Banning alcohol during lockdown: It is not just about the virus or economics
The announcement of the total ban on alcohol sales in the days before the COVID-19 lockdown led to an alcohol rush hour as South Africans flocked to liquor stores to fill their trolleys. Drug-policy activists warned that the ban was dangerous for addicts and the Gauteng Liquor Forum, which represents approximately 20 000 mostly township-based shebeens and taverns, threatened to go to the Constitutional Court if the ban was not lifted. However, on 17 April 2020, President Cyril Ramaphosa announced the ban would remain in force for the duration of the lockdown. Antoinette Oosthuizen looks at research evidence on the devastating effects of alcohol on society that supports this decision.
According to the HSRC’s first South African National Health and Nutrition Examination Survey (SANHANES-1), which was conducted in 2012, 45.6% of households reported that they had drinkers, but the majority of the heads of households (61.3%) did not perceive the drinking in their homes as misuse of alcohol.
Yet, South Africans are among the riskiest drinkers in the world, according to the Global status report on alcohol and health 2018, published by the World Health Organization (WHO). Data from 2011 showed that the country had the highest reported alcohol consumption in Africa. Among those who consumed alcohol, 48.1% of men and 41.2% of women engaged in heavy episodic drinking. South Africans consumed an average of 9.5 litres each per year, substantially higher than the African regional average of 6.2 litres.
South Africa’s road-traffic death rate (39.7 per 100 000 each year) was double the global rate, albeit not only due to drunk driving. An estimated 40% of road-traffic deaths in 2007 were of pedestrians, and over half of them had blood-alcohol concentrations above the legal limit (for driving). According to the HSRC’s SANHANES-1 report, the overwhelming majority of the household heads (83.6%) did not report violence or disturbances due to alcohol use in their homes. Yet, the South African Police Service crime intelligence unit reported in 2011 that with approximately 80% of murders, 60% of attempted murders, 75% of rapes and 90% of assault cases, the perpetrators had been under the influence of alcohol when they committed the crimes.
The researchers made the point that as the questions on alcohol were asked of household heads, perceptions of misuse, violence or disturbances may not have included incidences when the heads themselves had misused alcohol or were the perpetrators.
Data on binge drinking
In an attempt to quantify the prevalence of self-reported drinking and binge drinking, University of Cape Town researchers looked at data obtained from the 2014–2015 National Income Dynamics Study, a nationally representative dataset of just over 20 000 individuals aged above 15 years. Their findings, published in the South African Medical Journal in 2018, showed that one in three South Africans reported drinking alcohol and one in seven reported binge drinking on an average day of alcohol consumption. Alcohol use was reported by 33.1% of the population and binge drinking by 14.1%. Notably, more than 20% of men reported binge drinking and 6.4% of women.
The WHO also reported on several research studies showing elevated blood alcohol concentrations related to occupational injuries in mining, road accidents, domestic violence, murder, suicide, accidental deaths (such as falls, drownings and burnings) and risky sexual behaviour. Citing a 2015 paper in Alcohol and the Immune System, Dr Charles Parry, director of the Alcohol, Tobacco & Other Drug Research Unit at the South African Medical Research Council, recently warned on social media that lung damage from heavy drinking might worsen the outcomes of respiratory infections. According to the paper, heavy drinkers are more likely to develop pneumonia, tuberculosis, respiratory syncytial virus infection, and acute respiratory distress syndrome, caused by an impaired immune response.
Alcohol misuse, when combined with certain circumstances, culminates in a “perfect storm” with catastrophic results in hospital settings, wrote Dr Ernest Moore in an article published in The Journal of Trauma: Injury, Infection, and Critical Care in 2005. It impairs judgment and increases the likelihood of serious injury. An intoxicated patient is more likely to be hypotensive and less likely to be able to protect his or her airway, says Moore. They also have an increased chance of complications. He also said the management and evaluation of, and surgery on, intoxicated patients cost the health-care system more than sober patients.
Between December 2014 and February 2015, a team of researchers from the University of KwaZulu-Natal’s Department of Surgery analysed 100 patients at the King Edward Hospital’s trauma unit. They correlated blood alcohol concentrations with the severity of the patients’ injuries, how they got injured, the length of their hospital stay and in-hospital mortality. Their findings showed that positive blood alcohol levels were associated with significantly more severe injuries. Injuries due to interpersonal violence were seen in 83 patients of whom 42 (51%) had positive blood alcohol. The hospital stay for alcohol-positive patients was also significantly longer compared to alcohol-negative patients.
A study at Groote Schuur Hospital in Cape Town, which looked at 9236 trauma admissions in 2010 and 2011, found a strong association between injury and alcohol use, with alcohol implicated in at least 30.1% of cases. The WHO report stated that the harm per litre of alcohol was substantially greater for less affluent drinkers, citing a study that found 60% of all alcohol-attributable deaths occurred in the lower 30% of the country’s socioeconomic distribution. A study in BMC Medicine estimated that one in ten deaths in South Africa was attributable to alcohol use in 2015. The potential harm to addicts, including symptoms such as psychosis and seizures, and the risk of them breaking the law by accessing black markets to cope, would need to be weighed against these factors.
The impact of the lockdown
Ten days into the lockdown, emergency services officials told the SABC that there had been a steep decline in the number of trauma-related calls, particularly in relation to alcohol. According to a report by the Bhekisisa Centre for Health Journalism, an unpublished modelling study by Parry and his colleagues has shown that two-thirds of an estimated 35 000 weekly admissions to hospital trauma units around the country have disappeared, including 9 000 of which would have been alcohol-related admissions.
In a media release on 22 April, police minister Bheki Cele provided crime statistics for the first 25 days (27 March to 20 April 2020) of the lockdown compared with the same period in 2019. Murders had decreased by 72%, rape by 87.2%, attempted murder by 65.9%, and assault with intent to inflict grievous bodily harm by 85.2%. Domestic violence, which included murder, attempted murder, rape and sexual assault, decreased by 69.4%. In most of the domestic violence incidents, the perpetrators were well-known to the victims and in a few cases, the murder was a result of an argument over liquor.
It could be said that these reductions were also influenced by the increased visibility of law enforcement, reduced traffic and reduced movement between areas during the lockdown. However, Parry and his colleagues have warned that lifting the ban during lockdown may lead to an increased risk of violence to women and children and the reappearance of just under 5 000 alcohol-related trauma admissions per week.
Economic versus social costs
Referring to the Gauteng Liquor Forum’s threat to take the alcohol ban to court, economists told Fin24 that all sectors were struggling and the Forum would have to present a compelling argument for why liquor traders are an exception. On 14 April, the WHO advised against relaxing alcohol regulations during the COVID-19 pandemic. Three days later, President Cyril Ramaphosa announced that the alcohol sales ban would remain in force for the duration of the lockdown.
We have to weigh the economic costs of the alcohol sales ban against the social costs, says Prof Cheryl Hendricks, head of the HSRC’s African Institute of South Africa (AISA). The institute conducted a study in Mpumalanga, which found that although alcohol sales provided some employment opportunities, it may not be worth the direct and indirect harm in less developed communities. Dr Palesa Sekhejane, who led the study, says community members told researchers that alcohol misuse was common practice, with children suffering the most from the indirect effect of it, mainly due to parental neglect.
But for how long do we keep the outlets closed? asks Hendricks. “What are the other things that need to accompany the alcohol ban during this time for it to have a lasting impact when we come out of the lockdown? If we do not consider that, we may be putting a Band-Aid on the deeper problem.
As Maurice Smithers, director of the Southern African Alcohol Policy Alliance of South Africa (SAAPA SA) writes in the Daily Maverick, the reduction in costs to the country of alcohol-related harm as a result of the lockdown ban is likely to more than offset the decline in revenue from excise tax. He suggests that surveys be done to determine the change in the quality of life of people living in communities that, before the lockdown, experienced challenges with liquor outlets operating in their neighbourhoods.
Author: Antoinette Oosthuizen, HSRC science writer