RESEARCH CENTRES SERIES
Addiction Research Centres and the Nurturing of Creativity
The Alcohol & Drug Abuse Research Unit at the South African Medical Research Council – strengthening substance abuse research and policy in South Africa
Charles Parry, Alcohol and Drug Abuse Research Unit, Medical Research Council, PO Box 19070, 7505 Tygerberg, South Africa. E-mail: firstname.lastname@example.org
The Alcohol and Drug Abuse Research Unit (ADARU) was established at the South African Medical Research Council (MRC) at the beginning of 2001, although its origins lie in the activities of the Centre for Epidemiological Research in Southern Africa and other MRC entities. Initial challenges included attracting external funding, recruiting new staff, developing the skills of junior staff, publishing in international journals and building national and international collaborative networks. ADARU currently comprises a core staff of 33 members who work on 22 projects spanning substance use epidemiology and associated consequences, intervention studies with at-risk populations and services research. A large component of this portfolio focuses on the link between alcohol and other drug use and human immunodeficiency virus (HIV) risk behaviour, with funding from the US Centers for Disease Control and Prevention. Junior staff members are encouraged to develop independent research interests and pursue PhD studies. Research outputs, such as the 20 papers that were published in 2010 and the 35 conference presentations from that year, form an important part of the unit's research translation activities. We engage actively with policy processes at the local, provincial, national and international levels, and have given particular attention to alcohol policy in recent years. The paper includes an analysis of major challenges currently facing the unit and how we are attempting to address them. It ends with some thoughts on what the unit intends doing to enhance the quality of its research, the capacity of its staff and its international standing.
EVOLUTION OF THE UNIT
The Alcohol and Drug Abuse Research Unit (ADARU) at the South African Medical Research Council (MRC) was established in 2001. However, a solid basis for establishing the unit was built in the preceding decade. Following completion of a PhD in community psychology and a postdoctoral fellowship in clinical services research in the United States, the current director (C.P.) was recruited to work at the MRC Centre for Epidemiological Research in Southern Africa in 1990. These were exciting times in South Africa following the release of Nelson Mandela and the preparations for future elections open to all races. Health structures were being reconstituted, health policies were being debated vigorously and health research was being revitalized. At that time the director of the centre was involved actively in pushing for greater controls on tobacco products and he steered C.P. towards a local alcohol and other drug (AOD) forum, where the latter's interest in alcohol issues was kindled.
Early staff included social, research and clinical psychologists, one of whom had received graduate and postgraduate training in the addiction field in the United Kingdom and United States. Among the most significant activities before the formal establishment of the unit were research studies on adolescent drinking , alcohol advertising and young people , the link between alcohol use and tuberculosis , alcohol and trauma  and drugs and crime ; the establishment of the South African Community Epidemiology Network on Drug Use (SACENDU) in 1996 ; writing an editorial on substance abuse in South Africa ; and the publication of a book on alcohol policy .
Early development of operations and activities
During the first decade our priorities were directed towards the major challenges that faced the new unit. These included attracting external funding to facilitate epidemiological research on AOD use and associated consequences, research on adolescent AOD use and AOD intervention research; recruiting and training new staff to enable the unit's expansion at a time when there were few researchers in the country with graduate degrees in the addiction field; writing up research findings at a level that would facilitate publishing in international journals; and building national and international networks.
ADARU sought to have a broad range of funders including provincial and national government departments, national and international foundations and other international agencies by applying for grants and contracts, marketing the unit and participating in funding applications with international collaborators. One important facilitator of the unit's growth has been having core funders over 5 or more years. Such funders have included the European Union (through the Southern African Development Community), the US National Institutes of Health (through Mt Sinai School of Medicine/New York University and RTI International) and the US President's Emergency Fund for AIDS Relief [through the US Centers for Disease Control and Prevention (CDC)]. These large projects also enabled us to hire new staff, typically people in their mid- to late 20s with masters degrees in clinical or research psychology, but more recently also newly graduated PhDs.
With the establishment of the unit in 2001, there was a formal push to increase our publication record. During this 10-year period we published more than 100 journal articles. To accomplish this, ADARU staff capitalized on the prevailing international interest in research coming out of post-Apartheid South Africa and became more systematic about how we went about writing and publishing papers.
With regard to recruiting good staff, senior staff members were routinely on the look-out for promising candidates. This often required taking chances that ongoing funding could be accessed after the initial funding for a post had been depleted. This approach paid off, and by the end of the first 10 years of operation we had five senior researchers and two administrative staff on ‘hard’ funding. In terms of staff development we have benefited from being able to tap into US National Institute on Drug Abuse (NIDA) funding for several staff members to attend the annual scientific meetings hosted by the NIDA International Forum and College on Problems of Drug Dependence. We also benefited from NIDA's Southern African Initiative as well as from other collaborative relationships with staff from NIDA who provided guidance during the early years of SACENDU, a number of National Institutes of Health (NIH)-funded US investigators from Mount Sinai School of Medicine/New York University and from RTI, who have provided capacity building opportunities; and colleagues from the CDC who provided guidance and input regarding working with vulnerable populations. We see ongoing mentoring of staff as being very important, and our satellite office (based in Pretoria) runs a monthly journal club for continued staff development. After working for several years on the projects for which they were hired, staff with masters degrees are given the opportunity to develop and be principal investigators on projects that can be used for their doctoral research. To date, two staff members have completed PhDs and a further five are busy with dissertations.
PRESENT CORE OPERATION
ADARU is an intramural research unit within a national research agency which both funds external research through a request for applications (RFA) process and also conducts research through 44 intramural and extramural research units, centres and lead programmes. It is administered by the MRC, with its head office in Tygerberg, a suburb of Cape Town, the legislative capital of South Africa. It is situated across the road from the Health Sciences Faculty at Stellenbosch University and within a 30-minute drive of the Universities of Cape Town and the Western Cape. The unit also has a satellite office in Pretoria (the executive capital of South Africa) and a project site office in Parow, a Cape Town suburb, from where two large projects are conducted. ADARU currently comprises 33 core staff members: 15 based at the MRC in Cape Town, eight in Pretoria and 10 at the project site. In addition, ADARU employed a further 42 temporary staff during the course of 2010/11. The unit also subcontracts certain fieldwork to non-governmental organizations (NGOs) and other research agencies.
The MRC is headed by an Executive Management Committee and a Board, with the latter appointed by the Minister of Health. The MRC has to submit an annual report to Parliament and is accountable to that body (via the Parliamentary Portfolio Committee on Health) and to the Minister of Health (directly and through the Board). ADARU is subjected to a 5-yearly external review process, with reviews having taken place in 2009 and 2003. In addition, as with other MRC units, ADARU has to submit a detailed annual budget application in February each year which, among other things, has to specify outputs and outcomes in several areas. This is reviewed by a small internal panel that recommends the baseline funding allocation for the unit in the next financial year.
Focus of activities
The focus of the unit's activities is best captured in its mission statement, its vision and its objectives.
Mission of ADARU
To generate answers to questions relating to AOD use and abuse problems in South Africa, to propose responses to address AOD-related problems, and thereby have a positive impact on individuals and society.
Vision of ADARU
To conduct research to influence policies and practices that lead to a reduction in AOD-related harms.
Objectives of ADARU
- (i) To conduct research on the nature, prevalence, trends, and risk factors for AOD use and abuse and associated problems in South Africa.
- (ii) To design and evaluate interventions aimed at reducing AOD-related harm.
- (iii) To engage in activities that will lead to the translation of research findings into policy and practice.
In the 2010/11 financial year, in addition to salaries for five research and two administrative staff on ‘hard’ funding [approximately ZAR 3.23 million (ZAR 11 = £1; ZAR 7 = $1)], ADARU received ZAR 529 914 for running costs and seed money for new projects from the MRC's parliamentary allocation. During 2010/11 ADARU also raised ZAR 13 209 707 from external sources. The total budget for the unit for the year, therefore, was ZAR 16.96 million, or approximately £1.54 million ($2.42 million). The largest single funder was the US President's Emergency Fund for AIDS Relief (59.8%), followed by the South African government (26.9%) and the US National Institutes of Health (11.4%).
Current programme of work
The current research portfolio comprises the following.
- • Seven epidemiological studies (involving clients seen by district social service agencies, psychiatric hospitals and specialist AOD treatment centres, high school students, pregnant women and patients attending human immunodeficiency virus (HIV) clinics).
- • 10 intervention studies (focusing on fetal alcohol syndrome, substance abuse in the work-place, substance use and delinquency among youth, alcohol use and adherence to antiretroviral medications, alcohol-related sexual HIV risk behaviour among bar patrons, AOD risks for HIV, AOD-related risk for HIV and gender-based violence among women and their partners and vulnerable drug-using populations at risk for HIV).
- • Four studies aimed at understanding substance abuse treatment more clearly, barriers to accessing treatment and ways to monitor service provision more effectively.
- • One study aimed at understanding more clearly the linkage between alcohol and HIV and the associated burden of disease.
Our early research was mainly quantitative, descriptive and cross-sectional in nature. More recently we have used more mixed-methods designs. Our quantitative studies are also better controlled and include case–control and randomized controlled trial designs. Our work spans the entire country (urban and rural populations), although the main focus has been on the Western Cape, Gauteng and KwaZulu-Natal provinces.
Senior staff have traditionally guided the unit's research agenda but this is changing, with some mid-level research staff now choosing their own PhD topics and developing speciality research foci. Our initial focus was on research to explain the problem (AOD use), followed by research to identify risk factors. Since then we have focused increasingly on conducting intervention research to respond to AOD problems and associated problems (particularly HIV) and services research to strengthen the country's response to AOD prevention and treatment. The strategy has been to recruit junior researchers with potential, develop their skills through a mentoring process while they work on contract research for a few years and then stimulate their independent interest in new (fundable) areas of research that will build the unit and capitalize on the unique populations and circumstances of South Africa. South Africa has a multi-cultural population comprising people with African, European, Asian or mixed ancestry. The unique circumstances in South Africa include a high prevalence of infectious diseases such as HIV and tuberculosis (TB), high prevalence rates of injury and interpersonal violence and growing problems associated with chronic diseases of life-style —all of which are understood increasingly to be linked with alcohol (and in some cases other drugs) ; one of the highest levels of heavy episodic drinking globally among men and women ; and a mix of illicit drug problems that would not be out of place in the United States or Australia, except for the use of the synthetic sedative methaqualone (known locally as Mandrax), which is smoked together with cannabis .
Research outputs form an important part of the unit's research translation process. In 2010 ADARU produced 66 formal outputs, including 20 journal articles, eight technical reports, one dissertation and 18 local and 17 international conference presentations; 2010 was also a busy year for various policy-related activities. Prior to the May 2010 World Health Assembly in Geneva, C.P. was asked to prepare a briefing on alcohol policy for the Minister of Health. C.P. and B.M. were also contracted by the Department of Health to prepare an Inter-sectoral Alcohol Strategy and a departmental Mini Drug Master Plan. These documents formed the basis of departmental policy documents due to be released during 2011. N.M. also presented at a Department of Education inter-provincial meeting on the HIV and acquired immune deficiency syndrome (AIDS) life-style education programme that informed recommendations on best practices for conducting school-based interventions for substance abuse.
N.M. and C.P. also participated in processes related to the Liquor Control Policy for the 2010 FIFA Football World Cup. These inputs contributed to recommendations to minimize alcohol use in and around football stadiums. C.P. also gave an oral presentation at a national consultation meeting arranged by National Treasury that influenced policy changes around alcohol excise taxes due to be announced later this year. He also wrote an Opinion Editorial in the Cape Argus newspaper (24 October 2010) that was used to guide the City of Cape Town's policy on limiting hours of liquor sales in the city, and in November 2010 gave a presentation on the topic of epidemiological networks at an African Union expert meeting that fed directly into a regional drug strategy agreed to by African Union Ministers . In 2011 ADARU staff have been involved in preparing a briefing document on alcohol and non-communicable diseases which will feed into the UN General Assembly special session on non-communicable diseases in September 2011 , and were involved in a critical thinking forum on alcohol that was hosted by the Mail & Guardian newspaper . In 2011 B.M., along with other members of the International Reference Group (R.G.) to the UN on HIV and injection drug use (IDU), was involved in developing a briefing statement on IDU and the global response to HIV which fed into the UN high-level meeting on HIV/AIDS in June 2011 .
Research translation also occurred through the preparation of research and policy briefs [17,18]; through websites (e.g. http://www.sahealthinfo.org/admodule/alcdrug.htm); via media interviews; and through written input into various policy documents. Staff members are given substantial freedom in publishing their own opinions, but the expectation is that they will consult the unit director if what they are saying is likely to be controversial.
‘Best five publications in past 5 years’
We have chosen as our best five publications in the past 5 years papers where the first author is a staff member of ADARU and which have appeared in peer-reviewed journals. The first paper  reports on the findings of a rapid assessment of alcohol and sexual risk behaviour. It proposed a model to explain the link between alcohol and sexual risk behaviour, and the model has been referred to and adapted in numerous subsequent publications. The second  shows our contribution to the topic of alcohol and HIV and how African research is an important contributor to the field. It reviews data on the linkages between alcohol and HIV and proposes that alcohol is linked causally to the progression of HIV disease, but that more evidence is needed to make a conclusive statement regarding the link between alcohol use and the acquisition of HIV. The third paper  is the most important paper coming out of our collaboration with the CDC and summarizes the key HIV risks associated with drug use and what is needed to reduce drug-related HIV risk in South Africa. The fourth  is one of the first studies globally to document associations between methamphetamine use and mental health problems among adolescents. The last  is a seminal example of the emerging treatment services research area, and highlights the need to address structural barriers to and improve the quality of treatment provided in South Africa.
MAJOR CHALLENGES FACING THE UNIT
A major challenge facing the unit over the past year has been the increasing administrative burden resulting from various changes in operational procedures imposed by the MRC, largely in response to pressure from National Treasury, the Auditor-General and changes in labour legislation to address perceived inequities in the system and to reduce corruption. Among other things, we have seen changes to procurement practices, changes in the required content of legal contracts, requirements to provide quarterly reports on research outputs, changes to staff recruitment practices which make it more difficult to hire temporary staff, the imposition of time-sheets to allocate time spent to research projects on a daily basis and the requirements to allocate budgets to micro-spending areas. The effect has been to increase the time being spent on following ‘correct’ procedures and having to live with delays, particularly in areas such as procurement and getting contracts signed and also senior research staff having less time available to focus on core research activities, such as new protocol development and writing. We will support efforts to lobby to have the MRC, as a science council, exempted from some of these requirements as they are more appropriate to a government department than an academic institution. In the meantime, we have set up internal systems to facilitate compliance.
A second major challenge is funding. As a result of historical inequities in funding and not having a zero-based budgeting system in the organization, ADARU still receives one of the lowest baseline funding allocations of intramural units in the MRC. This is also due to the disease/condition-based focus of the organization, which allocates more funds to research units focusing on what are considered to be more serious health problems (such as HIV, TB, malaria) rather than underlying risk factors (such as alcohol or tobacco use) that contribute to multiple diseases/conditions. This is something that we have been lobbying to have addressed for several years. A further challenge relates to the fact that ADARU is heavily dependent on external funding to conduct research, with the CDC currently funding approximately 60% of our total budget. This funding is likely to continue for at least 2 more years, but in the meantime we are also working on proposals that will reduce this dependence.
A third challenge comes from the fact that when we first started our research in South Africa there were relatively few researchers in the country involved in work in AOD abuse research, and hence there was pressure on us to become generalists. This pressure also came about because we were considered to be a research centre with a national mandate. This is different for academics based at universities, who tend to follow a narrower research agenda and can more easily become specialists in one or two areas. There are now more researchers in universities and research organizations focusing on AOD research in the country, which has reduced some of the pressure on us to be generalists. Related to this challenge is the pressure we have experienced from various quarters in the MRC, and even from members of our external review panel, to become involved in research not only in areas near to our two urban hubs but also in other parts of the country, and especially in rural areas. Our coverage is now better in this regard, with one-quarter of our projects having some rural focus, but it remains a challenge to ensure that our research is relevant to the needs of rural populations but without being stretched too thinly. To address this, we will need to consider linkages with universities and other research agencies with capacity in rural areas.
As a result of our local and international networking and increasing number of publications in international journals, we receive numerous requests to participate in writing proposals for local and in international funding opportunities. As some of these opportunities are likely to be successful, this could alleviate the funding challenge referred to above. However, with 22 projects on the books many staff members have heavy work-loads that put them under stress, and this puts the unit at risk of not being able to deliver on time and makes it hard to respond to new and interesting opportunities. This pressure is exacerbated by the numerous requests to senior ADARU staff to present at local or international conferences, participate on journal boards or other international committees, take on more graduate students or respond to media requests for information. To address this we have, among other things, recently set up a rating system by which to determine whether or not we should take up new research opportunities as they arise (see Table 1). This process, which involves both scientific and administrative staff in the unit, results in prospective research projects gaining a ‘consensus’ rating out of 100, which can be used to gauge whether or not it should be taken on. It also provides a platform for all staff to engage in a debate about the various advantages and disadvantages of taking on particular research projects and discuss whether the project falls within one of ADARU's strategic research foci.
Table 1. Criteria for evaluating new research opportunities
|Feasibility to impact on policy in short- to medium-term||5|
|Priority substance abuse issue in South Africa||10|
|Opportunities for enhancing/improving understandings of the science||20|
|Opportunity to broaden our research focus/balance our research portfolio||5|
|Opportunity to go to greater depth in an area we are already working in||5|
|Will move us to under-researched populations||5|
|Opportunities for publishing||20|
|Burden on research staff (including unrealistic time-frames)||−5|
|Burden on support staff||−10|
|Burden on infrastructure (office space, equipment)||−5|
|Opportunity for balancing spread of projects among staff||5|
|Opportunities for staff development||20|
|Income generation potential||5|
|Broaden our funding base||20|
|Nice people to work with (collaborative, pay on time)||20|
The last decade has been a period of expansion, and for the immediate future ADARU aims to consolidate its growth and focus on deepening the quality of its research To manage further growth in our research portfolio (without compromising quality) we are likely to advocate for more collaborative research with the Universities of Cape Town, the Witwatersrand and Stellenbosch, where several staff have honorary appointments. We will also endeavour to encourage experienced academics from research centres in other countries to spend sabbaticals at ADARU to strengthen the fledgling collaborations we have with these centres. We will also look to applying for World Health Organization (WHO) Collaborating Centre status, which will consolidate our position as a leading unit in addictions research on the continent.
All of the authors received a salary and infrastructure support from the South African Medical Research Council.