4  Measure of association between IAT scores and socio-demographic variables Chi-square test of association

Gender Age group Level of study Year of study Study discipline

Chi-square value

P-value

13.24, df = 3 22.64, df = 15 28.05, df = 6 15.81, df = 9 7.44, df = 3

0.004 0.092 0.000a 0.071 0.059

Association is significant at the 0.01 level (2-tailed)

a

Total Internet usage scores

100

80 19 60

40

20

0 Undergraduate

Postgraduate

Level of study Fig. 16.3  Description of IAT scores by level of study

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IAT score ranges

60.0%

less than 20 20 to 39 50.0%

40 to 69 70 to 100

Percent

40.0%

30.0% 55.1%

20.0%

10.0%

18.37%

14.29%

10.2% 2.041%

.0% 15–19

20–24

25–29

30–34

35–39

40+

Age group

Fig. 16.4  Proportions of IAT scores by age group

reported total IAT score is higher for undergraduates (38) than postgraduates (31). Although age group appears not to be significantly associated with experiences of problems due to excessive use of Internet, a majority of those in the IAT score range of 70–100 appear within age range of 20–24 (55.1%) than other age ranges (18.37%, 15–19; 14.29%, 25–29%; 10.2%, 30–34, and 2.04%, 35–39). Thus, students in such age range tend to experience significant problems because of use of Internet (see Fig. 16.4). These results suggest that while at age ranges 15–19 addiction to Internet may be lower, most likely due to non-exposure to the technology at first entry into college/university, the level of experiences of problems due to usage of Internet and related services decreases with age. However, going by Fig. 16.5, significant problems are more reported from students of year 1 (44.9%) in college/university than other years at undergraduate studies.

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IAT score ranges

22.45%

less than 20 Year 4+

20 to 39 40 to 69 70 to 100 10.2%

Year of study

Year 3

22.45% Year 2

44.9% Year 1

.0%

10.0%

20.0%

30.0%

40.0%

50.0%

Percent

Fig. 16.5  Distribution of IAT score ranges by year of study in college

Detection of General Psychological Distress among Study Participants Findings from the SRQ-20 tool reveal that about 25% of the students who completed it (see Fig.  16.6) demonstrate to have a probable CMD (with SRQ-20 ‘symptom present’ total score beyond cut-off value of 8). This reported percentage of probable CMD is above that which was reported for 28 surveyed districts in Malawi by Stewart et al. (2009). The cut-off point 7/8 for detecting proportions of individuals with probable common mental disorder, used in this chapter, has also been widely used by a number of research studies in Malawi and other developing countries (Faraci et al. 2013; Mkandawire and Senganimalunje 2011; Widyanto and McMurran 2004). Comparably, at the same cut-off value of 8, males were reported to be highly affected by existence of a probable CMD (55.7%) than females (44.3%) (Table 16.5).

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Categorized SQR_total_score Non-existence of a probable mental disorder 24.75%

Existence of a probable mental disorder

75.25%

Fig. 16.6  Description of probable common mental disorder students Table 16.5  Proportions of probable CMD symptom existence by gender Gender

Non-existence of a probable CMD symptom Existence of a probable CMD symptom Total

Total

Female N (%)

Male N (%)

236 (32) 109 (44.3) 345 (35.1)

502 (68) 137 (55.7) 639 (64.9)

738 246 984

In addition, t-test results indicated that there were significant differences in mean reported SRQ-20 total scores between female and male students ( t982 = 3.836 p-value < 0.01). These results suggest that more males are affected by mental disorder situations than female counterparts. This finding is consistent with Udedi et al.’s (2014) findings of a study conducted at a primary health care centre in Malawi. However, these results may not be a generalization of the entire student population in Malawian institutions of higher learning.

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Correlation Between IAT Attributes and SRQ-20 Scores Furthermore, we tested for existence of any correlation between IAT scores and those of SRQ-20 CMD scores. We found a strong positive correlation between the two (r = 0.390, p-value < 0.01) although the trend was not entirely oriented (Fig. 16.7 of the scatter plot). Nevertheless, an interpolation line over the scatter plot shows that an increase in IAT scores increases with an increase in SRQ-20 scores. The results are in agreement with what Young and Rogers (1998) found. These findings seem to agree with the large proportion of students who have probable CMD (63.41%) within the group of students (IAT score range 40–69) who were identified to be experiencing frequent problems due to excessive usage of Internet and social media (Fig. 16.8).

SQR-20 summarized total item scores

20

15

10

5

0 0

20

40

60

Total Internet usage scores

Fig. 16.7  Scatter plot of IAT and SRQ total performances

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Categorized SQR_total_score

100.0%

Non-existence of a probable mental disorder 80.0%

Existence of a probable mental disorder

32.89%

Percent

60.0%

46.39%

40.0%

63.41%

20.0% 17.78%

2.941%

20.33%

11.38% .0%

4.878% less than 20

20 to 39

40 to 69

70 to 100

IAT score ranges

Fig. 16.8  Distribution of existence or non-existence of common mental disorder within each IAT category

16.5   Conclusion While Internet and related services, such as social media, have become an essential part of our social fabric and work life, excessive Internet and social media use have been documented to cause neurological complications, psychological disturbances, and social problems among students (Li et al. 2015). As such this chapter has attempted to explore existence of Internet addiction among college/university students in Malawi, where gender (X32 = 13.24, p < 0.01) and level of study (X62 = 28.05, p < 0.01) have been identified as attributes that are significantly associated with addictions to Internet. There were more females (58%, 29/50) than males (42%, 21/50) among the students who were identified to have significant problems because of frequent usage of Internet. Furthermore, addiction to Internet was associated with mental disorder symptoms among these students with more males (55.7%) than females (44.3%) being identified as affected by existence of a probable CMD. Lastly,

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this chapter has established that there is strong positive correlation between the Internet addiction and probable establishments of CMD (r = 0.390, p-value < 0.01) among university students in Malawi. While acknowledging that correlation does not necessarily mean causation and that there is a controversy as to whether Internet addiction is a valid diagnostic mental disorder, it is important to recognize that excessive usage of Internet may increase the vulnerability to CMD or vice versa  in college students in Malawi. This may affect study performance of college students resulting into increase in withdraw rates either on medical grounds or on academic performance. To establish causality, the relationship between Internet addiction and CMD needs to be evaluated further in prospective and longitudinal studies. Another possible extension to this study would be examination of the impact of using specific social media platforms on communication patterns and mental health.

References Beusenberg, M., and J.H.  Orley. 1994. A User’s Guide to the Self-Reporting Questionnaire (SRQ). Geneva: World Health Organization. Faraci, P., G. Craparo, R. Messina, and S. Severino. 2013. Internet Addiction Test (IAT): Which Is the Best Factorial Solution? Journal of Medical Internet Research 15 (10): e225. Griffiths, M. 2000. Does Internet and Computer “Addiction” Exist? Some Case Study Evidence. Cyberpsychology & Behavior 3 (2): 211–218. Harding, T.W., M.V.  De Arango, J.  Baltazar, C.E.  Climent, H.H.A.  Ibrahim, L. Ladrido-Ignacio, and N. Wig. 1980. Mental Disorders in Primary Health Care: A Study of Their Frequency and Diagnosis in Four Developing Countries. Psychological Medicine 10 (2): 231–241. Ingram, J.M. 2016. Online Usage Among College Students: A Comparison of Online Gaming and Facebook Users. Ellensburg: Central Washington University. Johnson, N.F. 2009. The Multiplicities of Internet Addiction: The Misrecognition of Leisure and Learning. Surrey: Ashgate. Li, W., J.E.  O’Brien, S.M.  Snyder, and M.O.  Howard. 2015. Characteristics of Internet Addiction/Pathological Internet Use in U.S. University Students: A Qualitative-Method Investigation. PLoS One 10 (2): e0117372. https://doi. org/10.1371/journal.pone.0117372. Mkandawire, M., and L. Senganimalunje. 2011. Pathological Internet Use Among College Students in Malawi. Malawi Medical Journal 23 (3): 99. Murphy, B. 1996. Computer Addictions Entangle Students. The APA Monitor 27 (6): 26.

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Nakaya, A.C. 2015. Internet and Social Media Addiction. San Diego: ReferencePoint. Parks, P.J. 2013. Online Addictions. San Diego: ReferencePoint. Paska, L.M., and Z. Yan. 2011. Internet Addiction in Adolescence and Emerging Adulthood: A Comparison Between the United States and China. In Internet Addiction, ed. H.O. Price. New York: Nova Science Publishers. Perdew, L. 2015. Internet Addiction. Minneapolis: Abdo. Reinecke, L. 2009. Games and Recovery: The Use of Video and Computer Games to Recuperate from Stress and Strain. Journal of Media Psychology 21 (3): 126–142. Stewart, R.C., F.  Kauye, E.  Umar, M.  Vokhiwa, J.  Bunn, M.  Fitzgerald, et  al. 2009. Validation of a Chichewa Version of the Self-Reporting Questionnaire (SRQ) as a Brief Screening Measure of Maternal Depressive Disorder in Malawi, Africa. Journal of Affective Disorders 112 (1–3): 126–134. Udedi, M., L. Swartz, R.C. Stewart, and F. Kauye. 2014. Health Service Utilization by Patients with Common Mental Disorder Identified by the Self-Reporting Questionnaire in a Primary Care Setting in Zomba, Malawi: A Descriptive Study. International Journal of Social Psychiatry 60 (5): 454–461. van der Westhuizen, C., G.  Wyatt, J.K.  Williams, D.J.  Stein, and K.  Sorsdahl. 2016. Validation of the Self-Reporting Questionnaire 20-Item (SRQ-20) for Use in Low-and Middle-Income Country Emergency Centre Setting. International Journal of Mental Health and Addiction 14 (1): 37–48. Widyanto, L., and M.  McMurran. 2004. The Psychometric Properties of the Internet Addiction Test. Cyberpsychology & Behavior 7 (4): 443–450. Young, K.S. 1998. Internet Addiction: The Emergence of a New Clinical Disorder. Cyberpsychology & Behavior 1 (3): 237–244. Young, K.S. 1999. Internet Addiction: Symptoms, Evaluation and Treatment. In Innovations in Clinical Practice, ed. L. VandeCreek and T.L. Jackson, vol. 17. Sarasota: Professional Resource Press. Young, K.S. 2004. Internet Addiction: A New Clinical Phenomenon and Its Consequences. American Behavioral Scientist 48 (4): 402–415. Young, K., and C.N. de Abreu. 2011. Internet Addiction: A Handbook and Guide to Evaluation and Treatment, ed. K. Young and C.N. de Abreu. Hoboken: Wiley. Young, K.S., and R.C. Rogers. 1998. The Relationship Between Depression and Internet Addiction. Cyberpsychology & Behavior 1 (1): 19–31. Zaremohzzabieh, Z., B.A. Samah, S.Z. Omar, J. Bolong, and N.A. Kamarudin. 2014. Addictive Facebook Use Among University Students. Asian Social Science 10 (6): 107–116.

CHAPTER 17

Curbing Tobacco Addiction in Kenya: Ethical and Legal Challenges Arising Smith Ouma and Jane Wathuta

17.1   Introduction Notable attempts have been made in recent years to control the consumption of addictive substances such as tobacco. Indeed, the first treaty negotiated under the auspices of the World Health Organization (WHO) was the evidence-based WHO Framework Convention on Tobacco Control (WHO FCTC) in 2005 (WHO 2003). The provisions of the FCTC are gradually being implemented at national level, with countries like Kenya enacting legislation like the Tobacco Control Act, No. 4 of 2007 and policies to realize the global aspiration of reining in the tobacco epidemic. The said efforts have come in the wake of growing realization that non-­ communicable diseases are increasingly contributing to majority of the deaths in Kenya, like in many other countries. These attempts are, ­however, S. Ouma School of Law and Politics, University of Cardiff, Cardiff, UK e-mail: [email protected] J. Wathuta (*) School of Law, University of the Witwatersrand, Johannesburg, South Africa Institute for Family Studies & Ethics, Strathmore University, Nairobi, Kenya e-mail: [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_17

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hampered by the unethical conduct of the tobacco industry (TI), both in high-income and in low- and middle-income countries like Kenya. This chapter starts by identifying the stakeholders in tobacco production and control, the market value, and sales and marketing strategies used by the manufacturers of tobacco products. It then highlights prevalence of tobacco use and addiction in Kenya, the implications of tobacco addiction for public health, legal and policy interventions of tobacco addiction in Kenya and their rationale, and unethical conduct hindering regulatory efforts. It concludes by reiterating the need for the tobacco industry to uphold and foster high ethical standards to render the said interventions effective, thus reducing addiction, morbidity and mortality rates.

17.2   Stakeholders in Tobacco Production and Control in Kenya Stakeholders in tobacco production include tobacco farmers and the companies involved in the manufacture and distribution of the tobacco products. In Kenya, these companies include British American Tobacco Kenya (BATK) Limited, Mastermind Tobacco Kenya (MTK) and Alliance One Tobacco Kenya. It is estimated that BATK controls 70% of the market, MTK 29% and the remaining 1% is shared between other manufacturers (IILA 2013: 15). The stakeholders involved in tobacco control form a much larger pool and include enforcement agencies, civil society, university and research institutions, the Tobacco Control Board and members of the public. The operations and nature of interference by some of the named stakeholders are discussed in the sections below. As we note in the subsequent sections, interference from some of the stakeholders noted above arises from the vested interests that they have in the regulation of the tobacco industry. Market Value of Tobacco Products and Aspects of the Prevailing Debate According to the Kenya National Bureau of Statistics (KNBS), Kenya produced 12.2 billion sticks of cigars and cigarettes in 2007, and by 2010, this was still well over 12 billion (KNBS 2011a, b). In 2016, the value of 19,126 tonnes of unmanufactured tobacco was estimated at Kshs 5.23 million (KNBS 2017). In the same year, the industry accumulated Kshs 803.5 million worth of earnings, which shows an upward trend from Kshs 758.2 million from the previous year. The gross marketed production of tobacco in 2016 was Kshs 1403.8 million (KNBS 2017).

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An earlier study cited in a report jointly published by the Ministry of Health and the International Institute for Legislative Affairs indicated that the most prevalent mode of tobacco use in Nairobi is smoking (91.7%), followed by sniffing (3%) (IILA 2013: 21). This partly explains why companies like BATK continue to report turnover growths and increased market shares (BATK 2017). In 2016 they reported a 2% increase in gross revenue, which translated to Kshs 36.7 billion (BATK 2017: 15). The smoking epidemic, while obviously lucrative for the tobacco industry, has also led to the widespread availability of counterfeit cigarettes. About 700 million fake cigarettes were sold locally in 2017 (Kariuki 2018). Several cigarette manufacturing companies have urged the government to eradicate black market and counterfeit trading, which causes losses of up to 5% of revenue, as reported by British American Tobacco Kenya (The African Business Fortune 2016). Water pipe tobacco (shisha) smoking has also become rampant in Kenya, and seemingly continues unabated (Ahmed 2018) despite a government ban and some prosecutions being initiated (Otieno 2017). Tobacco industry, particularly manufacturers, often argue that tobacco control will harm the nation’s economy, that tobacco farming, manufacturing, distribution and sale constitute a vital part of the economy and that if smoking is eliminated then the country will suffer substantial job losses, drop in income tax and a substantial reduction of tax revenue (Ross and Chalpouka 2002: 6). This argument is fundamentally flawed because even if tobacco production is entirely eliminated, the resources spent on it will not disappear from the economy altogether but rather will be redirected to other goods and services, thereby creating jobs in other sectors of the economy. Stakeholders in the Kenyan industry further claim that tobacco as a cash crop improves the lives of over 36,000 farmers. However, the tobacco growing districts are some of the poorest in the country, with high cases of food insecurity, illiteracy and poverty, not to mention diminishing returns for the farmers (IILA 2013: 21). This is further corroborated by the fact that in 2016 the amount of compensation given to employees in the tobacco manufacturing sector was Kshs 4419 million, while the value added was Kshs 7303 million (KNBS 2017).

17.3   Marketing and Sale Approaches in Favour of Tobacco Companies A study by Global Adult Tobacco Survey (GATS), the global standard for systematically monitoring and tracking key tobacco control indicators, found that the most common source of manufactured cigarettes were

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shops (65.2%), followed by kiosks (30.7%), bars or nightclubs (1.8%), and street vendors (1.4%) (KNBS 2014: 5). The Tobacco Control Act (2007) prohibits tobacco advertising, promotion and sponsorships, unless done in accordance with the Act. These measures have drastically reduced the marketing opportunities for tobacco manufacturing companies, as they face major challenges in connecting with customers. The Tobacco Control Act (2007) also prohibits the sale of less than ten sticks of cigarettes in a pack. This has, however, not stopped retailers from selling single sticks to customers, indicating the lack of enforcement of the regulations against retailers of tobacco products (Boseley 2017). MTK has found various ways around the Act in order to stay in business, considering that it can no longer rely on traditional marketing strategies in order to remain competitive. The company primarily relies on employing innovative and sometimes manipulative marketing techniques, such as expanding regionally to the Common Market for Eastern and Southern Africa (COMESA) region to supplement local revenue, taking advantage of the fact that promotion activities are not restricted. Tobacco product promotion in the entertainment media is extensive and is a major drawback for tobacco control efforts; numerous studies have proven that there exists a causal connection between the depiction of smoking in the entertainment media and the initiation of youth smoking (ITC 2015: 9). Despite the existing control measures, these companies have paradoxically been readily granted other platforms for publicity and for the promotion of their brands. BATK was even crowned employer of the year in 2017 at an event presided over by the United Nations Resident Coordinator in Kenya (Ogutu 2017). In fact, the UN Resident Coordinator praised BATK and like-minded employers for taking initiatives that create employment in a manner that is unmatched by any government anywhere in the world (Ogutu 2017). Such platforms ultimately frustrate initiatives driven at suppressing tobacco advertising, promotion and sponsorship. The use of favourable stories in the media is moreover considered inimical to tobacco control objectives (IILA 2010). These favourable stories inadvertently provide platforms for the companies to be known by potential ­consumers of their products and can provide justification to the sale of tobacco products. Other covert mechanisms that have been adopted by the tobacco companies include sponsoring trade fairs and launching products such as insurance schemes that are targeted at farmers (IILA 2010: 13).

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17.4   Prevalence of Tobacco Use and Addiction in Kenya Cigarette smoking, as aforementioned, is the most prevalent form of tobacco use in Kenya (ITC 2012: 19); 8.3% of adult smokers use it daily, compared to 3.6% of the demographic that uses smokeless tobacco (WHO 2017). In 2001, 13% of youth used a tobacco product, which increased to 18.6% in 2007 and then decreased to 9.9% in 2013 (ITC 2012: 20). The pattern of tobacco use was similar among both boys and girls, although tobacco use in any form remains more prevalent among boys at 12.8% in 2013, compared to only 6.7% of girls (ITC 2012: 20). Seventy-two per cent of daily tobacco consumers use tobacco (smoking and/or smokeless tobacco) within 30 minutes of waking up (KNBS 2014). The 2014 survey in Kenya conducted by GATS (KNBS 2014: 2) established that 2.5 million adults were at the time using tobacco, with 1.7 million of them currently smoking tobacco (KNBS 2014: 3). The Global Youth Tobacco Survey of 2014 revealed that 10% of the Kenyan youth aged 13–15 years are regular consumers of tobacco. A survey conducted by the World Health Organization showed that in 2016, 9.9% of the adults were using tobacco (WHO 2017). The high prevalence of tobacco use among the youth has in the past been attributed to the mass media campaigns that were common at the time and the fact that a majority of these users are too young to fully understand the implications of their decisions (IILA 2010: 5). High rate of usage of tobacco products is a manifestation of high levels of addiction to the product. Nicotine dependence has been assessed inter alia through an examination of the frequency of smoking (KNBS 2014: 30). Statistics indicate that approximately 76% of adult smokers were daily smokers with only 24% being occasional smokers (KNBS 2014: 30). Amongst this group, 43.2% use tobacco in less than 5 minutes upon waking up while 28.7% use tobacco within 6–30 minutes upon waking up (KNBS 2014: 37). The high frequency rates of smoking among this group are indicative of the fact that a majority of tobacco users are addicted to the use of tobacco. Moreover, statistics paint a gleam picture on the success rates among smokers to quit the use of tobacco. In 2013, more than half (52.4%) of smokers in Kenya attempted to quit with very low success rates (6.9%) (KNBS 2014: 39). Even though legislative safeguards have been put in place to prevent the advertising and sale of tobacco products, the youth still have easy

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access to tobacco products, leading to increased addiction rates in this age group. The limited success in reducing the use of tobacco products shows the detrimental effect of covert tactics employed by the tobacco product manufacturers to promote the use of their products.

17.5   Public Health Implications of Tobacco Addiction There is increased global awareness of the public health implications of tobacco dependence. This comes in the wake of continued campaigns driven at reducing the prevalence of non-communicable diseases (NCDs), which account for large proportions of deaths globally (Gostin and Wiley 2016: 435). In Kenya, the burdens occasioned by NCDs have contributed to significant healthcare expenditures incurred by households, resulting in slow economic growth and loss of requisite skill power (Mwai 2014: 74). Notably, the burden of these NCDs is disproportionately borne by people living in low-income communities, people of colour and people with disabilities (Gostin and Wiley 2016: 437). The Kenya Household Health Expenditure and Utilization Survey (2013) painted a bleak picture regarding the reasons individuals sought hospitalization. According to the survey, approximately 12.2% of the hospitalizations witnessed between 2003 and 2013 were occasioned by some form of respiratory disease (MoH 2014: 31). This was the second highest contributor to hospitalization after malaria. Tobacco is the leading preventable cause of death and disease, killing about six million people annually: about 600,000 of those deaths are caused by second-hand smoke (ITC 2015: 5). The Ministry of Health in its website cites tobacco use as the top most preventable cause of death in the country, with an average of 80% of premature deaths being related to the use or exposure to tobacco. Tobacco companies have in the past also conducted research that has linked the smoking of tobacco products to deleterious health outcomes. For instance, it has been established through studies conducted by the tobacco companies themselves that there are certain cancer-causing effects of tobacco (Hirschhorn and WHO Tobacco Free Initiative 2005a). The US case of Cipollone v Ligget Group, Inc. et al, 112 S. Ct. 2608, revealed that cigarette companies knowingly misrepresented the health implications of cigarette smoking to consumers, despite having scientific knowledge of the harmful effects of these products.

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Additionally, tobacco products are known to contain highly addictive substances like nicotine (Hirschhorn and WHO Tobacco Free Initiative 2005a: 12). Despite being privy to this information, tobacco manufacturers have still engaged in practices contributing to increased addiction to these products (Hirschhorn and WHO Tobacco Free Initiative 2005a: 12). This shows how tobacco design and marketing play a role in fostering addiction (Carpenter et al. 2007: 102). Cigarettes, in particular, are manufactured in a manner that enables easy and rapid absorption of nicotine into the pulmonary venous circulation, causing release of neurotransmitters in the brain that signal a pleasurable experience (Benowitz 2010: 2295–2303). The combination of these chemical processes fosters addiction, which is further exacerbated by the fact that cigarette manufacturers have devised mechanisms to speed up the addiction process. For instance, Philip Morris Inc. (a leading manufacturer of cigarettes) developed mechanisms to speed up the delivery and absorption of nicotine in the lungs, contributing to increased addiction (Hirschhorn and WHO Tobacco Free Initiative 2005a: 12). The fact that cigarette smoke has been found to contain more than 7000 chemicals (HHS 2010) means that inhaling cigarette smoke exposes the smoker to toxins that have a range of short- and long-term health effects (Bonnie et  al. 2015). The short-term effects are manifest in the range of health problems that active and passive smokers may experience, while the long-term effects relate to ailments such as coronary heart disease, cancer and, chronic obstructive pulmonary disease that develop over a long span of time (HHS 2014). Women smokers face an added challenge, especially during pregnancy. Research has established that the infants of mothers who smoke during pregnancy have reduced birth weight and are more likely to be small for their gestational age (Hirschhorn and WHO Tobacco Free Initiative 2005b). The mothers are also at increased risks of experiencing stillbirth. Smokers also impose direct burdens on those who do not smoke through second-hand smoking (or environmental tobacco smoke, ETS) which has been linked to numerous health problems (Ross and Chalpouka 2002: 6). These range from sudden infant death syndrome among children to lung cancer and coronary heart disease among adults (CDC 2018). Studies indicate that persons exposed to second-hand smoke are more vulnerable to nicotine addiction (Okoli  et  al. 2007; NIDA 2011). The implications of second-hand smoke are particularly pervasive among children who are, as a consequence, more likely to initiate use of tobacco products (Thornhill 2008). In the US, tobacco companies were compelled through a court order to own up to having misled the public on the effects

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of second-hand smoke and to sponsor television commercials warning of the effects of smoking and second-hand smoke (Mears 2012). Considering the tobacco epidemic, complacency insulates the industry and contributes to the continued rise of the tobacco-related death toll every year. This is notwithstanding the numerous legal and policy interventions to rein in the tobacco epidemic that have been adopted both at the national and at the international levels. The following section discusses some of these interventions.

17.6   Legal and Policy Interventions on Tobacco Addiction in Kenya Tobacco control is a task undertaken by the government “to protect the health of individuals, purchasers and consumers of tobacco and the public, as well as to provide relevant information” as established in British American Tobacco Ltd v Cabinet Secretary for the Ministry of Health and 5 Others (2017). Given the public health consequences of smoking, some governments began to intervene in the tobacco market with the intention of reducing tobacco use. However, some other governments have refrained from taking decisive action either due to concerns that these interventions may harm the economy, or because of strong political links with the tobacco industry (Ross and Chalpouka 2002: 3). The latter scenario has been particularly evident in Kenya where tobacco companies have directly or indirectly sought to influence lawmakers, as will be illustrated later on in this chapter. Rationale for Intervention The primary reason for government intervention in tobacco control is that consumers have insufficient information about the products they are consuming (Ross and Chalpouka 2002: 6), thus tending to underestimate the health consequences of smoking and the risk of becoming addicted (Ross and Chalpouka 2002: 6). Evidence of government efforts to bridge this gap is the enforcement of the provisions of the Framework Convention on Tobacco Control (FCTC) which, inter alia, requires parties to ensure that tobacco product packaging includes health warning messages on 40% of the packaging (WHO 2003: ART 11(b) (iv)). Regulation is also important since, as already discussed, stakeholders in the tobacco industry employ various tactics to deceive the unsuspecting public, with grave health outcomes.

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Intervention by the State is also justifiable as a paternalistic measure to ensure that individuals do not end up engaging in activities that may be harmful to them. Moreover, the Constitution of Kenya in Article 43(3) guarantees every person the right to the highest attainable standards of health with the state being overall responsible for ensuring its realization. Gostin and Wiley argue that poor individual choices are likely to impose enormous collective costs which may end up affecting human well-being, the community and the economy (Gostin and Wiley 2016: 436). The government may therefore step in to influence or control individual behaviour (Gostin and Wiley 2016: 436), also in recognition of the fact that health outcomes are not only influenced by individual choices, but also by certain social, economic and environmental determinants (Gostin and Wiley 2016: 443). WHO FCTC-Based Policy The most notable development with regard to tobacco regulation globally came with the adoption of the FCTC in February 2005. The Convention is an evidence-based treaty drafted and adopted under the auspices of the World Health Organization. It reaffirms the right of all people to the highest standard of health and asserts the importance of demand reduction strategies as well as addressing supply concerns (WHO 2003: Foreword). The FCTC was developed in light of the global tobacco epidemic that was exacerbated by factors like global marketing, transnational tobacco advertising, promotion and sponsorship, and the international movement of contrabands and counterfeit cigarettes (WHO 2003: Foreword). Importantly, the FCTC mandates its signatories with the task of regulating the contents of tobacco products (WHO 2003: art 9). The regulations adopted by the signatories may, as a consequence, help to ensure that manufacturers of tobacco products eliminate the addictive substances in their products. Parties to the Convention are also required to enact national legislation to guide the way manufacturers of tobacco products package their goods (WHO 2003: art 11). This mandate was to be fulfilled by State parties within three years of the entry into force of the Convention. The Convention also requires signatories to adopt measures driven at promoting cessation of tobacco use and provide adequate treatment for tobacco dependence (WHO 2003: art 14). The Convention in this regard takes cognizance of the tobacco addiction epidemic and

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requires states to take tangible measures aimed at redressing the ills occurring. States are inter alia, required to design and implement programs to promote cessation of tobacco use, to incorporate diagnosis and treatment of tobacco dependence in national health and education programs, and to establish facilities and rehabilitation centres for counselling and treatment of tobacco dependence (WHO 2003: art 14). Targeted initiatives by the state in line with the Convention are likely to go a long way in ensuring that addiction rates are reduced and to prevent new cases of addiction. Kenya became party to the FCTC in February 2005, immediately after its adoption. As a contracting party to the treaty, Kenya is legally bound by the treaty’s provisions and objective of protecting present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke (WHO 2003: art 3). Under this treaty, the government is also required to allocate budgetary expenditure for tobacco control, although as of 2007, the amount was only Kshs 4.5 million (WHO 2017). The Kenyan Health Ministry also encourages tobacco addicts to enrol with the national health insurance program, the National Hospital Insurance Fund, which the Ministry assures will foot medical bills for smokers to quit tobacco (Muchangi 2017). The National Campaign against Alcohol and Drug Abuse (NACADA), a State Corporation tasked with the prevention, control and mitigation of alcohol and drug abuse, also has a helpline for persons addicted to drug substances like tobacco. NACADA provides a list of rehabilitation centres on its website, although these are few in number and not easily accessible. Health care providers in these facilities may also not possess requisite skills to provide proper treatment to those seeking to access smoking cessation services (Watiri 2014: 76). Tobacco Control Act, 2007 The legal framework for the implementation of the FCTC in Kenya is the Tobacco Control Act of 2007 which, as we discuss below, has faced some hurdles in creating awareness and ensuring enforcement and involvement of stakeholders (Musau 2014). The Act was enacted to control the production, manufacture, sale, labelling, advertisement, promotion and sponsorship of tobacco products. It contains salient provisions that, if implemented, can go a long way in ensuring that the tobacco addiction problem is contained. Some of these provisions are discussed below.

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The definition of “advertising” in the Act essentially bars manufacturers of tobacco products from adopting mechanisms meant to entice individuals to start or to continue using tobacco products. The Act in Section 3 outlines its objectives as, inter alia, to protect the purchasers or consumers of tobacco products from misleading and deceptive inducements to use tobacco products and consequent dependence on them and to inform them of the risks of using tobacco products and exposing others to tobacco smoke. The Act in Section 7(4) (b) also establishes the Tobacco Control Fund intended, for instance, to promote national cessation and rehabilitation programs. It should be noted, however, that the 2015 and 2016 BATK annual reports do not indicate any contribution to the Fund (BATK 2016, 2017) (Mastermind’s financial reports could not be accessed at the time of publication of this chapter), raising doubts about whether or not the company made any contributions. Appropriate enforcement of the provisions of the Act is essential to guarantee that tobacco products manufacturers contribute towards the elimination of the hazards that are occasioned by the substances that they manufacture. The Act in Section 9 places an onus on the government to promote public awareness about the health consequences, addictive nature and threat posed by tobacco consumption and exposure to tobacco smoke. It identifies groups that are at risk of tobacco consumption and addiction and mandates the State to target them. Section 10 of the Act specifically requires the Ministry responsible for education to integrate tobacco-­ related topics in the syllabus. This ensures that school-going children are educated on the harms of tobacco products as they are more susceptible to manipulation by tobacco manufacturers. Section 18 of the Tobacco Control Act further requires that cigarettes be sold only in packages containing a minimum of ten cigarettes; prohibiting the sale of cigarettes in individual units as has been commonplace in Kenya. This in effect makes cigarettes inaccessible to many who can only afford to purchase single sticks. Many retailers, nevertheless, violate this requirement by continuing to sell individual cigarette sticks (Magut 2018). The sale of cigarettes in packets may also inadvertently lead to increased addiction rates as smokers have access to multiple sticks that tempt them to smoke more over shorter periods of time. The requirement regarding warning labels may, nonetheless, deter individuals from buying cigarettes as they will readily discover the consequences of smoking.

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The application of the Act has seen a number of milestones attained including prohibition of direct forms of tobacco advertising and the Act has further provided protection from the harms of second-hand smoke in some public places (ITC 2015: 5). However, there is an ostensible lack of proper administrative structures (except for the lacklustre Tobacco Control Board), which has further hampered enforcement of the legal requirements. An immediate consequence of this has been inadequate promotion of research and dissemination of information, with the available information being largely outdated. Challenges in enforcing the provisions of the Act against small-scale retailers are also replete (Waithaka 2014: 30), which is indicative of the fact that intervention measures are better directed at the manufacturers of tobacco products. Cigarette manufacturers are known to exploit these gaps by engaging in indirect advertisement at retail points where they do not bear direct responsibility (Waithaka 2014: 35). The regulations introduced by the Act have, besides, indirectly led to the strengthening of the market share of existent tobacco companies as it is almost impossible for new companies to trade in a market that prohibits advertising (Waithaka 2014: 38). Health Act, 2017 The Health Act in Section 68 recognizes the need for interventions to reduce the burden imposed by communicable and non-communicable diseases and also to promote healthy lifestyles. The Act further stipulates interventions to reduce the use of tobacco and other addictive substances. Both the Health Act and the Tobacco Control Act require that the government puts in place requisite measures to curb addiction by the adoption and implementation of relevant policies. Tax Laws A 2015 study by the International Institute for Legislative Affairs concluded that increased taxation of tobacco would reduce tobacco consumption, save lives and raise government revenue (IILA 2011). This and many other studies have extolled the merits of tobacco taxation, necessitating appropriate legislative intervention. In Kenya, The Excise Duty Act 2015 establishes the taxation regime applicable to tobacco and other products, with tobacco products being taxed more heavily than other products. For cigarettes containing tobacco or tobacco substitutes, the Act imposes duty at Kshs 2500 per mile. Increasing taxes and therefore prices payable for tobacco products are supposed to make the product less accessible to

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actual or potential consumers (Nargis et al. 2015: 8). This legislative intervention can be particularly effective if enforced together with Section 9 of the Tobacco Control Act which mandates the government with undertaking information, education and communication initiatives since, as it has been established in this chapter, there seems to be an information deficit which enables tobacco addiction to thrive. The flooding of the Kenyan market with cheaper counterfeit cigarettes has at times necessitated the lowering of taxes on cigarettes to enable easier access to genuine products by the poor (Alushula 2017). This approach may however hinder tobacco addiction control initiatives as it makes cigarettes more affordable to the general public. The more appropriate strategy would be for the government to put in place adequate safeguards to ensure that counterfeit tobacco products do not enter the Kenyan market. Taxation should, however, not be over relied on as a measure to curb consumption and addiction to tobacco products as its use has not always been effective. Price controls have been established to be an ineffective tool for curbing tobacco dependence (Kilonzo 2015). Kenya has also developed and adopted The National Protocol for Treatment of Substance Use Disorders in Kenya to provide guidance to healthcare providers assisting alcohol- and drug-dependent persons to attain the highest level of personal, professional, familial and social functioning (MoH 2017). The Protocol recognizes the need for conducting treatment programs in a manner that respects human rights and dignity (MoH 2017: 12). The initiatives proposed under this Protocol help to deal with addiction concerns. Organizations like The Kenya Tobacco Control Alliance (KETCA) also play a crucial role in curbing addiction. KETCA is a non-profit organization that has several programs to advocate for effective regulatory measures to curb the ‘tobacco menace’ (KETCA 2019). It also coordinates tobacco control efforts within and among stakeholders in the industry, builds capacity and creates awareness regarding the devastating effects of tobacco use.

17.7   Ethical Consideration Unethical Conduct Hindering Global and National Regulatory Efforts It is now common knowledge that the TI has, over the years, employed various tactics, including provision of phony statistics and research evidence aimed at interfering with the policies adopted to dissuade people

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from smoking (WHO 2008). This is a derogation from the ethical standards required of the industry, which in turn fosters increased addiction, with deleterious health outcomes, in addition to undermining the value of research altogether. The industry has been known to make deliberate attempts to undermine tobacco control measures proposed or meted out over the years. There is documented history of scientific misconduct with a significant amount of evidence obtained, thanks to public access to tobacco industry documents available at the Truth Tobacco Industry Documents library. These documents revealed decades of hidden attempts to “resist smoking restrictions, restore smoker confidence and preserve product liability defence” (Saloojee and Dagli 2000: 902–910). The WHO, moreover, issued a comprehensive report that exposed, with supporting evidence, a wide range of tactics or strategies used to control, thwart, subvert and exploit tobacco control (WHO 2008). Kenya has also investigated and documented tobacco control interference within its borders (IILA 2013). The unethical conduct in question consists of attempted or actual interference to avoid, delay, dilute, block, nullify and modify legislation. WHO groups the strategies into five categories, namely, education, environment, lobbying and political campaign contributions, corporate social responsibility (CSR)  movement and philosophy, and economic arguments (WHO 2008). A variety of professionals such as lawyers, executives and scientists have been implicated. Interference has occurred in diverse places such as Argentina and other parts of Latin America, the Caribbean, Germany, Switzerland, EU, Middle East, Thailand, Cambodia, Former USSR and the US, with ripple effects being seen in many other countries. Ethical Classification of the Tactics Used The ethical dimension of the strategies used is broadly classified below, under business/corporate ethics, and research and publication ethics, and professional ethics. Business Ethics Angle  The business of tobacco is tainted with evidence-­ based charges of causing premature death and preventable disease to both active and passive users. This is the basic justification, as earlier seen, of the mechanisms of tobacco control.

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The engagement of the tobacco industry in CSR is, consequently, one of the controversial issues arising. CSR is typically done by making monetary or in-kind contributions to various programs; the TI has been known to engage in CSR partly to restore a damaged reputation (Hirschhorn 2004: 447–453). Philip Morris justified its use of CSR to maintain its responsibility to the investor, despite tobacco use being detrimental to public health. This approach is further compounded by the attempted replacement of government-mandated regulation with self-regulated CSR (Lee and Bialous 2006: 419). In response to this contradictory modus operandi, the International Organization for Standardization issued guidelines for social responsibility in 2010 (ISO 2010) encouraging businesses and organizations in their efforts to act in a socially responsible way by being ethical and transparent, thus contributing to the health and welfare of society. There have also been notable efforts by various stakeholders to dissociate with the TI (Chapman 2014: 445–447) although this has not prevented the industry from devising new ways of exerting influence and secretly enhancing its public image. CSR engagement by the TI, moreover, contravenes the FCTC and Kenya Tobacco Control Act of 2007, which prohibits all forms of Tobacco Advertising Promotion and Sponsorship, as this is likely to be used to advance TI’s vested interests. One such case is the involvement of the TI in the elimination of child labour in tobacco growing, so as to be perceived to be responsible and, on the contrary, the refusal to support HIV/AIDS programs on the grounds that little publicity and recognition would be achieved. TI sponsorship of public health campaigns has nevertheless been rightly regarded as inherently contradictory, considering that tobacco is the leading cause of non-communicable diseases (WHO 2004: 5). Other strategies of business ethics relevance that are aimed at influencing legislation include political donations and lobbying governments (Givel and Glantz 2001: 124–134), philanthropy, contributions to political campaigns and policymakers’ favourite charities, among other opportunities (Tesler and Malone 2008: 2123–33). The industry also uses, to its advantage, voluntary agreements to hinder legislation or regulation (Wander and Malone 2006: 2048–54), creating good will and allies within policymaking and regulatory bodies, promoting inaccurate or false messages, such as forming misleading alliances with the hospitality industry that are aimed at weakening smoking restrictions, without protecting public health (Dearlove et  al. 2002: 94–104). Another tactic is conducting

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youth smoking prevention programs with an ultimate objective of preventing tobacco control legislation (Landman et al. 2002: 917–30). Tobacco industry interference with national policymaking has also occurred in Africa, although this has not prevented governments from developing and implementing tobacco control measures (WHO 2015: 9). Likely attempts to delay or block the enactment or implementation of tobacco legislation in Kenya are evident in the case filed in the High Court by British American Tobacco (BAT) in 2015, challenging the Tobacco Control Regulations of 2014 that were made pursuant to the Tobacco Control Act of 2007. The regulations in question pertain in part to advertising, packaging, smoking in public spaces, limitation of interactions between the TI and public officials, which according to the petitioner were unconstitutional, oppressive, irrational and unreasonable. BAT’s legal challenge was mostly unsuccessful and so they appealed in 2016, again challenging the legislation, but the Court of Appeal upheld the High Court’s decision. BAT thereafter lodged an appeal before the Supreme Court of Kenya; this matter was still in court at the time of writing this chapter. Although it is within the rights of the TI to have recourse to the legal system in defence of its interests, it still has to contend with the fact that there is a greater good at stake, which is public health. This clearly explains the requirement to extend compensation for the negative effects of tobacco product use as upheld by the Court. It is also a reiteration of the state’s obligations to safeguard the present and future generations’ constitutional right to health and to a healthy and clean environment, as evidenced by Kenya’s decision to sign and ratify the WHO FCTC soon after its finalization in 2004, and subsequently to enact the Tobacco Control Act and the corresponding Regulations. As the Court of Appeal stated, public health will even override intellectual property rights, where this is deemed necessary, despite the provisions of international agreements on intellectual property rights (CTCA 2017). In this way, the State is ensuring that public health policies are not subordinated to commercial and other interests of the TI, as spelt out in Article 5.3 of the FCTC and Article 43(1) of the Constitution of Kenya, 2010. The 2015 constitutional petition by BATK was preceded by deliberate attempts to delay the processing of the Tobacco Control Bill that began with the presentation of an alternate Bill by a private member, making the process drag on for nine years, from 1998 to 2007 (Opukah 1998). Once the Act was enacted, MTK challenged its constitutionality in 2008 arguing

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that it contravenes fundamental human rights and freedoms. The matter was unduly delayed by MTK, resulting all the same in its dismissal by the High Court in 2012 (IILA 2013). Earlier on, in 2006, BATK and MTK actively hampered the introduction of the Public Health (Tobacco Products control) Rules aimed at ensuring smoke-free places in the country on the basis that they were not consulted in their development (CTCA 2017). Documented facts further show how the TI has lobbied members of parliament on different occasions so that the enactment of tobacco control legislation is delayed or modified in their favour. Two specific instances are in 2004 when BATK and MTK lavishly hosted 40 members of parliament to lobby against the Tobacco Control Bill (2007) (Patel, Collin and Gilmore 2007: 1) and again in 2015 to prevent the passing of Tobacco Control Regulations (2014) (CTCA 2017: Annex 1). Another clear manifestation of interference by the tobacco industry relates to tobacco tax and price policies (CTCA 2017: Annex 1). Tax and price measures may be, as discussed above, an effective means to reduce initiation and to motivate cessation of tobacco use and so parties to the FCTC are required to adopt them. For this reason, the Tobacco Control Act (2007) empowers the Minister for Finance to implement the corresponding policies. There is evidence, gleaned from TI documents, which shows decades of interference in tobacco tax and price measures. A pertinent example is the development of a housing estate in Nairobi in order to obtain tax waivers (Hartley 1992). The Minister for Finance in his 2017/2018 fiscal year budget speech modified the tobacco tax system to protect local cigarette manufacturers. This is deemed to advance the commercial interests of the TI industry while contradicting public health ­policies aimed precisely at reducing tobacco consumption as per Article 5.3 of the FCTC. Illicit trade is yet another form of unethical business dealings that is used to argue against tobacco tax and price policies and often blamed on government’s use of excise taxes. Evidence shows that, BATK and MTK have, on the contrary, been involved in the illicit trade of their own products, at times taking advantage of weak laws and poor enforcement. Unethical Scientific Research and Publication  Unethical scientific research and publication is also evident in the conduct of the tobacco industry. This involves distorting, discrediting, ridiculing or contradicting research and research-based reports, going so far as to refer to scientific evidence as

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“junk science” in a bid to weaken the regulations based on this evidence (Samet and Burke 2001: 1742–44; Michaels and Monforton 2005: 39–48). This tactic also impedes public health practice as it should be guided by the best evidence available (Michaels and Monforton 2005: 39–48). Among the strategies used is undermining of confidence in studies by spearheading contradictory research and additionally shaping opinion by manipulating the media and the public (Ong and Glantz 2000: 1253–59). Philip Morris even formed the Philip Morris External Research Program (PMERP) in 2000 with a majority of peer reviewers with previous ties to the TI, leading to the conclusion that it existed to boost its public image, rather than promote scientifically sound research (Hirschhorn et al. 2006: 267–69; Hirschhorn 2000: 242–48). The tobacco industry is also known to compromise the independence of scientists by funding prestigious academic centres like the Harvard Centre for Risk Analysis and scientists such as Dr. Feinstein of Yale University who was also the editor of the Journal of Clinical Epidemiology. Another journal found to have questionable research integrity is the Indoor and Built Environment, whose editorial board at one time was largely constituted by people with a history of TI consultancies. This in turn cast a doubt on the scientific soundness of the journal content (Garne et al. 2005: 805–09). Research by Cohen et al. shows dependence on TI funding and connections by universities and healthcare institutions despite the health promotion role they should have been playing vis-à-vis tobacco and TI activity (Cohen et al. 1999: 70–74). The industry has also been known to publish articles in scientific literature to create misconceptions about the hazards of smoking, thus preying on the ignorance of smokers (describing smoking as healthful pleasure and cessation as stressful and unhealthy) and thwarting health promotion efforts (Smith 2007: 162–70). TI-funded studies include Life Sciences Research Office and Institute for Science and Health (by PM and BAT, respectively), both of which have “downplayed or concealed their true level of involvement with the tobacco industry” and whose key members have “significant and long-standing financial relationships” with the TI. This again puts into doubt the independence of research published by them (Schick and Glantz 2007: 157–64). On the Kenyan front, BAT sought to penetrate the field of medical research by withholding information regarding the link between tobacco consumption and heart diseases, while sponsoring a study conducted by a leading Kenyan cardiologist as a public relations exercise to further its own ends (CTCA 2017).

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Professional Ethics  The type of misconduct just described clearly constitutes unethical professional behaviour. The industry managed for years to create networks of scientists to support their cause, such as the allegation that environmental tobacco smoke is not a health risk. In addition to research scientists, the involvement of a cross section of professionals should be noted. These include TI lawyers who promoted their agenda through industry-organized symposia and non-peer reviewed research, disregard for scientific merit of research projects, with the hidden intention of swaying policymakers and generating good publicity for the industry, while paying little attention to the associated health dangers (Drope and Chapman 2001: 588–94; Yach and Bialous 2001: 1745–1748; Bero et al. 1995). The so-called EPA saga similarly involved TI attorneys, as well as a US Congressman and executives, all intent on circumventing public health policy (Ong and Glantz 2000: 1253–59). The tobacco industry in Germany also fought to inhibit regulation of public smoking through “carefully planned collaboration with selected scientists, health professionals and policy makers…” (Bornhauser et al. 2006: 1) Philip Morris also engaged an international network of consultants to generate controversy on second-hand smoke in Europe, Asia and Latin America. The academia-affiliated consultants were hired by a law firm to generate “pro-industry” information regarding, inter alia, smoking regulations about second-hand smoke. They also engaged in research and participated in symposia without acknowledging funding by the TI (Barnoya and Glantz 2006: 69–77). The use of front groups as well as close collaboration with professional associations in Kenya, like in other parts of the world, also manifests unethical professional practices. One such manifestation is the close engagement between BATK and the chair of the Kenya Association of Physicians (KAP) who served as a consultant and facilitated direct collaboration with the industry (Adrian 2000;  KAP 2000; BAT 2016; BAT Records 2016). The Kenyan Tobacco Farmers Association (KETOFA) has also been used by the tobacco industry to campaign against tobacco legislation and regulations (IILA 2013). The Kenya Association of Manufacturers (KAM) is a front group for the TI as seen in its bid to oppose tobacco taxation and the implementation of the Tobacco Control Regulations of 2014 (CTCA 2017: 32). All in all, it could be correctly stated that the tobacco industry’s unethical tactics have greatly contributed to increased tobacco consumption and addiction, and, as a consequence, to increased morbidity and mortality.

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17.8   Conclusion This chapter has highlighted the way in which the TI has been complicit in encouraging tobacco addiction, despite the legal and policy interventions at a global and national level. The actions of the TI amount to an abrogation of ethical requirements that the industry is required to uphold. These actions also point to the existence of certain gaps in the law which have been exploited by TI to the detriment of public health initiatives. The State has a serious obligation to promote and protect public health, but it requires the collaboration of the tobacco industry in the corresponding efforts so that this vital goal is achieved.

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CHAPTER 18

Conclusion: Defining the Future of Addiction Research in South and East Africa Yamikani Ndasauka and Grivas Muchineripi Kayange

In this book, we have focused on two-fold issues that have characterized modern studies of addiction, the understanding of the concept of addiction and the problem of prevalence of addiction in various cultures, with a special focus on South and East Africa. We have traced addiction in oral traditions, literature as well as popular culture. It is evident and apparent that addiction has existed and continues to exist in traditional as well as modern Africa. As Telamisile Mkhatshwa and Gloria Malambe demonstrate, the song “Pikiliyeza” is a celebratory song that is sung by both men and women during gatherings. It is commonly sung in shebeens, as a celebratory song for beer. In Dave Namusanya’s analysis of Mafo, he also contends that Mafo glorifies alcoholism. Although these works don’t necessarily touch on addiction, the mere glorification and simplification of alcoholism are seen as propagating or leading to addiction. Similarly, Beaton Galafa traces sex and sex addiction in selected African fiction works.

Y. Ndasauka (*) • G. M. Kayange Chancellor College, University of Malawi, Zomba, Malawi e-mail: [email protected]; [email protected] © The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5_18

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In addition, what is coming out clear from this book is that Africans conceptualize addiction as a form of failure of will power. Both Metz and Lajul express the moral failures of the individual as well as community where they belong as responsible agents of addiction. Contrary to this, though not explicit, Ntewa et al. present the neurochemistry of addiction in Africa. What is unique about their chapter is that they trace that Ibogaine, a hallucinogen from plants in Gabon and Cameroon, has been used to obliterate withdrawal symptoms from alcohol, cocaine, and heroin. Thus, addiction is conceptualized as a disease from that perspective. So we see evidence on both sides of the isle. On prevalence of addiction, we note that research in this field is minimal. As we expressed in the introduction, most literature on prevalence have  conflated addiction with mere abuse or dependence. In this book Milanzi and Ndasauka have attempted to make a case for alcohol addiction by studying number of days spent consuming alcohol in 19 African countries. Although they accomplish this successfully, future research (DHS data) should focus on a number of elements as discussed in Chap. 1 that pertain to addiction.  Manda et  al. also draw us to Internet addiction, a form of technological addictions. With technological advancement in Africa, technological addictions are bound to be a major problem for Africa. In addition, Kayange makes a rather paradoxical case for cannabis. He traces cannabis consumption in Africa from pre-colonial period. What he fails to address, which we hope future research will address, is the addictive nature of cannabis to an African mind. However, as argued by Mtewa et al. and Bbosa in the same book, there is evidence that an African mind is prone to addiction of cannabis. Nevertheless both chapters remain at hypothetical level hence the need for future research to map the prevalence of cannabis addiction in Africa. The topic of addiction in Africa is still young in Africa, and this book has just began to scratch the surface; there is vast room for research on addiction in Africa, but there is need for governments and research institutions to take a leading role in growing number of experts and providing adequate facilities for the study of philosophical, neurobiological, neurochemistry, psychological, and social-cultural aspects of understanding and treating addiction. Firstly, future research should focus on establishing actual prevalence of addiction to alcohol, drugs, and Internet in Africa, by employing psychometrically validated tools for measuring different addictions that take into consideration African conception of addiction. This will be first step

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towards understanding the extent to which this ‘disease’ is robbing Africa of its valuable citizens. Additionally, studies must also be conducted to find out the root causes of this phenomenon so that treatment and preventative interventions should be evidence based. As Ouma and ­ Wathatu note, there is lack of explicit laws dealing with addiction and lack of enforcement of the existing laws. This maybe one cause that derails efforts to curb alcohol but also drug use and addiction in Africa. Future research should endeavour to further understand addiction from genetics perspective. As Mtewa et al. argue in this book, addiction can be understood from race perspective. So, are Africans more vulnerable to addiction? What biopsychosocial dispositions are Africans exposed to that would promote addiction? Future research should also focus on treatment of addiction. As Manthalu argues, would Ubuntu ethics of care help to prevent and treat addiction? What other biopsychosocial elements would we appeal to in treating addiction?

Index

A Abuse, 231 Addiction, 129, 184, 195 Alcohol, 130–133 Alcoholism, 97

Disorder, 55 Dopamine, 180 Drug addiction, 195, 250 Drug control system, 252 Drugs, 179

B Behavioural addiction, 197 Broncleer, 245

E Etiology, 108

C Cannabis, 33 use and addiction, 35, 37 Common relationship, 23 Community, 51, 61, 64 D Discrimination, 236 Disease, 58–59 Disease Model, 1

G Gender, 115 Genetic predisposition, 177 H Hypersexuality, 108, 110 I Immorality of addiction, 10 Instrumental value, 43

© The Author(s) 2019 Y. Ndasauka, G. M. Kayange (eds.), Addiction in South and East Africa, https://doi.org/10.1007/978-3-030-13593-5

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INDEX

Internet, 262 Internet addiction, 263–265 Internet Addiction Test, 269 M Malawi, 267 music, 127 Marginalisation, 234–235 Marijuana, 133–135, 245 Masturbation, 114 Mental health, 235–236 Mental illness, 178 Morality, 120 Moral perspective, 13 Music, 126 N Neurobiology, 198 Neurochemistry, 175 Neurocircuitry, 198–200 Neuroscience, 176, 186 Neurotransmitters, 201 Norepinephrine, 182 O Obsession, 112 P Pharmacological approaches, 184–185 Physical Disorder, 52–54 Popular culture, 127–130 Prevalence of tobacco, 285 Proverbs, 100, 101 Psychoactive drugs, 201

S Sex, 109 Sex addiction, 106, 107, 109, 111, 118, 135–138 Sex work, 230 Sex workers, 229 Social exclusion, 234 Songs, 96 Substance abuse, 196 Swazi, 96

T Therapy, 255–256 Tobacco, 281 control, 288 dependence, 286 U Ubuntu, 21, 22 V Vitality and community, 17

W Will Power Model, 1

Y Youth, 254

Z Zimbabwe, 242