Thursday, December 28, 2017

Look what they done to my song (Musings on how paid plasma mirrors Rumpelstiltskin)

Updated: 5 Jan. 2018 
When I was a small child my grandmother always read me fairy tales and later had books for me to read. One of my favorites was Rumpelstiltskin originally published in 1812 by the Brothers Grimm, Jacob and Wilhelm (Further Reading). Since then the story has undergone many variations.

For the holiday season it seems appropriate to write a feel-good blog and I've done that in past years. (Further Reading) But recent news items made me think of Rumpelstiltskin. At its heart it's a fairy tale about greed and those who happily exploit others for personal gain.

What follows is my transfusion-related version of Rumpelstiltskin. Recall that fairy tales are often filled with scary, gruesome violence but somehow children thrive on them. Perhaps they're a way of exposing children to anxiety, fear, sorrow, and surprise and let them come away with new tools for managing their emotions?

Keep in mind that fairy tales are medieval (even prehistoric) morality tales and morality features in my Rumpelstiltskin tale. Of course, fairy tales derive from compelling stories told and retold over many centuries that have survived without being written, until folks like the Grimms put them on paper (Further Reading).

The blog's title derives from a 1970 ditty by Melanie Safka, known professionally as Melanie.

There's no executive version. Why read the blog? I hope it resonates with all transfusion professionals. If you disagree, I'm delighted and would love to see your comments. But you need to read the fairy tale to appreciate its meaning as a gestalt.

RUMPELSTILTSKIN (my version)
Once upon a time there was a poor man in America who had a beautiful 18-year old daughter. His wife had died years ago and he struggled to support himself and his daughter and worried how he'd pay for her upcoming post-secondary education.

Now it happened that he read an advertisement by a paid plasma collection company and saw that his daughter could transform her plasma into gold.

He couldn't donate because he didn't meet donation criteria, specifically he had spidery veins and blood draws were difficult. He called the blood collection facility and, to make an impression, he said, "I have a young daughter who can become a lifelong plasma donor."

The representative replied, "Great. If your daughter is as you say, then bring her to the plasma collection center tomorrow and we'll put her to the test."

When the girl went to the plasma collection facility, a staff member greeted her and asked for a current, valid photo ID, proof of her Social Security number, and proof of her current address. Then she underwent the standard process, as outlined in the example in Further Reading.

Even though she was afraid, she completed the online questionnaire and eventually donated her plasma, knowing she would please her Dad and would be able to pay for her own education. She vowed to do her best to transform her plasma into gold.

After multiple donations, because she could not afford protein-rich food, the young woman's protein levels fell below eligible plasma-donor criteria. It was then that her father introduced her to Mr. Rumple Stiltskin, a short man full of energy, indeed the prototype of an entrepreneurial hustler. Mr. S. said, "If plasma donation is kaput, I can help you transform your stem cells into gold. But I need a payment in return. What will you give me?"

"A body organ," said the girl, after thinking long and hard. She had a friend who donated a kidney to her brother, a living, directed donation, and the friend was doing well with one kidney.

Rumpel got her hooked up with a brokerage company overseas that brokered tissues and body organs for clients worldwide. The clients bought stem cells and used them to treat all sorts of conditions, even those for which evidence did not exist. But they touted themselves as helping patients, and who knows, maybe sometimes they did. Certainly they had many sports and entertainment celebrities praise their stem cell and platelet rich plasma injections as 'miraculous'.

She was paid a pittance for her stem cells compared to what recipients paid, but it helped since the plasma money-stream had dried up.

Later Rumpel came to collect on her promise. He said, "I'll harvest one of your kidneys. You'll earn a great deal for it. But in return I'll need another payment.'

The girl did not know what to do, but, now in too deep, and asked what she must do to collect her kidney money. I have nothing more that I can give you."

Rumpel replied, "Then promise me, whenever it happens, your first child."

Who knows what will happen, thought the poor man's daughter, Maybe I won't have a child. Not knowing what else to do, she promised the little man what he demanded. In return Rumpel once again paid for her body part, this time a harvested kidney.

A few years later, after graduating from college and getting a well paid job in Silicon Valley that supported her and her father, she met the love of her life. Within a year she delivered a beautiful child into the world. She had forgotten all about  the little man, Rumpel, but suddenly he appeared in her hospital room and said, "Now give me that which you promised."

She was frightened and offered the little man all the money she had saved if he would let her keep the child. But Rumpel said, "No. Something alive is dearer to me than all the money you now have. This kid will be a gold mine of body tissues and organs."

Then the young woman began crying so much that the little man uncharacteristically took pity on her and said, "I will give you three days. If by then you know my real name, then you shall keep your child." Of course, he felt certain she could not.

She spent the entire night thinking of all the names she had ever heard. Then she did a Google search on what names existed. When Rumpel returned the next day she showed him a huge printout of all the names she had retrieved. The little man scanned the pages and said, "None of these is my name."

The second day she sent inquiries to her Facebook, Instagram, and Twitter accounts as to what unusual names existed. Finally, she recited the oddest and most curious names she'd heard of to the little man.

But he always answered, "That is not my name."

On the third day someone on Twitter replied that he saw a comical little man in front of a house on his street dancing and chanting:
Today I'll bake; tomorrow I'll brew,
Then I'll fetch the new child,
It is good that no one knows,
 ____________ is my name. 
You can imagine how happy the young woman was when she heard that name. Soon afterwards the little man came in and asked, "Now, Madam, what is my name?"

She first asked, "Is your name 'Plasma for Humanity'?"
"No."
"Is your name 'If it Saves Lives It's OK'?"
"No."
"Is your name perhaps, 'First We Take Paid Plasma, Then We Take It All'?"

"The devil told you that! The devil told you that!" shouted the little man, and with anger he decided he needed to expand outside the USA.

 He set his eyes on the Great White North, Canada. Sure it was the land of universal health care, but these sappy socialist suckers could probably be sold anything if packaged right.

He concocted his plan of attack and called it 'The 7 Habits of Highly Successful Plasma PACs'. After all, he wanted to create a well funded, coordinated lobby group to influence decisions made by Canada's government on paid plasma. And plasma would be but the first step of many body tissues and organs.

RUMPELSTILTSKIN'S 7 HABITS PAC PLAN
1. Get well meaning stooges to tout the benefits of paid plasma. Probably right-leaning provincial politicians and the odd academic or two.

2. Pump up how Canada needs a more secure supply of plasma. A supply chain dependent on the USA has never been more at risk, given its current POTUS. He breaks long-standing negotiated international agreements in a New York minute. His protectionist, America first rhetoric suggests he's happy to tell the rest of the world to 'eff-off' so long as he can crow (tweet) to fans that he's made America great again, whatever that means.

Plus, of course, the Canadian dollar, with a fluctuating exchange rate vs the U.S. dollar, lately not to Canada's advantage, presented a major risk of unexpected cost increases.

3. Have the plasma industry fund as many research projects as possible to create markets for plasma and its derivatives that don't yet exist. For example, it doesn't matter if platelet rich plasma or IVIG works or not for a particular condition, so long as gullible, suffering folks think it might.

4. Encourage paid-plasma acolytes to fear monger. Promote that without an ever-increasing supply of plasma-derived products, 1000s of folks who depend on them will die. Make sure that patient groups funded by paid plasma's Big Pharma, and reliant on its plasma-sourced derivatives, see this as true. Post-truth arguments that play on emotion trump reality every time.

5. Get Health Canada to set up an Expert Panel to validate paid plasma as a good option under the guise of assessing the security and sustainability of Canada's immune globulin product supply. Be sure to have respected Canadian physicians on the Panel as well as U.S. reps, preferably someone with shares in Big Pharma.

6. Have the Panel apply the sexy, scientific 'risk-based decision-making framework' to the paid plasma issue and security of Canada's supply. (Further Reading) That's sure to clinch the argument.

7. Make the Panel's proceedings un-transparent and as hard to follow as possible. No need to upset the natives with what's truly happening. There's even a Canadian precedent. During times of regionalization and centralization, hospitals often kept staff in the dark because the powers-that-be didn't want to upset them, believing the 'poor little dears' couldn't handle the truth.

ORGAN TRAFFICKING  (See Further Reading for links)
Organ trafficking hasn't gone away, it's likely become more common. In 2007 the WHO published a paper on international trafficking in body organs. Excerpt:
The most common way to trade organs across national borders is via potential recipients who travel abroad to undergo organ transplantation, commonly referred to as “transplant tourism”....
“Transplant tourism” involves not only the purchase and sales of organs, but also other elements relating to the commercialization of organ transplantation. The international movement of potential recipients is often arranged or facilitated by intermediaries and health-care providers who arrange the travel and recruit donors. The Internet has often been used to attract foreign patients. Several web sites offer all-inclusive “transplant packages” – the price of a renal transplant package ranges from US$ 70 000 to 160 000 (Table 1).
The Middle East is increasingly a hot spot for the body organ trade. See 'Meeting an organ trafficker who preys on Syrian refugees' below. Here's an associated 2 min. 36 sec. video:
See Further Reading for more. 

BOTTOM LINE
Will Rumpel's Plasma PAC Plan work? Will my Rumpelstiltskin fairy tale come true? Or am I mistaken? Time will tell.

Musings: Is all change good? Selling plasma strikes me as morally wrong. Not just that it inevitably exploits the poor and earns Big Pharma $billions (spins plasma into gold) but that it diminishes us as humans when our body tissues are bought and sold (marketed) as commodities. And once you start it's a slippery slope. If plasma, why not stem cells? If stem cells, why not organs like kidneys? If body organs, why not everything?

As noted, organ trafficking flourishes today and involves live donors and recipients wealthy enough to travel and pay. And even once dead, your body parts have buyers. See 'The Chop Shop' in Further Reading below.

FOR FUN
This song was written and recorded by Melanie Safka 47 years ago for her 1970 'Candles in the Rain' album. The ditty fits the blog because it expresses how I feel about the blood system I've worked in all my life and loved, and is now changing in ways I thought it never would.
I love this song for its clever lyrics:
Look what they done to my song, ma.
Look what they done to my song.
Well it's the only thing
That I could do half right
And it's turning out all wrong, ma.
Look what they done to my song.
Look what they done to my brain ma
Look what they done to my brain
Well they picked it like a chicken bone
And I think I'm half insane ma
Look what they done to my song.  
 
Wish I could find a good book to live in
Wish I could find a good book
Well if I could find a real good book
I'd never have to come out and look at
What they done to my song
As always, comments are most welcome.

FURTHER READING
Fairy tale origins thousands of years old, researchers say (20 Jan. 2016, BBC)

Fairy tale of Rumpelstiltskin

Dec. 2015 'feel good' blog: Islands in the Stream (Musings on how love of transfusion medicine unites us)

First time plasma donors (one example of paid plasma process)

Health Canada: Expert Panel on Immune Globulin Product Supply & Related Impacts 
      Members of the Expert Panel

ORGAN TRAFFICKING
WHO: The state of the international organ trade: a provisional picture based on integration of available information
Meeting an organ trafficker who preys on Syrian refugees (BBC, 25 Apr. 2017)
The body trade - Reuters series ('The chop shop')
Search on Google for organ trafficking (1.3 million hits, 29 Dec. 2017)
'Risk-based decision-making framework' (~ 2min. video, CBS's Judie Leach Bennett)

'Risk-based decision-making framework' (Multiple short animated videos: Alliance of Blood Operators)

Paying for stem cells: A bad idea (5 Feb. 2012)

Thursday, November 30, 2017

Always on my mind (Musings on lack of transparency in Canada's blood system)

Updated: Dec. 1, 2017 (Fixed typos)
For November I had to write a blog on a current controversy in Canada related to paid plasma. Yes, I know I've written a lot about it already but 20 years ago this month, specifically Nov. 26, 1997, this was published:
  • Final report of the Krever Commission of Inquiry on the Blood System in Canada
This blog will be briefer than usual, partly because I wrote two blogs for October, but mainly because I invite readers to draw their own conclusions by reading the resources in Further Reading.

Executive version: Seems that Health Canada has not been transparent in its dealings with Canadian Plasma Resources and has exceeded its role as regulator. And who knows what CBS has been doing behind the scenes on the paid plasma file because they've been inconsistent on the issue.

Why read the blog? For Canadians it matters because of the fiascoes of the 1980s and '90s, which we do not want to repeat, ever:
  • 2000 Canadians contracted HIV via transfusion, 1980-85;
  • 30,000 transfusion recipients were infected with HCV,1980-90;
  • See Krever Report (Further Reading) for the errors made by Canada's faulty blood system and its experts.  
20 years later Canadian Blood Services brags that we have a transparent, accountable blood system.

Readers in other nations may find the Canadian lessons learned (and not learned) useful.

The blog's title derives from a 1972 ditty about a love story gone wrong.

MEDIA REPORT
The report that stimulated the blog is
  • A bloody mess: The story behind paid plasma in Canada (Further Reading). 
Using Freedom of Information, Macleans reporter Anne Kingston discovered that communications between Health Canada, CBS and CPR (private plasma paid company) between 2009 and 2016 raise new questions about blood governance in Canada and its ties to industry. 

KEY ISSUES
What follows includes tidbits in the Macleans article and Health Canada's response that I see as key.

1. Documents show Health Canada and the private plasma company agreed on the need to co-ordinate their responses to media questions.
My take: If true, that's unacceptable collusion and damning to HC.
2. Health Canada instructed Canadian Plasma Resources to monitor donor history of prior blood donation to ensure there is no negative impact on voluntary blood donations.
My take: Since when does a regulator (HC) rely on a private company to determine facts used to formulate public policy. Too stupid for words.
3. HC: The Dublin Consensus Statement was convened by a group of patient organizations, not an industry lobby group. International blood operators, including Canadian Blood Services also attended the conference, as well as...the Plasma Protein Therapeutics Association.
My take: Big Pharma's paid plasma companies fund patient groups big time and it's not always transparent. Patient groups invariably support Big Pharma's views, whether because of fear their therapies are at risk or because they need the funds. Some patient group execs seem to be in the back pocket of industry.
4. CBS is not innocent in all of this. Why you may ask? Mainly because its views and actions are erratic and Canadians have to wonder why. Examples:
  • For years CBS rightly emphasized paid plasma manufactured into blood derivatives such as IVIG were safe. Their views were echoed by HC but it seemed a united front in favour of, almost promoting, paid plasma;
  • CBS closed its Thunder Bay plasma collection centre, citing lack of demand for transfusion plasma, not the reality that outsourcing to USA for plasma-derived products was cheaper;
  • Then CBS pivoted 180o. In January 2017, it announced a 7-year, $855-million strategy to increase Canada's plasma self-sufficiency from 17% to 50%, requiring up to 40 new plasma collection sites;
  • CBS also changed its view on paid plasma clinics decreasing volunteer donations. First it was no, then yes.You have to ask why all the changes. 
BOTTOM LINE
As André Picard asks, have we forgotten the lessons of history, namely Canada's tainted blood scandal? To me neither CBS or Health Canada has been transparent. And the organizations are closely tied, given that HC has always relied on experts, including those at CBS, to determine policies.

FOR FUN
I chose this song because I like it and as a lifelong blood banker who lived through Canada's tainted blood scandal - where only Canadian Red Cross took the rap in courts -  it hurts when those we rely on let us down and folks die as as a result. And that is always on my mind.

The beautiful song was released in 1972 and covered by Willie Nelson in 1982.
As always, comments are most appreciated.

FURTHER READING
A bloody mess: The story behind paid plasma in Canada (22 Nov. 2017, Macleans)
Freedom of information documents (859 pages)
Have we forgotten the lessons of the tainted blood scandal? (André Picard, 28 Nov. 2017)
André wrote The Gift of Death: Confronting Canada's Tainted Blood Tragedy, to be made into a TV miniseries, Unspeakable,  in 2018
André's entry on the the Krever Report (Canadian Encyclopedia)
Health Canada assisted private plasma clinics, newly released documents say (28 Nov. 2017)

Statement from Health Canada in response to Maclean's article on paid plasma (24 Nov. 2017)

Monday, October 30, 2017

The Sound of Silence (Musings on Health Canada's Expert Panel on Immune Globulin Product Supply)

Updated: 31 Oct. 2017  (Fixed typos) 
For October I've written a two-fer, one blog in two parts. This second blog focuses on Canada's blood regulator (Health Canada) setting up an Expert Panel on Immune Globulin Product Supply & Related Impacts. Musings will be on why the panel was set up, why now, and the impact of who its members are.

Part Two was stimulated by something I came across purely by serendipity (because Health Canada does not widely advertise to the public matters related to the blood system), namely, an update to Health Canada's Expert Panel on Immune Globulin Product Supply & Related Impacts. Discovering the new members of HC's expert panel sealed the two-fer deal. This too was a blog I had to write.

Why read the blog? To me, it helps if everyone involved in transfusion medicine in local, regional, national, global communities is aware of events occurring at a high level with 'biggies' (so-called 'thought-leaders') involved and driving the process and outcomes. That way, the 'hoi polloi', we trench workers, aren't blind-sided by decisions that seem to come out of nowhere from above.

Plus it's not so much that HC's panel is an example of GIGO (garbage in, garbage out):
  • Computer science acronym in which bad input will result in bad output. Because computers use strict logic, invalid input ('garbage') may produce unrecognizable output ('garbage')
It's more that results can be determined by the folks deciding, because even the most well intentioned come with a ton of baggage (experience, biases, and hard-wired beliefs) that influence their views.

Consider for a moment if a US Supreme Court decision was to be made solely by Antonin Scalia vs Ruth Bader Ginsberg, both respected, honorable Justices of integrity. (Google them, if needed)

The blog's title derives from a 1964 Simon and Garfunkel song I've used several times before.

HEALTH CANADA'S EXPERT PANEL: WHAT WE  KNOW 
Or more likely, what we don't know.

Let's discuss why the  Expert Panel on Immune Globulin Product Supply and Related Impacts in Canada was set up, why now, and the impact of who its members are.

WHY
Why was the expert panel set up? The stated aim:
The Expert Panel...will objectively assess the security and sustainability of Canada's immune globulin product supply.

There's that word again, sustainability. Also note the use of 'objectively', perhaps meaning the current catch-phrase of all health-related decisions, evidence-based. Interesting that HC used 'objectively' as if they needed to emphasize that. Who would ever think otherwise, that HC would assess subjectively? [She said, ROTFL]

WHY NOW
Who knows. My guess is that the USA's focus on a sustainable blood system played a role. Perhaps this motivated CBS CEO Graham Sher to ask provinces for $100 million over six years to
make CBS more self-sufficient in collecting plasma? (Further Reading) And less reliant on USA, more important than ever with unpredictable Trump as President?

Or maybe all the protests against paid plasma clinics motivated Health Canada to end the discussion once and for all? Remember in 2013 that they held a round table on paid plasma that was a farce (Further Reading):
  • Day tripper (Musings on HC's instructions to the jury on paid plasma)
PANEL MEMBERS
We now know all four of HC's expert panel members: a Canadian Chair and Deputy Chair, and two 'advisors' both working in the USA. Not that Health Canada advertised them. Fact is, I came across the update by chance. See Further Reading for their details and responses to competing interest questions.

First, the only panel member I've met F2F and talked to is Deputy Chair, Francine Décary, an award-winning transfusion medicine leader who I respect unconditionally. I know the Chair Penny Ballem by reputation only, an experienced physician-administrator. The two advisers are accomplished professionals, in many ways both 'forces of nature'. There is no reason to doubt their integrity.

Yet my skeptical meter is on high alert. Why you may ask? Reasons include HC's prior pro-plasma bias and its four expert panel members. See if you can discern my unease.

1. Chair, Penny Ballem,MD, FRCP, FCAHS 
Deputy Med Director CRC BTS, BC Deputy Minister of Health, Vancouver City manager, and several academic appointments.

Brilliant physician turned 'suit', at which she also excels. Civic and provincial government appointments involved finding ways to cut costs and still provide high level of service.

2. Deputy Chair, Francine Décary,MD, PhD, MBA
Much respected former CEO of Héma-Québec, epitome of person you'd love to have a beer with. Many honours including Order of Canada, was President of ISBT  and Chair of the Foundation for America's Blood Centers.

Dr. Décary is long-time blood system administrator - person responsible for running a business or organization - operating at the highest level in Canada, USA, and globally.

3. Adviser Patrick Roberts, PhD 
Roberts has been involved with the pharmaceutical industry that relies on paid plasma for years and his consulting firm specializes providing information on the plasma derivatives industry.

He was Bayer's (now Grifols) Marketing Research Manager of Plasma Products Division.

Also, he owns individual stocks in plasma companies: CSL Behring, Grifols, and Shire.

He's the President of Marketing Research Bureau (MRB), a supplier of information Big Pharma and more, including Canada's blood supplier, CBS. MRB is an associate member of the Plasma Protein Therapeutics Association (PPTA).

For reference, PPTA represents the private sector, a part of Big Pharma whose business involves collecting, manufacturing, and selling blood-derived plasma products.

From CBC 2013 news item, Paying for blood plasma raises new questions (Further Reading)
"Analyst Patrick Roberts has predicted that the industry will be able to meet future demand, even if a new market develops for IVIG, in treating Alzheimer's, a potential use that is still in clinical trials.  And now, with recent news that the largest placebo controlled clinical trial has been halted because IVIG did not show a statistically significant improvement in functional ability or a reduction in cognitive decline compared to placebo, this anticipated surge in demand for human plasma might never materialize."
Roberts' message: There's no imminent shortage of IVIG. Have conditions dramatically changed in past 4 years?

4, Merlyn Sayers, MBBCh, PhD
Dr. Sayers is President and CEO of Carter BloodCare in Dallas/Fort Worth, previously the Medical Director at the Puget Sound Blood Center in Seattle and was President of America's Blood Centers. Another experienced, respected physician who is a long-time administrator at the highest levels of USA's blood system.

BOTTOM LINE
All of Health Canada's panel members are impressive, accomplished individuals. No doubt HC chose Canadians Drs. Ballem and Décary with a view to shutting down criticism of the panel's conclusions.

Interesting that 3/4 panel members are long-time blood system administrators and one is a consultant who earns a living from the plasma-derivative industry. No doubt HC thinks they can OBJECTIVELY assess the security and sustainability of Canada's immune globulin product supply. I'm not so sure.

FOR FUN
I chose Simon and Garfunkel's song because it seems to me that Health Canada is too often silent on providing Canadians with access to major events involving the blood system. No press releases about updates, no tweets, no nothing. Plus HC has a history of skewing the playing field to get the results they want (Further Reading): Day tripper (Musings on HC's instructions to the jury on paid plasma)
As always comments are most appreciated.

FURTHER READING
Health Canada: Expert Panel on Immune Globulin Product Supply & Related Impacts

Industry advisors to Health Canada's expert panel
MRB: CEO Patrick Robert

Biographies of HC's 4 Panel members
  • Includes 'Questions asked to assess affiliations and interests' and replies.
CBC (25 April, 2013): Paying for blood plasma raises new questions

Canadian Blood Services calls for provincial funding for plasma clinics (26 Jan. 2017)

Day tripper (Musings on HC's instructions to the jury on paid plasma) (12 July 2013)

Take a chance on me (Musings on USA's unsustainable blood system)

Updated: 30 Oct. 2017 (Fixed typos)
For October I've written a two-fer, one blog in two parts. The first part was stimulated by three related items in TraQ's Oct. newsletter (Further Reading):
  • Klein HG, Hrouda JC, Epstein JS. Crisis in the sustainability of the U.S. blood system. N Engl J Med 2017 Oct 12; 377:1485-8.
  • Building a more sustainable U.S. blood system. (Rand Corporation, Research Briefs, Nov. 2016)
  •  Mulcahy AW, Kapinos KA, Briscombe B, et al. Toward a sustainable blood supply in the United States: an analysis. Rand Corporation, 21 Nov. 2016.
PART ONE: This first blog is on USA's non-sustainable blood system. In a way the two blogs Oct. are related. Both involve protecting the SUPPLY of life-saving blood components and products and managing threats to that supply.

EXECUTIVE VERSION: This first blog will discuss sustainability issues in the US blood system. Quite a wake-up call that the American private, market-based blood system is failing.

Why read the blog? To me, it helps if everyone involved in transfusion medicine is aware of the big picture nationally and globally because it helps us interpret background noise that may otherwise fly under the radar.

Moreover, many health professionals outside the USA may not be 'into' the economic conditions that a private blood system, or private healthcare for that matter, operate in.

Allow me two anecdotes. Medical Laboratory Science graduates who went to work in the US in the 1990s told interesting tales of some of the differences between Canada and the US. For example, how each new transfusion service work-up on a patient with difficult red cell antibodies required careful documentation of codes (time-consuming major distractor) in order to charge Medicare / Medicaid properly or to add to the patient's increasing hospital bill.

Or how one grad worked in a Las Vegas mega-lab where technologists were more like factory workers on an assembly line and didn't need to worry about quality control because that was someone else's job. No doubt the huge private lab had wrung every efficiency out of the system in order to decrease costs and compete for business.

The blog's title derives from 1978 ditty by Sweden's ABBA, which I've used once before.

USA BLOOD SYSTEM 
Regarding the USA situation, I recommend viewers read the three fascinating items in Further Reading. The 12 Oct. 2017 'Sounding Board' piece by Klein, Hrouda, and Epstein in New England Journal of Medicine clearly derives from Rand Corporation Research done in Nov. 2016.

What follows are my take-aways about the U.S. blood system. Although I follow events there closely, my grasp of the intricacies of the business side of things is limited. Bear with me as I describe what I see as the 'big pic' of the U.S. system.

Many developed nations have a single, government-funded blood supplier, e.g., Australia, Canada, France, Ireland, New Zealand, UK, and more. The USA opted for a private system composed of non-governmental organizations (NGOs) that sell blood on the open market to hospital clients. The U.S. even has blood brokers who buy from the blood centers who collect and manufacture blood components and sell to hospitals who need components to treat patients.

In the USA's free enterprise blood system, markets rule. The price of blood components and products depend on supply and demand. Suppliers (blood centers) compete for hospital customers based on pricing and service just as for-profit businesses do.

The pressure is on blood centers to produce products more efficiently and reduce the price, or improve a key required quality, so that hospitals will pay more to get it.

Under such a system, assuming no new major injection of funds, businesses, including non-profit blood suppliers, will fail once expenses exceed revenues, and cash reserves and sellable assets are depleted.

THREATS TO SUSTAINABILITY
The following is my take on the NEJM article and related Rand search.

The U.S. free market in blood struggles for several reasons. These include decreased demand for blood components because of
  • Patient blood management programs that reduce the need for transfusion and decrease healthcare costs, while ensuring that blood is available for patients who need transfusion;
  • Less invasive surgical procedures;
  • Development of drugs that reduce surgical blood loss and decrease the need for transfusion.
In business terms, demand for blood center products decreased. Data point: Blood transfusion decreased ~25% from 2008-2017 and may decrease by 40% by 2020. Accordingly, supplier (blood center) revenue decreased and their cost/unit increased.

The result has been that the client/consumer blood system (hospitals) have increased consolidation to decrease their costs. And blood suppliers now must deal with more large institutions with increased bargaining power, further driving down blood center revenues.

Another reality: Apparently U.S. blood collectors are reluctant to introduce new technologies that make the blood supply and transfusion safer because hospitals won't pay for them unless they are government-mandated, e.g., Zika virus and Babesiosis screening, red-cell genotyping.

Of course, today what determines introducing new blood donor screening tests is risk-based decision making, one factor of which includes economic realities. Decision makers look at factors such as
  • Condition prevalence;
  • How serious the condition/disease to be prevented is;
  • Cost of preventing one case.
Bottom line
Most of America's Blood Centers and the American Red Cross  operate at a loss, provide blood components below cost. The American blood system has become unsustainable.

What to do? 
Rand Corporation proposed three alternatives. Let
1. U.S. blood system continue to function as it has;
2. Government play a more active role;
3. Government assume complete responsibility.

Of course, predictably, they opted for #2 in which the U.S. blood system remains privatized but with some additional government intervention. Translation: The government funds and takes care of safety issues for which a good business case cannot be made by the private sector. Perhaps a form of corporate welfare in a good cause?

MY TAKE-AWAY CONCLUSIONS
As the NEJM authors state (no-brainer, obvious to all)
  • Adhering to supply and demand ignores the importance of safe, available blood because blood is more than just another consumer good.
I dig that USA will never opt for a government-funded blood system as many developed nations have. The transition would be too against the 'land of free enterprise' and too messy a transmogrification.

On one level it seems that USA wants to have its cake and eat it too. I'm reminded of private, for-profit healthcare clinics in Canada that the rich can access. They tend to 'cherry-pick' the healthiest patients, who are the easiest and cheapest to treat AND send those who are very sick and unprofitable to treat back into the government-funded public system.

Also seems similar to some businesses that carp about government intervention and regulations, even descend to diss folks on welfare, resent increases in the minimum wage because it affects their bottom line, yet are the first in line when their business is in trouble asking for a government bailout. But perhaps that's too harsh.

FREEDOM TO FAIL
To be philosophical for a moment, a private, free enterprise system based on markets, competition, supply and demand is messy and has proven to be the economic equivalent of democracy, the worst form of government, except for all the others. The quote is attributed to Winston Churchill but it's not his.

As an aside, an original Churchill quote, one that breaks me up:
  • 'The best argument against democracy is a five-minute conversation with the average voter.'
Like all market-based businesses, a private blood system has many freedoms and one is the freedom to fail. To succeed and survive, businesses, including NGOs, must continually eliminate waste, increase efficiency, and offer competitive prices for goods and services.

Even government-funded national blood suppliers like CBS constantly strive to decrease costs. Examples include the
  • Introduction of less well paid 'donor care associates';
  • Consolidation of donor testing and component manufacturing to a few regional centres;
  • Closing a plasma collection clinic because it was cheaper to out-source to the USA.
I wish the US blood system well as it struggle through its cognitive dissonance with upholding a private, market-based free enterprise blood system and realizing that government help in the form of funding is essential for the now dysfunctional system to survive. The market worked as it should for decades, then created a huge Oops!

FOR FUN
I chose this ABBA song as a message to the USA to take a chance on a government-based blood system. Guess I think the only causes worth fighting are the hopeless ones.

That's something U.S. will never do, just as they will never adopt universal healthcare system like Canada's even though it's proven to provide better outcomes at much less cost. They made their bed and are doomed to lie in it.
As always comments are most welcome.

FURTHER READING

Klein HG, Hrouda JC, Epstein JS. Crisis in the sustainability of the U.S. blood system. N Engl J Med 2017 Oct 12; 377:1485-8.

Building a more sustainable U.S. blood system (Rand Corporation, Research Briefs, Nov. 2016)

Mulcahy AW, Kapinos KA, Briscombe B, et al. Toward a sustainable blood supply in the United States: an analysis. Rand Corporation, 21 Nov. 2016.

Wednesday, September 27, 2017

While my guitar gently weeps (Musings on recent transfusion-related news)

September's blog will feature four news items in recent TraQ newsletters, items that are a tad different but worthy of featuring, nonetheless. For links to all featured news items see Further Reading.

EXECUTIVE VERSION: There's no need for one because this blog is just a few comments on a series of 'odds and sods' news items that I find interesting. I hope you do too.

The blog's title derives from a 1968 Beatles ditty by George Harrison I used once before in a 2012 blog.

ITEM #1
Why Canada needs USA sperm [and plasma] (13 Sept. 2017)

The article is by Peter Jaworski, who co-authored, 'Markets Without Limits', the primary thesis of which is, "Anything you may permissibly do for free, you may permissibly do for money."

Peter is a Canadian who teaches 'business ethics' (an oxymoron? - Just joking!) at Georgetown University in the USA and is associated with right wing organizations such as the Canadian Constitution Foundation.

He's getting his views that we should allow selling plasma, sperm, kidneys, indeed any body organ, published in many newspapers and journals. Same ideas, rehashed again and again. That's a well known marketing strategy for today's authors if they want to be successful. And it works because newspapers especially are desperate for free articles.

But in the latest oped to promote his book he (a 'business ethicist') doesn't mention - not one word - about the disgusting history of selling sperm in Canada. Facts (Further Reading), which include:
  • Donor lied about medical history, affecting 26 families;
  • Donors not fully screened for HIV and other infectious diseases;
  • Shortage of Canadian sperm is not that men are unwilling to donate without pay. It's about government health and safety regulations to protect people who use donated sperm and the children they conceive.
ITEM #2
The donor who saved over 2 million children (25 Aug. 2017)

80-year-old Australian James Harrison donated plasma with potent anti-D for ~60 yrs. He recently made his 1157th donation. Until 2015, every batch of anti-D [Rh immune globulin] made in Australia contained his antibodies.

If Mr. Harrison lived in the USA he could have opted to earn significant money from his plasma. Who knows how much if he wisely invested it, since he's unlike most US paid plasma donors, who are need the money and are willing participants (victims) in their own exploitation.

But the Australian chose to donate voluntarily for free. To revise a phase from US politics, 'I'm with him.'

ITEM #3
CSL (Australia): Bullying, sex toys and how CSL got rid of a complaining employee (6 Sept. 2017)

This is a fascinating case in which the employee being bullied was male and his boss was female. To get rid of him, CSL (world leader in the plasma protein biotherapeutics industry) started a campaign to find anything they could use against him, even to the point of discovering he sold sex toys on e-Bay. He was fired.

Australia's Fair Work Commission found that he was unfairly dismissed. His female boss apparently remains at the company.

ITEM #4
Case of a transfusion medicine physician, who with her then spouse, bought 4,000 shares of Immucor in 1982 for $11,000 (7 June 2017)

This real case focuses on the doctor's tax woes in the USA after her share became $1,717,038 in 2011. The Court found the doctor's tax issues were not due to her errors but rather the person who prepared her taxes.

Interesting 'What if': Would the transfusion doc, when she was publishing in medical journals decades ago, have mentioned her Immucor shares? In the 1980s did medical journals have conflict of interest or competing interest requirements?

For interest, the physician in question is now a septuagenarian but still active.

FOR FUN
I chose the song based on the first and third news items. In the first a 'business ethicist' promotes selling body tissues and organs without thought of where that will lead us. Especially how it will lead to the wealthy even more exploiting the poor people in this world.

And result in tissue/organ brokers getting rich off the misery of the poor and disadvantaged. Just as paid plasma companies gain incredible wealth from the needy selling their plasma.

All for the sake of a buck. But conveniently camouflaged under the guise of doing good by helping patients who need plasma-derived products. Kinda reminds me of Robin Cook's book, Coma, and the movie based on it.

In the third news item a man was judged to be unfairly dismissed but the issue is the company went after his private life to get evidence to justify firing him.
Love these words:
I look at the world and I notice it's turning
While my guitar gently weeps
With every mistake we must surely be learning
Still my guitar gently weeps 
As always, comments are most welcome.

FURTHER READING

NEWS ITEM #1
Jawarski articles
  • Early Career Research Spotlight – Peter Jaworski (Journal of the American Philosophical Association,10 May 2016)
What Jaworski doesn't mention:
NEWS ITEM #2
NEWS ITEM #3
NEWS ITEM #4

Monday, August 28, 2017

We are the world (Musings on the humanitarianism of selling body tissues)

Revised. 3 Sept. 2017 ( in 'Panda'; Further Reading)

August's blog was stimulated by three news items in TraQ's August newsletter (Further Reading):

* The Australian donor who saved over 2 million children. The donor developed anti-D from transfusions as a 14-year-old and since age 18 has voluntarily donated red cells and plasma, the later used to prepare Rh immune globulin;

* China: Liver problems boost demand for US blood plasma (China consumes half world's supply of human serum albumin);

* Canada needs blood plasma. We should pay donors to get it. Op-ed by the author of  'Markets Without Limits', the primary thesis of which is, "anything you may permissibly do for free, you may permissibly do for money.". Even selling body organs like kidneys okay and doesn't exploit the poor, if only people above a certain level of income are allowed to sell their kidneys. Indeed, it's desirable because the market in organs helps save lives. At least that's the theory.

The blog's title derives from the 1985 Lionel Ritchie - Michael Jackson song that 'United Support of Artists for Africa' (aka 'USA for Africa') recorded and became one of the biggest selling singles of all time. I wrote two earlier blogs in 2010 and 2013 using this song (Further Reading), but now I'm whistling a different tune.

EXECUTIVE VERSION: This blog will highlight my conversion to what my dear departed Dad would call crass commercialism and commodification of everything. But I've had my come-to-Jesus-moment, folks.

I've heard thought leaders like Peter Jaworski on the value of unlimited markets and the public's misconception that buying commodities such as body organs and tissues is immoral.
Peter's research at Georgetown University focuses on the moral limits of markets, including markets in blood and kidneys and the morality of markets.  He's also a Senior Fellow at the Canadian Constitution Foundation, which opposes what it sees as the watering down of constitutional principles by governments and left-wing interest groups. And now he writes opinion pieces for Canada's right-wing National Post (one of many Postmedia papers).
Henceforth, I've adopted the premise that there are no goods or services whose sale should be forbidden, except for those that it is morally wrong to sell and buy, regardless of whether filthy lucre changes hands or not. Oops! Make that shiny, clean lucre.

And your guess is as good as mine as to what 'morally wrong' may be. Because when nothing short of murder is okay to pay for - under the right circumstances - decided by gawd knows who - almost anything goes, providing it creates free enterprise markets and does some good.  

So, yes, the blog is provocative and satirical, and if I offend anyone, am politically incorrect by your standards, please forgive.

My 10 Second Pitch
I'm proposing two start-ups, Slum Dog Millionaires, Inc. and Panda Unlimited, both of which trade in human tissue for the good of mankind. Our costs are low, potential profits are high. And, best of all, there's an existing global demand for our products. 

Why continue reading? Maybe just food-for-thought on paying the poor and needy for plasma, which USA - land of 'make a buck' free enterprise - excels at? And to think about where the policy of
'anything you may permissibly do for free, you may permissibly do for money' will take the world? 

FUTURE MARKETS
Let me propose transfusion products that will do much good, create jobs and boost economies and stock markets. Forget Trump's selfish, tunnel-vision 'America first'. Many nations can play that game and trump the land of free enterprise. With my schemes, Canada - we embrace and welcome the world - will soon rule the global blood industry.

Let me expound on the business opportunities of the future in the wild-wild world of anything can be bought and sold. I plan to create two startup companies trading in body tissues.

Both start-ups are based on leveraging the populations of the world's most populous nations in 2017, which together constitute over 36% of the world's 7.5 million people:
  • China (1.389 billion ~18.47%)
  • India (1.344 billion ~17.86%) 
May even take my ideas to Canada's Dragon's Den if I can't get sufficient funding. But I'm bigly sure I can.

START-UP #1: SLUM DOG MILLIONAIRES, INC.
Slogan: 'Slum Dog Millionaires', supplying the world's plasma and making India's street urchins wealthy.

India has many street children. In 1994, UNICEF estimated that there were 11 million street children in India. Many are abducted and sold into slavery and the sex trade (Further Reading).

Slum Dog will recruit these kids into the equivalent of football (soccer in NA) academies. Fatten them up, get them healthy, send them to schools, indoctrinate them to believe they can save so many patients. Patients who  need plasma derivatives like intravenous immune globulin (IVIG), whose potential uses grow exponentially (even if many are based on artificially created uses), and human serum albumin, whose use continues to grow in China (Further Reading).

Though Slum Dog's profits will be in the $millions, perhaps $billions on the world's plasma derivative market, we'll give the urchins a few rupees, far more than they've ever seen before. We're generous that way, it's in our DNA. Why? Because
  • Maximize profits, decrease costs, is what free enterprise is all about, folks. 
Our strategy is to increase market share. Moreover, we're going to channel what Saudi Arabia has done with over production and flooding the market with oil, driving the cost down. If successful, we will cause the price of paid plasma and its derivatives to drop precipitously. The other big players in the plasma fractionation market will let staff go, struggle to survive. Profits will no longer justify investments:
  • CSL Ltd. (Australia) / Grifols S.A (Spain) / Baxalta Incorporated (U.S.) / Octapharma AG (Switzerland) / Kedrion S.p.A (Italy)
SECOND BUSINESS LINE
Wait, there's more.... It's not just the kids' plasma. Slum Dog has another business line. We can leverage the street urchins' red blood cells to generate profits for investors. Because in free enterprise, profits are all that count.

The urchins' young blood is a potential source of the elixir of youth. We're negotiating with USA's Ambrosia (Further Reading) as we speak. And we have the advantage of India already being a medical tourist destination (Further Reading), hence can decrease our advertising costs. Buyers come to us. Sweet, eh?

BOTTOM LINE
OMG, the good 'Slum Dog Millionaires' does. Following basic business practice, we'll  minimize expenses to street urchins, maximize our own profits, likely in the $billions, just as the world's paid plasma industry does.

That we get rich on the backs of the poor, children to boot, (risking their health) is only fair because we risk much by funding donation centers and equipment. Street urchins only donate their body tissues (red cells and plasma), which is no big deal, right? And it's all moral because some good comes of it.

STARTUP #2. PANDA UNLIMITED
Just to show you I'm not a total markets-not morals-rule creep, Slum Dog has another business line, in its subsidiary, Panda Unlimited.
Slogan:'Panda Unlimited', supplying the world with life-saving Group O Rh-negative red blood cells

'Panda blood' refers to the Rh-negative blood type in China, which, as the phrase suggests, is 'as rare as pandas.' (Further Reading).

Only three out of 1,000 people in China are Rh-negative. But the frequency of Group O in China is 47.7%. If multiplied by the total 1.389 billion population, the number is almost 2 million people, of which ~72% are between 15 and 64. So, potentially nearly 1.4 million blood donors. And increasingly Chinese are learning English, which helps, as you will see below.

Panda Unlimited's vision is to supply the entire world with Group O Rh-negative RBC.

Our ongoing capital and operational costs will include buying consumables like needles, tubing, blood bags, refrigeration storage, collection sites and their overhead, transportation, blood testing instruments and reagents. But because of massive volume, we expect to drive suppliers' prices down.

About transportation, we have an awesome supply chain management system, whose key component is drones (Further Reading). 

We've partnered with Amazon, one of the richest companies in the world, whose Prime Air will use drones to deliver goods, albeit it's not ready for prime time yet. (Further Reading)

As for collection centre costs, we've talked to Beijing about using Tiananmen Square once per week as weather allows, with royalty payment of 1% of our annual profits. As the world's largest square Tiananmen can hold up to a million people. With collection set-up and donation chairs, it still offers capacity of at least 100,000. In colder weather we plan to use heated giant tents.

Staffing costs, normally substantive, will be minimal. Forget cost efficiencies gained by RNs supervising inexpensive donor care associates for blood collection. We're  joined with Japan and Hong Kong's humanoid robotics makers (Further Reading) to pilot a robotics system for blood collection. These robots never tire, will work 24 hr shifts, don't demand raises and forget the burden of perks like health insurance, sick leave, and pension plans.

Face it, the more people you can eliminate in your operation, the more profits you make.

How will we entice the one million+ Group O Rh-negative Chinese to donate voluntarily? We've taken a page from US blood centres and offered various goodies. Moreover, even China has tried incentives (Further Reading):
  • Children of Chinese blood donors offered grades boost as incentive
Our biggie? We'll sweeten the pot by promising Chinese male Group O Rh-negative donors that they will be entered in a lottery to win an Rh-negative wife from Canada or the USA.

Because China's one-child policy left its men with a severe shortage of women to marry, they should leap at the chance. For example, There's now a black market selling women’s eggs to infertile couples who can now try for up to two children after the scrapping of the one-child policy.
  • Schoolgirl’s brush with death from selling her eggs casts spotlight on China’s black market
Added plus is that after 12 RBC donations (2 years) per male donor, they, their Rh-negative wives and offspring, can enter a lottery to migrate to Canada with transportation and legal costs paid courtesy of Panda Unlimited. We'll fund one lottery/month, meaning we potentially lose 12 donors per year. Unless no one's lottery ticket is drawn.

The only proviso is, if they meet Canadian blood donor criteria, they must agree to donate to one of Canada's government-funded blood suppliers for one year (six times). That way, Panda Unlimited gains credit as a supporter of CBS and H-Q and is not seen a competitor.

How will Panda motivate Group O Rh-negative women in Canada and USA to marry men in China?

1. We'll appeal to unmarried folks by advertising on all the Internet dating services, especially to women worried about their biological clocks ticking down and with iffy marital prospects, who desperately want children;

2. We'll pay their costs to travel to China to meet prospective mates F2F if required, or they can talk via the Internet. It's up to them which men they choose;

3. For every Rh-negative child produced they'll get a bonus payment via a prepaid credit card (as is done with paid plasma in USA and now Canada);

4. We'll support their efforts to bring spouse and children to Canada, which welcomes immigrants.

SECOND BUSINESS LINE
Wait, there's more....Our other business line is harvesting the recovered plasma from whole blood donations and supplying it to our parent company, Slum Dog Millionaires. No additional costs except transportation and storage, with mega-profits. Pretty sweet, eh?

BOTTOM LINE - OMG, the good Panda Unlimited does:
  • China's men have wives and offspring to care for them in old age; 
  • Moreover they can move to the West, experience democracy for first time in their lives;
  • Unmarred Western women can dream of children to fulfill their maternal instincts;
  • Panda stimulates economy and lessens the impact of baby boomers retiring; 
  • Supplies the world with Group O Rh negative RBC.
Yes, we're making mega-bucks off our blood donors who desperately want to mate and have families. But it's win-win-win-win. Panda wins - blood donors win - childless women win - world wins. Winning/doing good justifies everything. Even selling body corpses for profit, which may be Slum Dog Millionaires third business line

FOR FUN
'We are the World' is perfect for this blog. We and our bodies are commodities to be traded for profits that benefit free enterprise companies, their owners, and investors. Markets that value profits over exploiting humans rule. Of course, I'm kidding. Please Resist!

We are the world
We are the children
We are the ones who make a brighter day
So let's start giving...


How many iconic US artists can you recognize? And, admit it. This production and these singers are awesome, a word I seldom use.
  • We are the world (1985, written by Lionel Ritchie and Michael Jackson for 'USA for Africa' benefit)
As always, comments are most welcome.

FURTHER READING
Earlier blogs
  • We are the world - Musings on how we can lessen the global trade in body parts (15 Feb 2010)
  • We are the world - More musings on commercialization of the blood supply (13 April, 2013)
TraQ newsletter items
Slum Dog resources
Panda Unlimited resources

Saturday, July 22, 2017

Both sides now (Musings on where careers take us)

Updated: 2 August 2017

July's blog originated when, after decades of hoarding 'stuff', I finally decided to clean out a file cabinet. In the Medical Laboratory Science (MLS) folder, where I'd taught for 22 years+, I came across a graduation talk I'd given in 1991. The talk got me thinking about preserving (via a blog) some of the history of med lab techs who got caught in the cost constraints of the 1990s and had to work outside Canada. Some eventually decided to transition to other careers. 

The idea for the blog further crystallized when a local radio station used as its 'talking point of the day' 
  • 'How did your education (or lack thereof) play into your career? Are you doing the job you trained for and can people still learn on the job?'
I thought the question's focus was slightly off because it assumed that education for a career was mainly for a particular profession's job-specific tasks and ignored all the transferable skills students learn with a good professional education.

Executive version: What follows is an edited version of the grad talk followed by my musings on what happened to the careers of some graduates in the 1991 class. My thesis is that, if education for a career is sound, graduates come out with the self-confidence and transferable skills to transition to wherever life takes them.

Why read it? The educational issues discussed relate to med lab techs/biomedical scientists everywhere and cover a few of the transferable skills essential to any health professional. As well, the blog may resonate with nurses and physicians who find themselves forced to travel to foreign lands for job opportunities. 

Today where I reside (Edmonton, Alberta, Canada), depending on which provincial political party wins the election in 2019, health professionals could find themselves back in the 1990s when medical laboratory technologist, nursing, and laboratory physician jobs all but dried dried up due to the government's obsession with balanced budgets. 

The blog's title derives from an iconic 1967 song written by Canada's Joni Mitchell. I used it once before for a 2013 blog.

GRADUATION TALK TO MLS CLASS of 1991
What follows is an edited version of the talk. It's a run-of-the-mill talk but makes a few points I think are key to a sound education and still apply 26 years later.
Thanks very much Terry for your generous introduction. I am glad to have this opportunity because there are a few things I still need to cover with this class. First, I thought we would have a spot quiz, because students love them. Be aware that some of the answers will only make sense to the graduates. Let’s begin, starting with a test of your long-term memory.
Q #1: How many 1st-year MLS students does it take to change a light bulb?
  • Five. One to change it and four to set up Kohler illumination.
Q #2: How many 2nd-year students does it take to change a light bulb?
  • None. At least not in my class. You see, they were all asleep during my Powerpoint presentations and the light would only have disturbed them.
Q #3: How many 3rd-year students does it take to change a light bulb? [3rd yr is the clinical rotation yr]
  • The whole class. One student to change it and the rest to complain that their friends in other faculties had all summer off to do it.
Q #4: This one is a test of your short term memory. How many 4th-year students does it take to change a light bulb?
  • Again, the whole class. One to change it and the rest to complain that it should be deleted from Path 401 [a catch-all course, long since dropped].
Q #5: How many MLS instructors does it take to change a light bulb?
  • Ten. One to change it and nine to evaluate whether it was done right.
Now that the spot quiz is over there are a few things that I would like to talk to you about in a more serious vein. 
A few weeks ago I went to the Ambassador Awards at the Convention Centre. It was attended by people from all walks of life who belonged to associations like the CSLT [now CSMLS] that can bring conventions to the city. The organizers gave out awards and asked all of us to act as ambassadors by promoting Edmonton as a convention site. 
The thought occurred to me that in one way or another we all act as ambassadors. For example, when we are tourists in a foreign country, or when we interact with visitors to our city. 
So I would like to talk tonight about the idea that all of you—the MLS graduates of 1991—are going to be ambassadors for MLS whether you realize it or not. No matter what the future holds for each of you, all of the people you will meet will be gaining impressions of MLS through you, your actions, and attitudes. 
Now before you say, “Good grief! I can’t handle the pressure—-MLSers for life”—I want to tell you that I have great faith in each and every one of you. As an MLS instructor I have been privileged to share a part of your life for the past few years. 
Let me explain why I think that you will be great ambassadors. In a way, I feel like the mosquito in a nudist colony. I don't know where to begin.  
First, there are all of the things you have learned while in MLS. And I’m not talking about the knowledge and technical skills you have assimilated, although these are important. You have learned so much that what you have forgotten would fill a library.No—I’m talking about transferable skills that you will find useful all your lives. 
For example, you have learned how to be good listeners. Goodness knows you have had enough practice being listeners during your time here. As you begin your careers, remember the words of a wise person who once said, “good listeners are not only popular everywhere, but after a while they know something.” I have learned much from listening to you over the years.
You have also learned how to communicate clearly, both orally and in writing. Who can ever forget their first teaching assignment? I should explain that our students give at least three oral presentations to classmates and instructors beginning with teaching assignments during 3rd year. 
I’m sure that some of you think that teaching assignments were cruel and unusual punishment—both for the student and the audience. But, boy, do they ever pay off. The progress you made was really shown when you presented your 4th-year research projects. Your instructors and supervisors were impressed. 
This ability for you to make presentations will be a real plus for you in any career. I tell you this because I have listened to many technologists, scientists, and doctors who have not had the advantage that teaching assignments provide—namely to express ideas clearly and concisely. And listening was brutal.
There are many other intellectual skills you have learned. For example:
  • Your grasp of the scientific method and all that entails; 
  • The ability to be skeptical about so-called established knowledge, and yet to be open-minded about complex issues;
  • You know that it is okay to say, “Gee, I  don’t know, but I will find out”;
  • Most important of all, you know how to learn
You will draw on these skills over and over again— especially because medical laboratory science is evolving so rapidly. 
I would like to shift for awhile to some of the ways you have all grown in your personal development. 
Those of you who entered MLS lacking self-confidence have seen your belief in your abilities increase. Self-confidence is essential because no one will believe in you if you don’t believe in yourself. I’m not talking about being over-confident and self-important, but rather about the quiet self-assurance of people who are competent and know it. 
Conversely, if you came with a fair degree of self-confidence—if you were like me at 18 (and trust me, I was 18 once—and thought I pretty much knew everything) —then your experiences in MLS have added to your growth by teaching you humility. 
Your entire 3rd year was an exercise in discovering your strengths and weaknesses, coming to terms with them, and accepting both praise and criticism gracefully. 
It was hard to be evaluated each and every day of your hospital rotation; it was hard to accept feedback that you may or may not have felt was justified. But you all did it, and because of this you will have a big advantage in the workplace, as well as in life.  
Having a positive approach to learning will always serve you well. You know that imperfection is only human. The important thing is that we all try to do better. And keep in mind that misery is optional. 
You have also learned what friendship means. In the years ahead, you will remember your friends very fondly . One definition of a friend is “a friend is one who dislikes the same people that you dislike.” There is a lot of truth in this, but a better way to think of friendship is to realize that the only way to have a friend is to be one. You have all done that during your university days. 
Let me remind you that universities have always stood for the dignity of each human being—for the belief that each individual is to be appreciated for what they uniquely think, do, and feel. I want you to realize that you are important and have had an impact on your friends and teachers in MLS. 
Earlier I said that, whether you realize it or not, you are going to be unofficial ambassadors for MLS. Over the years, you have seen many role models—instructors, professors, nurses, doctors, and technologists. As ambassadors-—-with personalities and styles of their own—they succeeded to varying degrees in creating good-will for their professions. Soon you too will have this responsibility. 
As you leave MLS, remember the people who have influenced you. Think of those who have treated you with dignity and patience, who smiled rather than frowned, who took the time to criticize constructively, who showed you how to solve problems as medical laboratory scientists, who loved their subject, and who challenged you to be your very best. 
These are the people you will want to emulate as you become role models for others. And now, graduates—this is your night. You have struggled and succeeded in a difficult program. We, your instructors, are very proud of you. You have chosen a rewarding and challenging career.  
In conclusion, it's a cliche but always believe in yourself. You are graduates of the most rigorous Medical Laboratory Science program in Canada and one of the best in the world.  And don't be afraid to dream of what you want in life. No matter what the future holds, you have the right stuff to succeed.
MUSINGS
Of the 22 students in the 1991 MLS graduating class, here's what I know 26 years later about their careers. Most, as would be expected, went on to have careers as medical lab technologists/scientists. But the 1990s brought severe healthcare cuts in Alberta and throughout Canada and jobs became scarce. Graduates' careers I'm aware of:
  • Went to NZ to work for New Zealand Blood Service (NZBS) - 2
  • Worked for CBS, Canada's national blood supplier for years - 2
  • Dentist - 1 
  • Lawyer - 1 (after years of working as a med lab tech in Canada and later for NZBS)
  • PhD (microbiology) - 1
  • Gynecologist -1 (who was in Christchurch, NZ on a fellowship learning advanced laparoscopic surgery when the earthquake struck in 2011)
  • Radiologist - 1 (after many years of working as a med lab tech in USA)
To me, this validates that graduates of MLS at the University of Alberta learned many transferable skills and had the self-confidence to believe in themselves and accept challenges, as well as to dream. As one example, the MLS grads who went to NZ to work for NZBS (six in all from several graduating classes) were brave indeed and went through all the government hoops and regulations, requiring incredible stamina and belief that they could do it, no matter what. 

ANECDOTE #1
I'll share correspondence I had with one grad (John) 8 years later (when he was 30 years old) and again, 14 years post-graduation. John, like most MLS grads, had written the USA's ASCP(MT) exams when he graduated from the University of Alberta MLS program. As a result, he could go to the USA under NAFTA with a BSc (MLS) and work in a profession that was deemed needed in the United States. He worked for years as a med lab tech in Montana and also acquired EMS certification and worked part time as a firefighter. 

He wrote me and 3 others in MLS in 1999 because he had obtained his green card and could apply to U.S. medical schools and needed references from his instructors.

Bottom line was that John was accepted into an American medical school in ND, interned in Spokane, Washington, and later got a residency at the coveted Mayo Clinic in 2005, followed by specializing in radiology.He also did a fellowship in Neuroradiology at the Mayo Clinic. 
Mayo Clinic info (1999):"The Mayo residency and fellowship programs are among the most sought-after in the world. Last year, nearly 7,000 people applied for slightly more than 360 positions....Last year, the medical school accepted only 42 new students and only about 5% of those who applied for a residency or a fellowship."
Going back to MLS, in the 3rd year, students rotate through the clinical laboratories in groups of 3 or 4. I distinctly recall John's group because they were so motivated and, more importantly, so much fun to teach. Honestly, everyone should be so lucky to have such students.

John rotated with two female students (Donna and Jennifer), who both went to to work for NZBS in Hamilton, NZ for several years. Jennifer eventually became a lawyer and now works for a law firm in Edmonton where she represents hospitals/health regions and their employees, including AHS . Donna, who prior to NZ had worked for years in a Las Vegas mega-lab where technologists were more like factory workers, later worked for CBS and now works in a local hospital laboratory.

My spouse and I visited NZ for 6 weeks in 1998-99 over Christmas/New Years and touched base with two of the MLS grads, including Donna, who had the courage to go to a foreign country to practice their profession. They had made the best of a bad situation and were loving their foreign adventure.

These grads believed in themselves and were great ambassadors for MLS at the University of Alberta.

ANECDOTE #2
While the MLS grads worked for NZBS, a US software company visited to demonstrate and pitch its blood bank software. Reason I know this is that the software company (Wyndgate Technologies, now Haemonetics Software Solutions) contacted me. 

Specifically, they wanted to know if MLS had more grads like the ones working at NZBS because they were very impressed with them and would love to hire some.

Bottom line: Two MLS grads were brave enough to transition to software testing and moved to Sacramento, California to work for Wyndgate in 2000. One worked for Wyndgate/Haemonetics for 15 years, latterly in a senior management position.

FOR FUN
I chose Joni Mitchell's 1967 song for two reasons. Of note, it has been covered ~600 times by other artists and counting. 

First, I love it. By any standard, Canada's Joni Mitchell is a songwriting genius.

Second, to me it means that life isn't always what you expect it to be. We win some, lose some in the careers we choose but in the end we're left with the illusion of what we hoped it would be. And that's okay providing we acquired the skills to follow our dreams past the illusion. Perhaps too philosophical?
I've looked at life from both sides now 
From win and lose and still somehow 
It's life's illusions I recall 
I really don't know life at all. 

As always, comments are most welcome.