The Boxer (Musings on lies & jests in the blood industry)

Updated: 23 Oct. 2016

This blog, takes its theme from items in October's 'New on TraQ' and posts on my @transfusionnews Twitter account.

The title is from a 1969 ditty by Simon and Garfunkel.

For readers who choose not to read the full blog and to peak your curiosity, here is the executive version. The blog focuses on blood donor plasma, but not in the usual way I've blogged about plasma in the past. October's blog aims to

• Showcase hypocrisy in the USA's not-for-profit blood industry, specifically the approach of community blood centers to blood donation;
• Stimulate you to think about how your country's blood donor system operates and why national differences exist;
• Interest you in reading at least the 'juicier tidbits' in Canadian Blood Services' 2015-16 Annual Report.

PLASMA DONATION in USA
In the USA you can donate plasma twice a week. The FDA allows 2 donations within a 7-day period, with at least 2 days between donations.

The main ways to donate plasma include

• Commercial paid-plasma centers like  Biotest, CSL, Grifols (Canadian Blood Services plasma protein products supplier), OctaPharma, and more. 
• They tell donors they are saving lives as opposed to admitting, 'We're exploiting you poor folks who need extra cash so we can make mega-bucks'.
• 600 America's Blood Centers (ABC), who collect nearly 50% of the blood supply, of which the sole non-US member is Canada's Héma-Québec (where paying for plasma is illegal);
• American Red Cross (ARC), which collects and processes about 40% of the USA's blood supply.

So far as I can tell (please correct me if I'm wrong), plasma collection in the USA is roughly as follows:

1. Paid-plasma centers offer donors varying amounts of money, but not directly (no direct cash payments, which might make it seem like 'filthy lucre' for selling a body tissue). 

Payment is via a card similar to a debit card. And some have cutesy loyalty programs. Examples:

• Australia's CSL (prepaid Visa debit card and iGive Rewards)
• Biolife (No loyalty program, prepaid Visa debit card)
• Grifols (No loyalty program, prepaid Visa debit card)
• OctaPharma (Visa debit card and OPI Rewards)
• See Plasma Donation FAQ

2. ABC non-profit community blood centers like Blood Centers of the Pacific stress that volunteer blood donors provide a safer blood supply. 

Unsaid is that volunteers are safer than paid donors only for blood components such as red cells, platelets, and plasma (not plasma protein products, which, besides donor screening and testing, undergo many steps to make them safer, e.g., plasma quarantine, technology to inactivate viruses, and purification steps).  At least that's the theory based on evidence to date.

But all such centers offer an incredible amount of what they call 'swag' (products given away free, typically for promotional purposes). For example, Blood Centers of the Pacific's 'swag' for donating plasma. 

So what can Hero Reward Points get you? Quite a bit (and they apply to all donation types, not just plasma).

• For example 1,600 Points for your first plasma donation earns a $25 Shopping eGift Card. 
• Each successive donation earns 600 points. At two/week potential earnings can amount to 4800 pts/month or three $25 eGift cards. 

Admittedly $75/mth doesn't compare to the money donors could earn at paid-plasma centers. But donating is not exactly unpaid as it is in many countries.

3. American Red Cross offers a true voluntary blood donor system. No money or similar for donating red cells, plasma, platelets, whatever.

PLASMA DONATION in CANADA
When you donate plasma in Canada at CBS or H-Q  you get what all voluntary blood donors get. 

In Edmonton, that's 'Cookies by George' and maybe some juice. And I mean to munch away on, post-donation, and on-site.

CBS's 2015-16 ANNUAL REPORT
So how does CBS's Annual Report (begin on p. 39) fit with this blog's theme of donating plasma for payment (no matter how defined) vs donating voluntarily?

First, consider that the plasma protein product market, including intravenous immune globulin (IVIG), stood at US$18.5b in 2015 and will continue to grow.

CBS reports that from 2013-14 to 2015-16 Plasma Protein Products (PPP)  (bought in $US) increased from $459,120,000 (45% of total costs) to $623,198,000 (53% of total costs), an increase of 36%. 

Besides IVIG utilization, the exchange rate affected CBS's PPP costs, because the CDN$ decreased 29% v $US during this time. In Jan 2013 Canada's dollar vs USA dollar was $1.01 vs 0.72 cents in Jan. 2016.

For 2016-17 CBS is trying to mitigate being captive to the exchange rate with the US$ by using a forward currency contract with its PPP supplier, Grifols.

LEARNING POINTS
1. Are USA's non-profit centers hypocritical in saying they offer a voluntary blood donor system? As a Canadian, I find the USA's debit card and cutesy loyalty programs cringeworthy. You decide.

2. By relying on the USA's paid plasma system for most of its plasma protein products like IVIG, CBS is captive to the exchange rate with the US dollar. Why doesn't CBS challenge Canadians to donate more plasma?

CBS makes decisions assuming outsourcing is always cheaper. And it often is in the short-term. But in the long-term, who knows? Plus, relying so heavily on poorer Americans who donate a body tissue (plasma) for money is not admirable, especially when you give up on promoting voluntary plasma donation to Canadians because it costs more. See

• Blood collection in Thunder Bay too costly, CBS official says (27 Mar. 2015)
• While my guitar gently weeps (8 Apr. 2012) 
• Broken links are now fixed.

CBS leaders have decided that Canadians cannot donate anywhere near enough plasma without even trying to challenge us.

3. CBS: How about challenging Canadians to donate plasma by being transparent (something you tout post-Krever) about the grim facts of what relying on USA's paid plasma costs tax payers?

Give young Canadian donors, those in community colleges, technical institutes universities, the chance to be voluntary plasma-donating heroes. Give long-standing oldster donors a chance to shine.

Don't cave and assume sufficient plasma donation in Canada is an impossible task, without even trying. Give our youngsters and oldsters a chance to prove you wrong. Or at least to increase plasma donation significantly. If a donate-plasma campaign falls short, so be it.

You haven't even tried, CBS. Despite all your 'leading edge' innovation rhetoric, you lack a vision for Canadian blood donors being special.

FOR FUN
To me Simon and Garfunkel's 'The Boxer' lyrics resonate with this blog.

• The Boxer (Simon and Garfunkel, Live in NYC Central Park, 1981)

Such are promises
All lies and jest
Still, a man hears what he wants to hear
And disregards the rest.

As always, comments are most welcome.

FURTHER READING

The twisted business of donating plasma (28 May 2014)

All about blood banks.  A multibillion-dollar business in a nonprofit world (1991)

Smile on your brother: Musings on labour woes in the blood system

The idea for this month's blog came from the latest labour relations difficulties facing North America's blood suppliers. The title derives from the lyrics of a 1960s song recorded by many, Get Together.

USA - American Red Cross [ARC]

• Staff cuts at ARC harm blood supply, coalition says
• Connecticut: Red Cross workers: Phlebotomist firings due to contract tiff (includes comments from fired worker)
• Southern California: Nurses may strike over wages, benefits, practices
• Background (labor's perspective): Labor relations at the ARC and its impact on employee and donor safety (23 page report by Philip Dine)

Canada

• Canadian Blood Services (CBS): Nurses vow to fight CBS pilot to phase out RNs from donor screening
• CBS: "Moving forward to pilot multi-skilled workforce"
• Hema-Quebec [H-Q]: H-Q deplores union's attitude and invites the public to give blood

This blog uses the above labour conflicts to offer musings on the role of trust among TM health professionals. Because the underlying issue in any management / employee negotiation relates to trust, I will not discuss the specifics of the news reports. Besides, without in-depth knowledge of what is actually happening, analysis would be folly.
Many good friends are either staunchly pro- or anti-union health professionals. I know from experience that discussing union issues, like religion and politics, is sure to lead to passionate disagreements fueled by anecdotes and emotion, not objective, evidence-based logic, and may result in hard feelings. I'm hoping not to wander into that morass as the blog's narrative unfolds.
UNIONS
As background, to my knowledge, Canada's blood system, both blood suppliers and hospital-based transfusion services, are mostly unionized. Unionized workers usually include laboratory technologists, lab assistants, and nurses, and a diverse group of other staff, e.g., clerical, IT, lab scientists, maintenance, etc.
Some employees, e.g., TS laboratory managers and blood centre management positions, may be "out of scope" (not included in union contracts).
Practical implications of being out-of-scope include the

• ability to negotiate salaries and benefits directly with employers (and to keep them private from co-workers);
• subtle promotion of a them-versus-us mentality;
• ability of employers to fire you without the hassle of a union grievance.

As well, for non-union health professionals at senior levels, including dismissal terms in personal contracts, and threats of legal action for wrongful dismissal, may result in generous, golden handshakes for staff such as TS and blood centre medical directors.
Many of the news items referenced in this blog involve contract negotiations. From my experience observing Canada's blood system, frequently workers do not trust employers / management to do the right thing for employees, patients, and the public at large. The worker view is often that management has a hidden agenda, typically to save money, even at the expense of safety.
Conversely, it's not that rare for employers / management to regard unions negatively, and by extension to view their members as overpaid and more or less lazy, with unions leading to unwarranted, costly job perks and promotion of the most senior rather than the most competent staff. Management seldom voices such opinions publicly and would deny them if asked, but these viewpoints exist nonetheless.
Indeed, these perspectives reflect public opinion, with proponents on both side of the union issue.
The unproductive, adversarial mentality in labour negotiations seems relatively common everywhere despite major progress in labour relations worldwide during the 20^th C.
The sad fact is, that with contract negotiations, a lack of mutual trust is common. When discussions reach an impasse, each side often sees the other as self-serving and sometimes in even more negative terms.
Tidbit: In 2007, the percentage of employees that were members of a trade union (Source: OECD - Union density 1960 - 2007) included:

• Australia: 10% (2006)
• Canada: 29.4%
• Norway: 53.7%
• Sweden: 70.8%
• UK: 28%
• USA: 11.6%

These statistics likely do not include the employees such as physicians and university professors who are not members of a union, per se, but do belong to professional associations that act as unions by negotiating contracts and benefits.
A ROSE BY ANY OTHER NAME
When is a union not a union? When it calls itself a professional association. When working at the University of Alberta I was in the Association of Academic Staff, which negotiated salaries and benefits for professors. The Association's activities approximate that of a trade union.
In Canada, health care is a provincial jurisdiction and provincial medical associations negotiate physician fees that are binding for insured services.

• See Paying for Physician Services in Canada (1996)

Despite their loftier broader goals and objectives, Canadian provincial medical associations perform some of the same functions as unions. Yet unions may be disdained by some professionals partly because of their origin as trade unions, with "trades" somehow being more lowly than professions.
For interest, Norwegian and Swedish physicians have no problem in identifying their medical associations as unions. Many of their physicians are state employees, as are physicians in many other European countries.

• Swedish Medical Association
• Norwegian Medical Association

To my knowledge, Canada's transfusion medicine physicians (hematologists, hematopathologists, pathologists) who work for transfusion services and blood suppliers are usually salaried employees, although they often have multiple appointments that earn additional salary. In essence, they too belong to professional associations that function partly as trade unions.
TRUST
People who work as part of any health care team must trust each other's competence, trust that each will to do the best job possible, maintain a high level of quality care, and put the patient first. There are checks and balances in the TM system, e.g., audits of blood transfusion requests, error management programs, etc., but the system would not function without trust in a colleague's motivation and competence. The first instinct of health professionals is to trust each other to maintain high practice standards, unless shown otherwise. For example:

• When talking to a nurse on the ward who reports a possible transfusion reaction or to a physician in the ER who requests unmatched RBC, do lab technologists routinely think, "That lazy bum is so self-serving"?
• When discussing follow-up treatment of patients suffering from transfusion complications with nurses, or holding a staff meeting with laboratory staff to plan implementation of an new LIS, do TS medical directors routinely think, "These nurses / techs deserve less pay and fewer benefits"?
• When management staff from national blood suppliers consult with blood centre medical directors across the country, does "head office" routinely think, "These MDs don't have patient safety at heart. Their attitude is deplorable."?

Do management staff who are not members of a health profession (whether representing health regions, hospitals, blood suppliers, or governments) often think such thoughts about members of the TM team?
I think not. The many technologists, nurses, and physicians that I have known over a lifetime in Canada's blood system are dedicated to patient safety and trust each other to provide the highest quality care possible.
How is it that trust seems to evaporate with labour negotiations?
CASE STUDY
In the mid-90s in Alberta, health care restructuring caused major job losses in the laboratory sector. One result was the creation of Calgary Laboratory Services* (CLS), a private lab that assumed 100% of clinical lab services in Calgary, one of the province's two major cities.
* CLS is now a wholly owned subsidiary of Alberta Health Services (organization responsible for providing publicly funded hospital and other health care in Alberta)
The case study below describes how a union (HSAA) and private-sector lab (CLS) cooperated under extremely traumatic circumstances. It paints a rosy picture of what's possible. I have no idea how closely it conforms to reality but there may be some lessons here.

• Beyond Collision: High Integrity Labour Relations. Calgary Laboratory Services -- HSAA Case Study1 (2004, by Darcy Shenfield and Allen Ponak)

All this lack of trust and conflict reminds me of a song from the 1960s:

• Get together (performed by the Youngbloods)

As the song's lyrics go,

C'mon people now, Smile on your brother Ev'rybody get together, Try and love one another right now

Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. Let me know if you think I'm off the mark.