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Purpose: Thesis submitted in partial fulfillment for the award of Bachelor of Medicine and Bachelor of Surgery (MBBS)

Authors: Siham Juan Lewai, Dona Joel Small, John Mabor Kok and Deng Simon Garang

Introduction

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University: University of Juba

College: College of Medicine

Study Area/Period: Juba, South Sudan (January 2012 – December 2012)

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INTRODUCTION

Despite general warning of its harmfulness to health, alcohol consumption has nevertheless re­mained a matter of public concern over the past few years in South Sudan. Major­ity of emergency cases at the Juba Teaching Hos­pital, for instance, are linked to terrible road traffic accidents that are also related to alcohol consumption.(MOH/RSS, 2013).

This research, Prevalence of Alcohol-Related Mortality Among Reported Cases in Juba Teaching Hospital, is a retrospective study of mortality due to alcohol among the population of Juba in a period of one year (January 2012 to December 2012). It assumes that without under­standing the gravity of deaths due to alcohol, no possible remedy could be forged to allevi­ate the negative impact of alcohol consumption among the population. It acknowledges the positive contribu­tion of pre-existing literature in this field, while fostering an understanding of the impacts of drinking on the lives of people, and as well present the many health issues for which alcohol is a great contributor. Where domestic violence and physical assaults have been strained by a drinker’s consciousness, there is less chance that the drinker reduces com­plications of excessive alcohol consumption.

Al­though it is controversial to state when exactly drinking is excessive, there is, however, consen­sus on the fact that any drinking that exceeds the guide to sensible drinking of alcohol at daily maximum of three (3) units for men and two (2) units for women is regarded as excessive. (Ku­mar & Clarke, 2011). Alcohol consumption can be assessed on the basis of units of alcohol in­gested. Drinking up to 21 units of alcohol a week for men and 14 units for women carries no long-term health risk. There is unlikely going to be any long-term health damage with 21-35 units (men) and 14-25 units (women), provided the drinking is spread throughout the week. Beyond 36 units a week in men and 24 units a week in women, dam­age to health becomes increasingly likely. Drink­ing above 50 units a week in men (and 35 units in women) is a definitive health hazard. Thus, a pa­tient’s frequency of drinking and quantity drunk during a typical week should be established.

Knowledge Gap

The above studies provide a general idea on the danger of alcohol in the global arena. However, less is known about alcohol-related deaths in the South Sudan context, and Juba in particular. With more traffic accidents, complications and many other causes of death in Juba, alcohol cannot be ruled out. But it would be a terrible bias to im­plicate this recreational drug (alcohol) in causing death without due evidence. Therefore, the study provides fresh information about this field for the benefit of the society.

Statement of the Problem

People are dying in Juba but by far and large the relevance of alcohol consumption to these deaths is underrated. Thus, this research shall delve into records to establish the significance of alcohol consumption as comorbidity and compounding factor in deaths.

Researches from around the globe indicate that many people are dying directly or indirectly due to too much alcohol consumption. There is unanim­ity on the threat imposed by increasing accidents and deaths due to alcohol among the population in Juba. The tradition that youths and old people could be differentiated on the basis of drinking is no more valid as alcohol consumption is no more an issue of age. Given the changing trend of our society, drinking has become synonymous with celebration: celebration makes sense when people drink, or no feast is feast without alcohol. More troubling than whether this behavior could be regarded as progress or retrogression in moral values of the society is how to save the popula­tion from the health and socioeconomic tragedies associated with drinking.

But when underscoring the negative consequences of drinking, for example, complications of drink­ing, it is pertinent to state at the outset that the dangerous extent of drinking is often above rec­ommended, and especially when it is addictive.

Despite public grievance that too much consump­tion of alcohol is harmful both to the individual and the society, there are no apparent signs that the drinking habit is reducing. In fact, many fac­tors (including peer pressure) keep recruiting on almost daily basis new drinkers, who subsequent­ly have to face the consequences of drinking.

In the light of the above fact, this research intends to examine deaths due to alcohol consumption and provide a categorical presentation of alcohol-related deaths.

Significance of the Study

In addition to contributing to already existing lit­erature, this research also seeks to provide one main goal. It aims to improve life and health by providing awareness information on all aspects of drinking with the view to shaping people’s perception of alcohol consumption well above recommended limits. As well, it seeks to curb al­cohol-related mortality by influencing stakehold­ers when enacting laws on the control of alcohol production and consumption.

Hypotheses

• Alcohol consumption is among the lead­ing causes of death in Juba City.
• People who drink alcohol are at higher risk of death compared to non-drinkers.

Goal and Objectives of the Study

The goal is to reduce alcohol-related mortality in order to improve the quality of life in South Sudan.

• To determine the leading causes of alco­hol-related deaths among the population of Juba City;
• To understand the distribution of mortality against gender and age;
• To raise awareness on the prevalence of alcohol-related mortality and inform the popula­tion about the recommended drinking habits and effect of excessive drinking; and,
• To share recommendations with policy-makers with the view to controlling and reducing alcohol consumption.

Limitations

Financial shortfalls dictate that the research area is only limited to Juba. It is highly probable that the drinking history of most death cases registered at the mortuary (Juba Teaching Hospital) may not be present, due to poor record keeping. This could render the research limited to only those whose previous medical records are available.

Also, this research does not establish deaths due to alcohol happening outside the hospital setting, because of lack of capacity to perform extensive research in the neighborhoods.

Although the research emphasizes the contribu­tion of alcohol to mortality, it nevertheless says nothing about how much alcohol the subjects studied consumed (that is, the units of alcohol consumed). But it is assumed that since they de­veloped the named conditions subjects must have consumed high quantities of alcohol prior.

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RESEARCH FINDINGS AND DISCUSSION  

1. General Presentation of Re­search Findings

The study examined mortality records obtained from Juba Teaching Hospital over a period of one year (from January 2012 to December 2012).

The mortality registered throughout the year 2012 was 1074 cases. 345 (32.12% of all mortality cases) were due to conditions such as liver cirrhosis, gastroenteri­tis, road traffic accident, alcohol intoxication, heart failure, hypertension, among others. Also, 133 of the subjects were known alcohol consumers, accounting for 12.38% of all mortalities and 38.55% of subjects of the selected conditions. This validates hypothesis 1, which asserts that ‘alcohol consumption is among leading causes of death among the population in Juba City.” (See Figure 5).

Besides, death among people known to drink alco­hol was found out to be more than twice as much as in those who are not known to drink, with 38 % and 16 %, respectively. Nevertheless, death was high­est among people whose history of drinking was unknown who comprise 46% of all alcohol-related conditions. It endorses the assertion that people who drink alcohol are at higher risk of death compared to non-drinkers (hypothesis 2).

Note: Of all the alcohol-related conditions, liver cir­rhosis, gastroenteritis, road traffic accidents and al­coholic intoxication accounted for most of the deaths throughout the years.

For the sake of clarity, alcohol-related conditions are conditions for which alcohol consumption is a known predisposing factor. As put forward earlier, the purpose of the research is to foster understanding on the impacts of drinking on the lives of people, and as well present the many health issues for which alcohol is a great contributor.

Direct death due to alcohol, taking the form of alco­holic intoxication, is a crucial part of the gross mor­tality, yet it accounts for just a minor fraction of all deaths. It is therefore relevant that more emphasis is put on the related conditions.

Unfortunately this research does not establish how much alcohol the subjects drunk in order to arrive at the conclusion that drinking culminated in their deaths. But throughout the study it has been found out that mortality is higher among subjects known to have been drinkers, compared to those without a his­tory of drinking. This relationship supports the patho­logical association between the disease causing death and alcohol as a predisposing factor.

One awkward challenge has been how to eliminate bias of results or explain inconveniences that are real. For example, consider Subject A, a known drinker, who dies of hepatitis. What are the chances that he died of hepatitis due to hepatitis B virus, and not al­cohol-related? What information is there to ascertain how much alcohol the subject drunk so that he/she later on developed alcoholic liver damage that result­ed in their death?

Generally, the key to answering this question is a con­cept on whether or not new symptoms suggest a new disease or are rather from an existing disease. And the odds ratio makes this clearer: the ratio of the prob­ability of the symptom, given the known disease, to the probability of the symptom given the new disease — the probability of developing the new disease – is usually vastly in favour of the symptom being due to the old disease because of the prior odds of the two diseases. Suppose s is quite a rare symptom of disease A (seen in 5% of patients), but that it is a very com­mon symptom of disease B (seen in 90%). If we have a man whom we already know has disease A and who goes on to develop symptom s, is not s more likely to be due to disease B, rather than disease A? The an­swer is usually no: it is generally the case that s is due to a disease which is already known, and does not imply a new disease. In other words, the probability of a subject dying of hepatitis, given he is known to be a drinker, is much more likely than the probability of dying of hepatitis because of viral infection.

Probability of developing hepatitis given alcohol consumption = P(H/A) = P(H)…..……(i)

Probability of acquiring viral infections = P(V) ………………………………..…………(ii)

Probability of developing hepatitis given viral in­fection = P(H/V) …………………….…(iii)

Probability of dying of hepatitis due to viral infec­tion = P(V) X P(H/V) …………………(iv)

A similar scenario in life is that a pilot is much more likely to die in a plane crash than a layman, given the fact that the pilot is already at risk. For the layman, he will have to board a plane in order to expect death from plane crash!

From the above equations, it can, therefore, be in­ferred that alcohol-consumption is much more likely to have caused death in the various conditions as op­posed to other aetiological factors.

1. The leading causes of alco­hol-related deaths in Juba

Alcohol-related conditions such as liver cirrhosis (as a complication of liver diseases), gastroenteritis, road traffic accident and alcoholic intoxication are among the leading causes of death in Juba. In 2012 (see An­nex 1), liver cirrhosis alone accounted for 20.58 % (71 cases) of deaths due to alcohol related conditions (345 cases), and about 6.6% of all deaths (1074 cases) recorded in the year.

Liver disease is the leading cause of alcohol-related deaths because 90% of alcohol is mainly metabo­lized in the liver. Because most people seek medical attention at late stages, liver cirrhosis appears to be the most common presentation compared to hepatitis. Lack of information on safe drinking habit among the South Sudanese people is a contributing factor to this mishap.

Gastroenteritis accounted for 20% (69 cases) of deaths due to alcohol-related conditions (345 cases), and about 6.4 % of all deaths (1074 cases) recorded in the year. It is worth noting that 29% of death due to gastroenteritis occurs in children, without obvious association with drinking. Thus, aetiological factors other than alcohol consumption are to blame.

On the other hand, road traffic accidents accounted for 15.65% (54 cases) of deaths due to alcohol-relat­ed conditions (345 cases), and about 5% of all deaths (1074 cases) recorded in the year; alcoholic intoxica­tion with 8.41% (29 cases) of deaths due to alcohol related conditions (345 cases), and about 2.7% of all deaths (1074 cases) recorded in the year; heart failure accounted for 7.83% (27 cases) of deaths due to al­cohol related conditions (345 cases), and about 2.5% of all deaths (1074 cases) recorded in the year. Other conditions, such as hepatitis, peptic ulcer disease, cerebrovascular accident (stroke), gastrointestinal cancer, pancreatitis and hypertension, altogether ac­counted for the remaining percentage of deaths.

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CONCLUSION AND RECOMMENDATIONS

The scourge of alcohol-related mortality is more than it can be underrated. It is a public health issue to which at­tention should be focused. Tackling this growing men­ace centers around effective policy design and enforce­ment. Planning and implementation of alcohol policies is a responsibility of national government, including health ministries, taxation and customs authorities, food and nutrition departments, education ministries, ministries of social affairs, and ministries of justice and police. Based on experiences in other countries where such policies are applicable, the following could be useful in formulating a public health approach as far as alcohol related mortality is concerned.

1. Education and health promotion

The citizens should be informed of health hazards of excessive drinking. For those who drink, awareness on a safe drinking habit is necessary to avoid them get­ting across the red-line. The media and public health departments, professional associations and academic clubs should be empowered to carryout public lectures and awareness rallies on thematic issues associated with drinking.

2. Regulation of physical availability

The most important factor in handling alcohol-related mortality is addressing availability. Take out alcohol from the reach of the population and see no more al­cohol-related mortality. Restricting sale of alcohol to only licensed companies or shops as well as increasing taxation with consequent increase in prices of alcohol­ic beverages could help reduce availability, as seen in Australia and Austria. In Kenya, for instance, licenses are issued to bars to brew and sell traditional African alcoholic beverages available only in the larger cities.

Prevention of purposeful addition of methyl alcohol to liquor can alleviate the danger of drinking. Methanol, which is issued in industrial products such as wind­screen washer fluids, copying machines and in embalm­ing fluids, is often referred to as wood alcohol because it was once produced chiefly as a destructive distilla­tion of wood. It causes retinal damage and blindness and features of poisoning, with resultant poisoning and death. The National Commission for Food and Drugs should embark on serious monitoring of all alcoholic drinks, including analysis in special laboratories.

Restriction of alcohol availability to young people (teenagers under-15) is also an effective regulatory mechanism in reducing alcohol-related mortality. At­tention to teenage involvement in handling and drink­ing alcoholic drinks should be abolished. This can re­duce the risk of reducing alcohol-related mortality in children.

3. Product labeling

This should be made mandatory to all breweries. The correct volume of alcohol by percentage should be made known to the public in order to avoid consump­tion of hazardous volumes out of ignorant.

4. Regulation of promotional activities

Breweries or companies dealing in sale of alcoholic beverages should be banned from making such mis­leading advertisements on the media. While they ad­here to the traditional warning that ‘excessive alcohol consumption is harmful to your health’, some compa­nies have developed adverts such as ‘alcohol relieves headache and pain which has undermined public health campaign to demobilize drinkers. (25).

1. Treatment strategies
2. Treatment Centers: Rehabilitation centers for people with drinking problems should be established in order to provide healthcare to subjects. Services that should be provided at these centers may include counseling and prophylactic medications to alleviate suffering. Should be included as part of primary healthcare – component of mental health
3. Pre-hospital treatment should include assessment of medical and psychiatric condition as well as severity of withdrawal in alcohol-dependence.
4. General measures consist in brief intervention by primary care physicians and family involvement. Treat comorbid problems, such as sleep, anxiety, and so on.
5. Nursing care is paramount in alcoholics. Fall preventions or restrictions are helpful if subject is de­lirious

 

You can download the research document here.