- Expert says tendency to binge drink is particular to South Africa in some ways
- Estimates of alcohol-linked trauma often don’t include sober patients whose injuries were a consequence of someone else drinking
- Opportunity to prepare for when the ban is lifted and look at alcohol regulation and education
The reinstatement of the ban on the sale of alcohol may have come as a surprise to many, but evidence suggest that it will in fact have a significant impact on trauma and hospital capacity in the coming weeks.
In his announcement of the ban last Sunday night, President Cyril Ramaphosa justified the decision by saying “it is vital that we do not burden our clinics and hospitals with alcohol-related injuries that could have been avoided”. On Monday, Health Minister Zweli Mkhize set out the evidence for the ban.
His presentation cited a 60-70% reduction in hospital visits and admissions related to trauma during the initial ban in Levels four and five of South Africa’s Covid-19 lockdown, followed by a surge after restrictions were eased at the beginning of June.
Models relied on by government project that there would be around 3 400 less alcohol-related trauma cases in public hospitals by the end of the first week of the ban and double that number by the end of the third week. Apart from the direct effect on hospital capacity increasing due to a reduction in alcohol-related trauma, it is also thought that people adhere less to transmission prevention methods after drinking alcohol.
'Like war zones'
Professor Charles Parry is the director of the Alcohol, Tobacco and Other Drug Research Unit at the South African Medical Research Council (SAMRC), who has done extensive, long-term work on how alcohol impacts health services in South Africa.
His models and research consistently support the idea that alcohol greatly contributes to trauma cases and thus the use of hospital capacity. He contributed to an advisory to the Ministerial Advisory Committee (MAC) on Covid-19, which included many of the statistics quoted by Mkhize.
Parry says that research over several years across the country showed that “45-55% of trauma is alcohol-related”.
He explains that this and the tendency to binge drink is particular to South Africa in some ways. Based on 2018 World Health Organisation data, the adult per capita consumption of alcohol in drinkers is double the global average, even though only 31% of people in South Africa drink.
In real terms this means trauma in the form of gunshot and stabbing wounds, blunt trauma, for instance, when someone has fallen and also gender-based violence.
“It’s like war zones, particularly over weekends, it’s huge levels of alcohol-related trauma,” says Parry.The models developed by Parry and others during Level five of South Africa’s lockdown projected that a lifting of the alcohol ban would cause only about half of the alcohol-related trauma presentations returning, because travel and gathering restrictions would continue to limit alcohol-related trauma.
Reviewing the available data from Level three, including from the Western Cape, Eastern Cape, and Gauteng, showed that there was a significant spike in cases once the ban was lifted, although it did not return to pre-lockdown levels. “Our conclusion was that there was only about 80% of the trauma coming to hospitals than there was before lockdown,” says Parry.
Based on all this observed data, the models developed by Parry and others now project that another ban on the sale of alcohol would result in around 50 000 fewer trauma presentations in the next eight weeks. Since trauma cases often need further treatment, this translates to about an overall reduction of 46 000 fewer days of patients in ICU beds.
“Overall, if we took those people out of the system for eight weeks we could potentially treat for example just under 13 000 Covid patients in ICU beds or 17 700 in general wards, or some kind of combination of that.”
This translates to about a 18% reduction in trauma cases in the public sector and a saving of around R1,3 billion. These projections, which Parry also presented to MPs in Parliament’s Portfolio Committee on Health this week, uses a chosen eight-week period purely for modelling purposes. The government has not indicated the duration of the ban.
A preventable pandemic
Over the last months these numbers have been palpably felt by those working in the trauma units, like Professor Sithombo Maqungo, the head of orthopaedic trauma at Groote Schuur Hospital in Cape Town and the clinical lead for trauma care and injury prevention at the Global Surgery Unit at the University of Cape Town.He confirms that they have seen the trajectory of the ban have strong effects and that he says he hears the same from colleagues around the country.
During the initial ban, the trauma section was quiet, freeing up resources to the point that people on waiting lists, such as cancer patients, could be brought in for surgeries. Waiting times for emergencies were reduced, and there was time to prepare for greater Covid-19 numbers.
Maqungo says trauma, particularly the high levels linked to alcohol use, “is actually a preventable pandemic”. “For us, it was such a powerful way to illustrate the problems we have with alcohol,” he says .The kinds of injuries he sees are most often linked to car accidents, including a significant amount of pedestrians who are hurt, and interpersonal violence.
Maqungo points out that the estimates of alcohol-linked trauma often don’t include sober patients whose injuries were a consequence of someone else drinking.
Maqungo says the floodgates opened again once the ban was lifted, with the first Monday night being as busy as some of the worst weekends in the trauma unit normally. He remembers noticing a clear sign of the change. “Oh wow, this is the smell that we’ve missed, which is that smell of alcohol and blood combined,” he says.
“If you’ve worked in trauma, everyone knows that smell.” The Groote Schuur trauma unit saw about a 135% increase in that first week, which levelled out after a while. With the reinstatement of the ban, Maqungo says the unit is back to being unusually quiet. Staff and beds can be dedicated to the pandemic.
Not a long-term solution
While this pressure of alcohol-induced trauma is clear from the evidence and anecdotes, both generally and during this time, experts like Maqungo and Parry agree the ban is not a long term solution and are not denying that it can have other serious consequences.
Instead, both see it as a possible tool to assist in the pandemic and an indicator of the greater problem in South Africa.
Parry says this is an opportunity to prepare for when the ban is lifted and look at alcohol regulation and education. “How do we set the stage for a better relationship going forward?”
His recommendations include relooking the hours of sale, legal drinking age, and liquor licence laws. Maqungo calls for stricter enforcement around laws, especially after an injury has occurred.
The South African Liquor Brandowners Association (SALBA) CEO, Kurt Moore, says they “believe there is a way to limit the impact of alcohol-related trauma cases by imposing a more nuanced regulatory framework to accommodate the complexity of the situation we face”.
He says the industry is “deeply disappointed not to have been able to engage in a dialogue with government in this regard” and that SALBA believes that population-level regulations like a ban are not effective. Moore says that they would need greater access to health information from the government to understand the situation and address the problems.
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