“It’s getting worse every year,” Dr Saadiq Karriem, Chief Director of Generalist Specialist and Emergency Services at the Western Cape Government Health Department told Daily Maverick. “And there are three main reasons: alcohol, alcohol and alcohol. It’s the most important causative factor.”

According to the WHO’s Global Alcohol Report, South Africa’s rates of diagnosed alcohol dependence come in at under 3%, but the rates of alcohol use disorders are high, at over 10% in males and nearly 6% overall. Some 25% of the population aged over 15 are classified as heavy drinkers – meaning they have consumed at least 60 grams of pure alcohol at least once in the past 30 days. The per capita consumption of pure alcohol was around 11 litres from 2008–2010.

‘Tis the season

The consequences for the healthcare system are particularly serious. According to a 2014 study published in the South African Medical Journal by RG Matzopolous et al, “(alcohol) is the third-largest contributor to death and disability after unsafe sex/sexually transmitted infections and interpersonal violence, both of which are themselves influenced by alcohol consumption… In total, 36,840 deaths, 787,749 years of life lost and 344,331 years lived with a disability were attributable to alcohol, which together accounted for more than 1.1-million disability-adjusted life years (DALYs), or 7% of the total disease burden.

^“More recent analysis has included the contribution of alcohol to infectious diseases, which increased the estimated total alcohol attributable DALYs for SA to more than 1.3-million in 2004.” The study further noted injury-related costs, interpersonal violence and suicides, road traffic injuries, HIV/Aids and non-communicable diseases as consequences of alcohol abuse.

That’s in general. The festive season, punctuated as it is by the clinking of glasses, is a whole other ball game. Government has already appealed to the public to steer clear of substance abuse. “We urge South Africans to remember that life continues after the festive season and not to make bad choices during this brief period that … they will regret for the rest of their lives,” the Department of Social Development said in a statement.

According to the World Health Organisastion (WHO), South Africa has the highest number of drunk-driving accidents in the world; (nearly 60% of our approximately* 14 000 road deaths) and peak during holidays and weekends. Some 3,000 adult pedestrians are killed in motor crashes annually; 70 % of them are drunk. According to a recent report in Drum, one in seven drivers on SA roads are drunk at night and drunk drivers have twice the chance of causing an accident.

‘People go bananas’

The story of how the overburdened healthcare system affects patients has been told often. Less widely publicised is the effect on hospital staff. Dr Karriem explained that the consequences of drug and alcohol abuse – particularly over peak times – are severe not only for doctors, but all staff, from ambulance drivers and paramedics through to administrative staff, call centre operators, cleaners, security and even forensic and mortuary staff. Sometimes intoxicated patients are aggressive or abusive towards employees or place an additional burden on the security staff.

“It can be difficult to maintain staff morale,” he said. “We do our best. Some of the staff are exposed to a great deal of trauma, particularly during peak times. We hold debriefing sessions, both informally and formally – the latter being counselling for those who may need more psychological support.”

According to Karriem, the festive season is prime time for substance-fuelled gunshot wounds, knife wounds, gang violence, accidents, shebeen-related violence, not to mention injuries and illness related to child neglect. “You could write a whole separate series of articles on what happens to children and the abuse they suffer,” he said.

An additional risk, he added, applies to psychiatric patients, either those with a pre-existing condition or who are prone to anxiety or depression. The festive season is a difficult time for many, and this can trigger active episodes for those who suffer from mental illness. This, in turn, is also often a trigger for alcohol and substance abuse.

And just in case your festive cheer wasn’t quite sapped yet, coastal and holiday towns see a surge in drownings and disablings, often in children, owing to a lack of parental supervision.

“On any long weekend, people go bananas,” Dr B, a senior doctor in emergency medicine, told Daily Maverick. “Good Friday, December 16^th, New Year. The festive season is not necessarily worse than any other public holiday – you will see a peak because there is a series of public holidays in a row. But at any time that people have time off and money to drink, you will get a disaster.”

The good news, Dr B says, is that in most state hospitals, elective procedures are shut down over the festive season, so in some respects, medical staff experience relief. But conversely, there may also be senior staff on leave, so junior staff – although they are very well trained, she stressed – may be working with less direct supervision.

“On one hand, we do have less bed pressure because elective procedures are shut down, but sometimes people who would otherwise have gone to a clinic or day hospital then come to the emergency unit instead, so we have those people as well as the emergencies,” Dr B said. According to another source, some patients book hospital visits just before the holidays wishing to collect chronic medication in advance, which further adds to the festive load.

In the trauma unit, because the work is so intensive, weekday shifts are up to nine hours, while weekend shifts are 12 – 14 hours. But inpatient teams have shifts that last 24 – 30 hours at a time.

Emergencies during crunch time can seem overwhelming, particularly for young staff. “I remember taking my first stabbed heart patient to theatre as a brand new registrar just after midnight on New Year’s Eve,” Dr N, an anaesthetist who previously worked in the emergency unit in Baragwanath before relocating to the Western Cape, told Daily Maverick. “I couldn’t get hold of my consultant, as the phone lines were jammed with well-wishers’ messages. Several theatre staff members had conveniently taken ‘sick leave’ that shift. Luckily the surgeon was very senior and guided me along, and the patient had a good outcome.”

For Dr N, the festive season is concerning, particularly due to the increase in patients versus the decrease in available staff. “?Many staff members take leave and so departments run on skeleton staff?. Although planned elective operations are booked after the festive season, this is mismatched with the increase in trauma that is seen,” Dr N explained.

The doctors Daily Maverick spoke to also mentioned the migration of patients affecting the capacity of state hospitals. Many urban patients visit family in rural areas (where hospitals and clinics have constrained resources) or alternatively, coastal towns or holiday destinations have to cope with an influx of travellers. “?The health sector is under tremendous financial strain, as severe budget cuts have been imposed for the next three years, despite increasing health demands. All resources are severely stretched, from staff to wards and ICU, as well as blood products. The influx of tourists to small towns further increase the demand on health services,” Dr N said.

Dr L, from Red Cross War Memorial Children’s Hospital, gave some perspective simply by indicating how many patients were seen even on a normal day. “We perform ten operations a day; there are typically five to eight emergencies as well as elective surgeries,” she said. She wasn’t sure how many patients were seen throughout the hospital; she thought hundreds or even thousands.

Almost all the interviewees said staff burnout, or a breakdown in team cohesion, were a risk for staff working under extreme pressure in an overburdened system.

Management

The festive season, as stressful as it is, is managed as well as possible at hospitals. Dr L said the shutdown of elective procedures meant that the festive season was in some ways actually better. Emergency and trauma units remain fully staffed throughout the festive season; the trouble is that there tend to be more accidents and emergencies.

All possible precautions were taken to minimise risk for patients and staff alike, said Dr Karriem. “Where necessary, we do hire agency staff,” he said. “We try to have breaks between shifts wherever possible.”

There is also the triage system where patients are categorised into green, orange and red (red being most urgent and green being least urgent). Emergencies take precedence, but this doesn’t mean they will be seen immediately. “Waiting lists for the emergency theatre at large academic hospitals can be up to 80 cases long,” said Dr N. “Patients with less severe, but nevertheless urgent, indications for operations sometimes wait 2-3 days for surgery.”

Patients with less serious injuries or illnesses will have even longer waiting times during the festive season. These might be as long as eight hours or the patient may be told to come back, said Dr N.

Dr Karriem and doctors at the coalface alike urged the public to drink responsibly and seek medical help timeously where possible.

“Please rather make an appointment at local clinic for minor aches and pains,” said Dr N. “Drink responsibly, buckle up, avoid fireworks and have responsible adults watch over children. Much energy goes into management of preventable trauma, so there are even less resources to cope with non-trauma related illness.”

A little help

UCT Emeritus Professor Norman Faull told Daily Maverick that there was light at the end of the tunnel for under-resourced hospitals. Faull is founder and Chairman of the Lean Institute Africa, which assists public sector institutions with service delivery and specialises in helping frontline staff meet customer requirements without additional resources. The Lean Institute has been working with five Gauteng hospitals including Baragwanath, Sebokeng and Tembisa, drastically reducing patient waiting times by introducing data-based tweaks to the workflow.

“People speak about evidence-based medicine, but there is also a case for evidence-based management,” Faull told Daily Maverick.

Small amounts of data can have dramatic results for hospital managers. At Marapong hospital, initial data revealed that waiting times averaged 143 minutes from the time patients arrived at the first counter. The Institute asked staff about processes and found that, although files were well-organised and collected timeously the day before appointments, 20 – 30% of patients did not turn up and files were needlessly returned. The Institute proposed that files rather be pulled five at a time just before appointments. Waiting times were reduced to an average of 37 minutes. Similar results were achieved at other hospitals simply by changing locations of certain functional areas and reducing distances that staff or patients had to walk.

Faull’s suggestions for more effective festive management include detailed recordkeeping and stocktaking of processes at each hospital – “being measured, not as a punishment, but because it’s possible to see more patients in less time, with less effort” – and to organise leave in a manner that would match patient loads.

“Each hospital has its own challenges,” he said. “But in a workshop I ran today, all participants had the same feedback: they feel they are firefighting all day. We need to stabilise.”

Patients are the primary, but not the only victims of an overburdened healthcare system. Asked for a response to critics of healthcare staff, Dr N simply said: “Put yourself in the shoes of patients, or of overworked doctors… Much relies on good management at all levels of the pyramid.” DM

* Africa Check investigated the number of road deaths in South Africa, and found that the death toll could be as much as nearly 17,000, but unreliable follow-ups and categorisation of deaths meant that this data was uncertain.