How about a night out at the movies to watch a black-and-white documentary about a mobile blood collection unit in rural Russia? Well, Mamma Mia it isn’t, but Blood turned out to be fascinating.
The team cram themselves and their clobber into a beaten-up minivan and drive through wintry forests, past dilapidated wooden houses into poverty-stricken towns. They are a jolly crowd. They visit these communities several times a year and they joke with the regular donors. At supper, the vodka and the banter flow around the crowded table, and the assignations follow. Something that lost a member of the team her job. Russian authorities do not like unvarnished truth being shown on-screen.
Much is familiar: dusty halls, anxious donors queuing at the registration table, the occasional struggle to get into a vein, the instructions to clench the fist. There are cups of tea, too, but just for the team.
There are other differences. Donors sit upright on hard chairs. Some have just come off a night shift, others haven’t the money to eat properly. Inevitably some feel faint. Their heads are shoved between their knees. It’s rough and dangerous treatment, although the staff aren’t unkind or, it appears, generally ill trained. It’s just the way things are done.
Staff worry about meeting their ‘bucket of blood’ targets. They are concerned about how many units will test positive for blood-borne viruses. Potential donors are worried about being accepted. A woman without an up-to-date residency certificate is turned away. A man insists he should be allowed to donate; he’s broke and he’s desperate to earn the 850 rubles (£13) payment. It is clear that most donors come for the money. For some it is a lifeline. When Russia passed a law forbidding payment for donation it was repealed after five months because blood supplies dried up.
Like Russia, the USA, China and Germany pay donors. Many other countries, rich and poor, now follow WHO’s recommendations that blood donation be voluntary. That’s because it is safer than blood from paid donors.
Altruistic Britons provide over two million units of blood per year. They feel they are doing good, and the cup of tea and digestive biscuit may have a retro charm. Many sessions are organised at workplaces, a bit of altruism for employers, and very motivating for the team to watch the boss be the first to roll up a sleeve. Now someone is trying to make it fun: Blood Sport is a video game which you play while hooked up for a venesection. When you are hit, some blood is withdrawn.
There is evidence that offering payment would put off at least as many donors as it would recruit. But donors need reassurance that their blood is not sold for commercial gain. It isn’t; their donations are separated into packed cells and platelets which are supplied to UK hospitals at cost price, and the NHS is self-sufficient in these products.
Nevertheless, thousands of NHS patients receive blood products from paid donors. Because of the risk of vCJD, British plasma is not used for patients. So we import plasma products from the USA.
Thousands of plasma donations go into one dose of clotting factors or immunoglobulin. If receiving a unit of red cells is like sleeping with six people, the risk of plasma products is equivalent to sleeping with 10,000. And blood-borne infections are a growing threat. In our overcrowded global community new diseases emerge from intensive farming or make the leap from wild animals to humans, and they can spread rapidly around the world. West Nile virus, SARS, parvoviruses – what bugs are already lurking in the plasma of donors from poor countries? And rich ones?
Few countries that pay for donation maintain the high standards of screening needed for patient safely. Even if testing kits are up to standard, available, and used, turning blood into a commodity opens the door to commercial pressures. Donors are dishonest about their risk factors, companies turn a blind eye, cut corners and bribe inspectors. Plasma proteins are extracted from circulating blood by plasmapheresis. Donors can donate every few days, so it can be a regular earner. In the USA the business has a long history of scandals. If you are on Skid Row, it’s a good way to pay for your next fix. China’s plasma trade has an appalling record.
Blood donation has never been without risk. Early transfusions, direct from donor to patient, were fraught with problems. Later, anticoagulation using citrate reduced the risk of clotting and made possible transfusion on the First World War battlefields. Incompatibility remained a hazard, exploited in Dorothy L Sayers’ 1936 short story ‘Blood Sacrifice’. When better cross-matching and screening became routine, the risks were all but forgotten. Then in 1983 haemophiliacs started developing AIDS.
British plasma is tainted because Mrs Thatcher’s business-friendly government relaxed the safety controls on cattle-feed processing. We now import our plasma via a government-owned company. Last year, the government sold an 80% share of the business to Bain Capital, a US venture capital group. Their interests lie in making money. As with cattle feed, industry takes the profits, the public bears the risks.
This year, the MRC developed a highly sensitive blood test for vCJD. If it proves adequate for screening donated blood we can decrease our dependency on imported plasma. But we won’t be self-sufficient.
We might possibly be able to supply enough intravenous immunoglobulin (IVIG) for patients with autoimmune diseases, immunodeficiency, and severe infections. But 85% of IVIG uses are off-label. This ‘wonder drug’ is being tried for everything from cancer to OCD in children. Immunoglobulin from the plasma of Ebola survivors is being trialled as a treatment for Ebola. Demand around the world is rapidly outstripping supply. Desperate situations demand desperate remedies.
Monovalent autoantibodies can be manufactured if the money and the will is there. But engineering IVIG products is a very long way off. The pressures on producers to exploit donors and cut corners will increase.
In myths and rituals all over the world blood has always had an ambiguous significance: giver of life and strength, but always tainted with menace.
Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.
Judith has now published all her articles from the NASGP website as a new book Perspectives: A GP reflects on medical practice and, well, just about everything…