As the full horror of the Orlando shootings unfolded, another story gained a slow and steady visibility in the media – the issue of blood donation. Not since Edward Cullen – the teenage heartthrob of the Twilight series – glided through the cafeteria doors of Forks High School, has the issue of blood received such attention, unfortunately at a price which society should never have had to pay. Two elements of the stories to have emerged struck me in particular: one was on the call from AIDS researchers and gay-rights activists to revisit guidelines on blood donation which do not allow men who have had sex with men in the year prior to the day of donation, to donate blood – this, an improvement from law which banned men who had sex with men from donating blood at all. The second element to have caught my attention was a small piece of information in a news story – on an organization other than the Red Cross being the point of contact for blood donation. This is important and relevant because it reminded me of how in many of our societies access to and availability of safe blood is a conversation yet to gain momentum; this blog picks up on the latter in the context of India.
Blood is sourced from other people, largely through donations. Voluntary blood donation is preferred over paid donation to prevent exploitation, as well as safer blood (for more on why voluntary donations are preferred, see here). Large disparities exist in blood donation rates between high income countries and low income countries. Almost 50% of blood donations are in high-income countries, at a rate of 36.8 per 1000 population, with it dropping to 11.7 for middle income and 3.9 in low-income countries. Disparities also exist in the way in which blood is used across countries. With very young children of less than 5-years receiving up to 65% of blood transfusions in LMICs whereas it’s those above the age of 65 who undergo blood transfusions in high income countries. In many countries such as India, almost half the collected blood is from those below the age of 25.
India, much like other LMICs, faces a chronic shortage of blood with a 25% gap (the WHO recommends at least a 1% reserve of a country’s population). For those of us living in cities in India – we’re better off. We might not have ready access to blood, especially for emergency services, and there is hope and the opportunity to arrange donations in exchange of blood used for scheduled and routine purposes (replacement blood – a concept wherein patients needing blood from a hospital would first have to provide donors from among family or friends – a separate donor for each unit of blood). It’s not unheard of getting urgent text or Facebook messages – usually from friends, of friends– all tapping into a network of people to look for potential blood donors. The country does not have a central blood agency; the Red Cross is well known for its blood donation drives, and creating visibility in this area of work. The private sector flourishes; even as stories on the poor standards and exploitation abound. From time to time the media picks up stories which reflect inadequate resources and regulation. The chronic shortage of blood is the perfect condition for an illegal market to flourish, nicknamed “red market” in this article. Horror stories of abuse and exploitation of the poor and vulnerable by an underground industry. The situation is perhaps even worse in rural and remote areas with places like Chhattisgarh facing a deficit of almost 81per cent. Even when available, quality and safety present major concerns; data sourced from National AIDS Control Organization (NACO) via a right to information initiative, indicate health system constraints have led to poor resources for testing, often leading to infections. It is estimated that in the past year alone over 2,000 people have contracted HIV as a result of blood transfusions in the country. And while efforts are being made to ensure regulations are in place to ban paying donors, to ensure quality and testing of blood by blood banks – the capacity to implement, regulate and ensure compliance is limited. And if exploitation and neglect weren’t horrific enough, one hears of things which border on the absurd, such as this week’s news when local authorities in the north Indian state, Punjab seized 7,600 liters of fake blood plasma – made of refined oil, soya bean milk and egg yolk. This really makes me wonder if people have lost all conscience.
Studies attribute the limited availability of blood in LMICs in general to a number of factors, including low donation rates, perhaps because of low awareness and poor health infrastructure; poor storage capacity and high prevalence of transfusion-transmissible infections in the blood supply from LMICs which often leads to greater wastage. Limited awareness and stigma on blood donation also contribute to lower donation. However, efforts, especially in the context of improving maternal health, have been undertaken over the last decade to set up blood storage facilities at first referral units, community health centres and primary health centres. India also has a National Blood Policy, and the regulation and monitoring is undertaken by the Drugs Controller General of India and also has the engagement of the NACO.
I wrote a draft of this blog on a day in which the Google Doodle celebrated Viennese pathologist, Karl Landsteiner who was born on the 14th of June 1868. Landsteiner classified blood into different groups in 1901 and created the blood grouping system we use today. It’s now also World Blood Donor Day. Voluntary blood donation in a high-income country has received reasonable media coverage over the last few days, unfortunately in the wake of unjustifiable violence; but perhaps this offers a chance for us to take this opportunity to think and include the issue of blood safety in our work as public health professionals.