Another research missile has been fired into the debate over the effectiveness of alcohol bans in reducing trauma admissions to hospitals in South Africa, thus increasing the number of beds available for COVID-19 patients. It provides “compelling evidence” that full alcohol restrictions – rather than curfews – reduce unnatural deaths.
The research, led by actuarial scientist Dr Tom Moultrie from the University of Cape Town, was published in the South African Medical Journal last week.
“There is a significant association between the weekly unnatural deaths and full restriction on the sale of alcohol. This effect increases with increasing duration of curfew, but even with fairly modest curfew hours (four to seven hours), full restriction on alcohol had the effect of reducing unnatural deaths by around 42 deaths per day, or 26%,” says the article.
“In all periods where there were full restrictions on the sale of alcohol for off-site consumption, the excess number of unnatural deaths was significantly lower than zero, indicating a protective effect of the restrictions.”
Generally, periods where there was no full restriction on the sale of alcohol – regardless of the duration of curfew – did not significantly impact on excess deaths.
In the research team with Moultrie was colleague Dr Rob E Dorrington from the Centre for Actuarial Research at UCT; and Dr Ria Laubscher, Dr Pam Groenewald, Dr Charles Parry, Dr Richard Matzopoulos and Dr Debbie Bradshaw from the South African Medical Research Council (SAMRC) in Cape Town. Parry is also with the Department of Psychiatry at Stellenbosch University; and Matzopoulos and Bradshaw are also in the School of Public Health and Family Medicine at UCT.
The following is a summary of the SA Medical Journal article, and below it is the abstract. The full article – open access – may be read in the journal, using the link below.
The South African government invoked a suite of policy responses to curb the COVID 19 pandemic, the authors write. These have included restricting mobility through curfews and measures aimed at reducing the burden on the healthcare system through restrictions on the sale or consumption of alcohol.
The question as to whether curfews and restrictions on the sale of alcohol have had an effect on reducing unnatural deaths and trauma unit admissions in SA is important, and has generated substantial debate and commentary due to its economic impacts.
The article refers to a recent study funded by an alcohol industry group that found the ban on alcohol sales and consumption had little effect in reducing trauma unit admissions, and that curfews could have contributed to the decline.
“This contradicted another analysis that ascribes a significant decrease in unnatural deaths to the implementation of a sudden unexpected prohibition on alcohol sales in mid-July 2020 and a negligible impact of curfew duration,” write the authors.
The researchers performed statistical analysis on the effects of the policy implementation on the number of excess unnatural deaths in SA, making use of the extensive time-series of data on unnatural deaths compiled by a team of researchers at the South African Medical Research Council and the University of Cape Town – the SAMRC-UCT Collaboration.
The SAMRC-UCT Collaboration has published a weekly report of deaths in SA since March 2020 using information on deaths reported to the Department of Home Affairs and recorded on the National Population Register. The data do not contain detailed information on the cause of death, simply whether the death was due to natural or unnatural causes.
There was a three-way classification of alcohol restrictions: no restriction on the sale and consumption of alcohol; partial restriction on the sale of alcohol; and complete restriction on sale for off-site or on-site consumption.
Discussion and conclusions
“Our results provide compelling evidence that the restriction on the sale of alcohol rather than curfew is associated with the reduction in unnatural deaths observed during the COVID-19 outbreak in SA,” write Moultrie et al in the SA Medical Journal article.
These results are corroborated by data from a Worcester hospital study showing that full restrictions on the sale of alcohol were substantially more effective than partial restrictions in reducing trauma admissions.
“While bans on alcohol are particularly blunt instruments, the argument that it is curfews rather than bans on the sale of alcohol that avert unnatural deaths is refuted by this analysis.
“All instances of full restriction on the sale of alcohol are associated with a significant decrease in unnatural deaths (ranging from 42 deaths per day with a curfew of four to seven hours’ duration to 74 deaths per day under full lockdown),” the authors continue.
“However, this latter estimate is most certainly at the extreme of the likely impact of a ban on the sale of alcohol: that reduction arose from a very sudden imposition of the ban, and in the context of particularly severe restrictions on mobility and economic activity.
“Nevertheless, these results are consistent with work that estimated a minimum of 21 unnatural deaths averted per day in SA coincided with the implementation of the mid-July 2020 ban on alcohol sales.”
The authors list as study limitations a lack of data on potential confounding factors such as restrictions on inter-provincial travel, beach attendance, or data on liquor trading hours, along with absence of detailed information on the underlying causes of the unnatural deaths.
In the short term, the authors argue that the study will help policy-makers assess the impact of implementing alcohol bans as an emergency public healthcare response.
“It also strengthens the case for the implementation of bans on the sale of alcohol as part of the emergency response to ease the demand for emergency healthcare services during COVID-19 or future infectious disease outbreaks in SA and other countries with high alcohol-related injury burdens.”
The authors concede that “long-term implementation of alcohol restrictions would require significant trade-offs in terms of economic activity, as well as lives and livelihoods. Further research into this aspect is urgently required.
However: “By demonstrating an association between alcohol and unnatural deaths, the present study adds to the corpus of evidence that enables SA policymakers to adopt evidence-based strategies known to reduce alcohol harm through actions such as stricter advertising and promotions restrictions, minimum unit pricing, increased excise taxes, raising the minimum drinking age, restrictions on container sizes etc.”
Unnatural deaths, alcohol bans and curfews: Evidence from a quasi-natural experiment during COVID-19
TA Moultrie, RE Dorrington, R Laubscher, P Groenewald, CDH Parry, R Matzopoulos and D Bradshaw.
Author affiliations: Centre for Actuarial Research and the School of Public Health and Family Medicine at the University of Cape Town; the Biostatistics Research Unit, the Burden of Disease Research Unit and the Alcohol, Tobacco and Other Drug Research Unit at the South African Medical Research Council in Cape Town; and the Department of Psychiatry in the Faculty of Medicine and Health Sciences at Stellenbosch University.
Published in the South African Medical Journal on 2 July 2021.
Coronavirus disease-19 (COVID-19) restrictions, particularly relating to the sale of alcohol and hours of curfew, have had a marked effect on the temporal pattern of unnatural deaths in South Africa.
Death data were collected over 68 weeks from January 2020 to April 2021, together with information on the nature of restrictions (if any) on the sale of alcohol, and hours of curfew. Data were analysed using a simple ordinary least square (OLS) regression model to estimate the relative contribution of restrictions on the sale of alcohol and hours of curfew to the pattern of excess unnatural deaths.
The complete restriction on the sale of alcohol resulted in a statistically significant reduction in unnatural deaths regardless of the length of curfew. To the contrary, periods where no or limited restrictions on alcohol were in force had no significant effect, or resulted in significantly increased unnatural deaths.
The present study highlights an association between alcohol availability and the number of unnatural deaths and demonstrates the extent to which those deaths might be averted by disrupting the alcohol supply.
While this is not a long-term solution to addressing alcohol-related harm, it further raises the importance of implementing evidence-based alcohol control measures.
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