Alcohol, alcohol harm and alcohol dependency: Putting things in perspective

Source: Maurice Smithers writing on Daily Maverick

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For some people in South Africa, one of the tougher restrictions in the Covid-19 lockdown is no access to liquor. It is frustrating for those who drink regularly and a particular challenge for those who have some form of dependency on this normally freely available legal drug.

Nevertheless, the Southern African Alcohol Policy Alliance in South Africa (SAAPA SA), fully supported the initial State of Disaster Regulations which ruled that all liquor outlets, on-consumption and off-consumption, had to close at 6pm on weekdays and Saturdays and 1pm on Sundays and public holidays. We also endorsed subsequent Regulations that imposed a complete ban on the distribution, transportation and sale of liquor in any form during the 21-day lockdown which began on 27 March 2020 (and was later extended by another two weeks until 30 April).

How South Africans have responded to the lockdown

Responses to the lockdown restrictions on liquor have been remarkably measured. South Africa has, in the past, been fifth in the race to be the hardest-drinking country in the world, so, unsurprisingly, the day before the lockdown began, liquor outlets were swamped by people wanting to ensure that the 21 days ahead wouldn’t be totally dry.

The privileged, of course, were able to stock up for the entire three weeks and beyond, the less-advantaged for maybe for a few days. Apart from that, reaction to the restrictions was initially muted, but the issue is now the subject of heated discussion and there have been incidents of liquor stores being looted.

After the lockdown began, there were, predictably, liquor outlets that didn’t observe the restrictions and operated as though they had not been written. Some have since been shut down and, as the lockdown bites, more will be identified and dealt with by the authorities. There will, of course, be some that continue under the radar, serving a small, diehard cadre of regular customers. There have been reports of liquor outlets admitting patrons and then locking them in to give the impression that the establishment is closed.

Some spaza shops are known as sellers of Alomo Bitters and other such (usually illegal) imports from West Africa, despite the fact that they contain over 40% alcohol, requiring them to be sold only by someone with a liquor licence. They are normally sold in 50ml sachets for R5, making them both affordable and an environmental curse. Not only are these products likely to be in even greater demand because of the lockdown, some spazas, allowed to stay open to sell basic foodstuffs and other essentials, have reportedly turned to selling other liquor too.

< The wisdom of closing the liquor taps has been questioned, including by those concerned about loss of livelihoods of people involved in the liquor trade, especially the economically vulnerable.

It is also said the government has shot itself in the fiscal foot because the ban on alcohol and tobacco means it will not get the benefit of an increase in excise tax on these products announced in the February Budget by the Minister of Finance.

There are also justified worries about the impact on people who have some form of liquor dependency – hard drinkers and alcoholics – who are now going through an enforced cold-turkey period, with potentially tragic consequences for some.

It is true there will be serious economic consequences for some of those trading in liquor (as is the case for all retailers selling “non-essential” products), especially those who make a subsistence living selling the product in shebeens and taverns. It is critical for the government to ensure its efforts to mitigate the economic impact of the Covid-19 lockdown include those running liquor outlets, but without succumbing to the temptation to rescind the ban.

It is equally true that the government will suffer a loss in excise tax. However, 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. Research by the government and the public health sector suggests that the annual tangible and intangible cost to the country of alcohol-related harm could be 10-12% of GDP, or two to three times the contribution the liquor industry makes to the fiscus.

One of the voices that have been raised in opposition to the restrictions is from the South African Drug Policy Initiative (SADPI). It is particularly concerned about people with substance-use disorders who cannot simply stop using whatever drug they are using, including alcohol.

Such people could have severe physical and/or mental reactions, including possible death. To avoid this, some will try and get alcohol illegally. SADPI is particularly concerned about people in precarious communities, living in overcrowded, uncomfortable conditions. They have to face the lockdown without the alcohol that some desperately need and many use to find relief from the reality of their harsh circumstances.

The people at SADPI are not wrong in identifying some of the unintended consequences of the State of Disaster Regulations governing the distribution and sale of liquor.

Liquor-related harm is a serious problem in South Africa (and the world) and not enough is done here or elsewhere (with rare exceptions) to mitigate the harm to those who drink and to those who are affected by those who drink. It is this failure to manage liquor effectively in “normal” times that has contributed to the crisis the lockdown poses for those with an alcohol dependence.

They are also not alone in their views. Numerous articles have raised similar issues since the lockdown began. One such report cites two doctors who also correctly call for South Africa to adopt an approach to Covid-19 that is appropriate to South Africa and not simply a response imported from elsewhere.

However, it is important to note that in the US and most European countries – indeed in most other countries in the world – there is access to liquor and tobacco even under lockdown. South Africa (and a number of other African countries), have considered what is most appropriate in their respective contexts and decided to impose total bans on alcohol sales. It is important, therefore, to investigate the extent, if any, to which allowing people access to liquor in some countries is contributing to both the rate of infection and to the levels of domestic violence, a major concern across the world which we will address below.

In anticipation of the extension of the original lockdown for another two weeks, announced on 9 April by President Cyril Ramaphosa, the liquor industry proposed an easing of the restrictions on alcohol which would allow off-consumption sales for a limited number of hours a day. Since the extension was announced, the Gauteng Liquor Forum (GLF) and others have written a letter to the government demanding that the President relax the restrictions by 14 April or they will seek relief through the courts.

The GLF was reported on 26 March to have issued a statement fully supporting the government’s Covid-19 lockdown measures.

Factors influencing the government’s decision to stop the flow of liquor

The reality is that, in crafting the Covid-19 Regulations, the South African government had to weigh up many factors, the most urgent being to decide what would be the most effective way to contain the virus and prevent its rampant spread across the country. Even if they had discussed the issues raised by the SADPI and others (including SAAPA SA in a press statement issued on 25 March) – and one hopes they did – their course of action would have been determined by considering what would contribute to the greatest good. Their decision, therefore, would not have been taken lightly.

So what would have compelled them to decide that the country should go “dry” for the period of the lockdown?

In a ministerial briefing on the day the Regulations were published, reference was made to the risk of an increase in domestic violence during the lockdown. The government’s opinion was that an increase was possible, given the inevitable tension that would arise from people being forced 24/7 into artificial proximity with each other for three weeks. Adding liquor into the mix was deemed likely to exacerbate the situation and therefore it was decided that it should not be sold while the lockdown was in place.

At the same briefing, the Minister of Police said all spare beds in hospitals should be available for Covid-19 patients and that this could be facilitated by freeing up beds normally used by persons who might be there as a result of alcohol-related harm, such as road accidents and assault.

SAAPA SA supports these views. Statistics have shown that liquor contributes to about 65% of “contact crimes”, one of which is domestic violence. Even under normal circumstances, liquor use is associated with up to 60% of domestic violence cases.

In recognition of the risk of an increase in domestic violence over this period, the government announced it had boosted the capacity of its gender-based violence hotline (Gender-Based Violence Command Centre: 0800 428 428 / *120*7867# from any cell phone) to be able to assist those subjected to abuse.

It is, of course, very difficult to know with any certainty whether the ban will help limit domestic violence or whether it might instead lead to a greater number of incidents. In the end, a hard decision had to be made, based on what was deemed likely to be most beneficial. It should also not be forgotten, in the context of the country’s understandable concern about gender-based violence, that domestic violence is not restricted to male violence against women. It also refers to high levels of violence by men, drunk or not, against children in the household who are, arguably, even more vulnerable than women.

Another reason for making liquor unavailable was to assist in the preventive measures considered key to the successful containment of the coronavirus. By now, virtually everyone on the planet knows, or should know, that these are physical distancing and the regular washing of hands.

It is difficult enough for sober people to change ingrained habits – shaking hands or embracing when greeting or saying goodbye to someone, touching one’s face, standing or sitting close to people – and to adopt new ones, such as washing hands thoroughly with soap and water every 20 minutes. How much more difficult is it for someone who has had a few drinks? After all, one of the many myths about liquor is that it helps one to relax, to overcome one’s inhibitions, to socialise more easily. That “relaxation” can be fatal.

Furthermore, someone who is drunk is less likely to observe the lockdown itself. We all know how stubborn and bloody-minded and difficult to manage an intoxicated person can be. Imagine trying to stop such an individual if he or she is determined to leave the house and go visiting friends, possibly even driving drunk to get there: “Ramaphosha can voetshek. Itsh a free country and I can go where I want!”

A further consideration in deciding on the ban on both tobacco and liquor was that these products are known to compromise the immune system and make a user more susceptible to communicable and non-communicable diseases. Tobacco reduces lung functioning, a serious risk factor with Covid-19, which attacks the lungs and renders a person unable to breathe properly. Liquor is increasingly shown to be associated with a range of non-communicable diseases, including a number of cancers, weakening the system and rendering it vulnerable to communicable diseases such as Covid-19.

Balancing individual and collective rights and wellbeing

One can, of course, argue that people have the right to live the way they like and to take risks with their own health. This is a debatable assertion at the best of times, especially in relation to alcohol. A study in the UK in 2010 showed that, out of 20 commonly used recreational drugs, alcohol causes the most harm to both consumers and the people around them. What’s more, alcohol is the only one of the 20 that causes greater harm to society than to the users themselves.

Even tobacco, opposition to which is largely driven by the problem of secondary smoke, causes more harm to individual smokers than to those around them. But the “free choice” argument simply cannot apply under current conditions. One of the primary objectives of the containment measures being adopted across the world is to prevent people from passing the disease on to others. So, while individuals may enjoy the questionable right to jeopardise their own lives, they don’t have the right to threaten the health and lives of others.

Of course, for those who are liquor-dependent, these arguments are difficult to accept as they struggle, in a very real and painful way, to deal with the consequences of not having access to their drug. Such people need and deserve empathy and society’s support in dealing with the challenges they face as a result of their addiction. But is opening up liquor outlets the answer?

When the government considers the best way to address a complicated issue, they must be guided by the principle that whatever they decide must serve the common good. In this instance, they had to decide what needed to be done to protect the majority of people from Covid-19, even if that decision would have a negative impact on a (limited) section of the population.

Some facts about drinking in South Africa

Let’s look at some statistics.

The World Health Organisation (WHO) Global Status Report on Alcohol and Health (2018) is a useful indicative overview of South Africa’s relationship with liquor.

Firstly (and surprisingly for some), WHO figures reveal that only 31% of South Africans aged 15 and above actually use alcohol (note that the legal drinking age in South Africa is 18, but WHO includes 15-17-year-olds to take into account the high level of underage drinking in the country).

Of the rest, a full 53.5% are lifetime abstainers and 15.5% are former drinkers. Of those who drink, 59% engage in “heavy episodic drinking”, also known as binge drinking. In other words, they don’t drink heavily all the time but, when they do, they go for it. This would include people who don’t drink at all during the week, but go overboard on the weekends (Phuza Friday etc).

On the other hand, only 7% of people aged 15 and above are classified as having “alcohol use disorders”, which include both the harmful use of alcohol (regular, excessively heavy drinking) and alcohol dependence (ie alcoholics). Those classified as alcohol dependent comprise 2.4% of people 15 years and above.

But, according to the WHO report, people aged 15 and above make up 71% of the population. Therefore, the 31% of those aged 15% and above who drink only comprise 22% of the entire population (ie 100%). It follows from this that the 7% of 15-year-olds and above with alcohol use disorders and the 2.4% who are alcohol dependent represent 5% and 1.7% of the whole population respectively.

The hard truth, then, is that the government cannot make decisions, such as whether to restrict access to alcohol, primarily to meet the needs of 5% of the population, especially if, in doing so, it potentially puts the lives of the rest of the country at risk.

In other words, the government’s response to the Covid-19 threat cannot be based on the challenges faced by a minority of a minority (people with alcohol-use disorders) or a minority of a minority of a minority (people who are alcohol dependent). Their decisions must be made in the interests of the majority of the country. And it should not be forgotten that this includes the interests of the aforementioned people with alcohol-use disorders, because they too need to be protected from the risks of contracting the virus.

In fact, given the observation above that alcohol compromises the body’s immune system, people with alcohol-use disorders are more vulnerable than most to communicable diseases such as Covid-19.

Giving support to people made vulnerable by alcohol addiction

But we are talking about people here, not statistics. The danger with statistics is that they reduce the real world to numbers on paper. But those numbers, for example, the 5% and the 1.7%, represent living human beings who may be in real pain, struggling to deal with their reliance on alcohol at a time that it is simply not available to them. The fact that they are a tiny minority in the country doesn’t mean their needs should be ignored. Steps must therefore be taken to protect and support them as much as possible during this difficult time.

What can be done? In correspondence recently sent to the government, Professor Charles Parry and others have suggested that, within the limited time and resource constraints available for mitigating the problems faced by people with dependency problems during the lockdown, the following measures are both necessary and possible:

1. Already identified individuals on treatment plans should receive continued support by treatment services. Existing services (state and private) should be supported to find creative ways to connect with their clients e.g. sending airtime vouchers; linking them to a free helpline; encouraging cell phone networks to allow free access to specified support services either by calling or connecting to websites, WhatsApp groups, Zoom/Skype sessions etc.
2. Undertake a wide-ranging communication campaign using all forms of traditional and new media to encourage people to seek help e.g. clinic or hospital visits, free helplines, daily television sessions to manage mild withdrawal symptoms.
3. Identify primary health care clinics and general practitioners for first-line treatment services, train identified staff in management protocol, deploy treatment experts to clinics and provide stock to treat withdrawal. This would include some form of screening (e.g. use of the 10-item Alcohol Use Disorders Identification Test) and might include provision of benzodiazepines (e.g. diazepam), thiamine (vitamin B12), Acamprosate, and/or Naltrexone and possible even Disulfiram (Antabuse) as medically assisted treatment, together with psychosocial interventions.
4. Increase staffing of helplines using social workers, psychologists, students, trained lay counsellors and staff currently employed by specialist substance-abuse treatment services registered with the Department of Social Development.
5. Produce and broadcast stress management sessions on all media platforms e.g. 10-minute work-outs with Siya; laughing yoga; thai chi; hand massages etc.
6. Promote alternative activities, e.g. provide people with seedlings/seeds and soil delivered by the army and police and have a national gardening competition with different categories, e.g. children, the aged and families.

The liquor restrictions are about more than just crime

It would also be helpful if the Minister of Health talked about the public health drivers of the alcohol restrictions during ministerial briefings on television and radio. To date, much of the public discussion of the restrictions has been led by the Minister of Police with respect to the role of alcohol in crime, domestic violence and other negative socio-economic indicators.

While these issues are critically important, the public need to be reminded of the many ways in which the restrictions are also contributing to the protection of public health.

The Minister of Health can also use the opportunity to encourage people to reconsider their relationship with alcohol and tobacco and take advantage of this period to reduce or end their consumption of these products in the interests of their own health and that of those around them. In addition, he can talk about how they can be supported in their efforts.

The minister can also share information regarding hospital admissions since the activation of the first State of Disaster Regulations on 18 March. Anecdotal evidence points to a remarkable drop in hospital presentations or admissions of people with liquor-related health issues, whether as a result of disease or trauma. While it’s difficult to determine the extent to which this is primarily an outcome of the general restrictions on movement or of the liquor restrictions, it is very encouraging.

There has also, according to the Minister of Police, been a dramatic reduction in crime. In its statement, the ministry said current analysis was based on a preliminary report that was yet to undergo the necessary verification and endorsements. Figures for the first week of the lockdown were compared to the same period in 2019 and revealed the following:

• Murder cases – from 326 to 94
• Rape cases – from 699 to 101
• Cases of assault with intention to inflict grievous bodily harm – from 2 673 to 456; and
• Trio crimes (car/truck hijacking, business robberies and house robberies) – from 8,853 to 2,098

On gender-based violence, the minister said over 2,300 calls/complaints had been registered from the beginning of the lockdown on 27 March to 31 March. As a result of these calls, 148 suspects have been charged so far. The total number of calls/complaints between January and 31 March stands at 15,924, an average of 1,225 per week. This seems to indicate a more than 100% increase in calls in the first five days of the lockdown compared to previous weeks.

This is a cause of great concern.

Research is needed to establish the drivers of this increase, which could include the overall stress of the lockdown itself and the involvement of alcohol in some cases. It is, of course, also possible that more people than usual have used the government’s GBV hotline because of heightened awareness of its existence as a result of government and civil society messaging during this period.

Over time, global research will also give some indication of whether reducing access to alcohol can be deemed to have contributed to an increase or a decrease in domestic violence incidents during lockdown periods. In the meantime, government and civil society must continue to do what they can to minimise this terrible scourge.

As with hospital admissions, it is not possible at this stage to determine the extent to which the ban on alcohol has contributed to the reduction in crime, given the restrictions on movement as a result of the lockdown. It is also not clear if the seemingly isolated incidents of looting of liquor outlets is a trend that will escalate further into the lockdown, especially now that it has been extended.

What to do

There is no doubt economic and political commentators, the liquor trade and sectors of the general public will continue to call for an easing of the restrictions on alcohol. They will do so citing economic hardship, crime, domestic violence, looting of liquor outlets, illegal selling and buying of alcohol, human rights violations, the suffering of people with alcohol dependencies and other considerations.

There is no question that the lockdown has brought about devastating economic pain, especially for subsistence traders. However, it is simply too early to argue definitively either way on whether the impact of the liquor restrictions on the other cited issues has been positive or negative. This lack of evidence is the most compelling reason to maintain the status quo for now. But proactive steps can be taken to mitigate as many of the challenges thrown up by the restrictions. SAAPA SA would therefore like to make the following recommendations:

• Government should present a united front with respect to the liquor restrictions. So far, the Ministers of Police and Social Development have commented on them. It is important that other ministers – for example, from Health, Transport, Trade and Industry, Small Business Development, even the President – should talk about the issue regularly and explain why, from different societal perspectives, the restrictions are necessary and important.
• Government should work with practitioners and researchers in the public health sector and with civil society to identify where interventions are necessary to reduce the negative impact of the liquor restrictions.
• All liquor outlets with shop windows should either remove their liquor products from public view or paper over their windows, as some outlets have already done – this should help to reduce the number of looting incidents.
• Government must use a combination of law enforcement and financial support to discourage the illegal distribution, transportation and selling of liquor under the lockdown. Communities must be encouraged to assist the authorities to identify places where liquor is being transported, distributed or sold, whether in liquor outlets that should be closed or in alternative outlets like spaza shops.
• If the Covid-19 situation improves to the extent that it is possible to consider easing the terms of the lockdown, government shouldn’t remove all restrictions on alcohol and go back to what was considered normal before the phased introduction of restrictions began on 18 March – i.e. closing times as late as 4am. Instead, SAAPA SA encourages an interim return to the initial restrictions which set the closing times of all outlets at 6pm from Monday to Saturday and 1pm on Sundays and public holidays. If this is accompanied by a relaxation allowing at least some freedom of movement, it will be possible to measure the impact of the limited operating hours on the country’s levels of alcohol-related harm. The findings will enable the government to make an informed decision, based on evidence, as to whether it would be wise to return to the old “normality” or to introduce a new “normality” of earlier closing times that could contribute to a permanent reduction in alcohol-related harm and to safer, more peaceful communities.
• As soon as the lockdown is over and/or the government and parliament resume their duties, they must reactivate the processing of liquor-related Bills, especially the Road Traffic Amendment Bill of 2015 and the Liquor Amendment Bill of 2017. Both Bills will contribute significantly to a reduction in the high levels of liquor-related harm and the saving of lives.

Covid-19 offers the country a unique opportunity to determine the extent and impact of liquor-related harm on the country and to take steps to limit such harm. It should not be wasted.

• Research can be undertaken to evaluate the effects of the liquor restrictions (and the phased post-lockdown period) through accessing information on a range of measurables including alcohol sales and other economic factors, and health and social harm such as trauma unit admissions, non-natural deaths including road deaths, and crime (such as rape, assault with the intention to cause grievous bodily harm, murder and theft of liquor). This will help to ensure that harm reduction imperatives are the main drivers of future liquor policies.
• Statistics can be compiled reflecting the extent of public access during the lockdown to helplines and other services for problems associated with domestic violence and alcohol dependency and withdrawal. The results will identify gaps in institutional capacity and service delivery that need to be filled.
• Finally, and perhaps most importantly, surveys should be done to determine the change, if any, in the quality of life of people living in communities that, before the lockdown, experienced challenges with liquor outlets operating in their neighbourhoods. The findings will provide guidance on how to ensure that the sale and consumption of liquor does not pose a threat to the public health, safety and wellbeing of ordinary people living in communities across our country. DM/MC

Maurice Smithers is director of the Southern African Alcohol Policy Alliance of South Africa (SAAPA SA), which aims to give civil society a “loud” voice in the formulation and implementation of public health-oriented liquor policy and to counter the influence of the liquor industry.