The Boxer (Musings on HC's Expert Panel Report on immune globulin & paid plasma)

Updated: 30 June 2018 

June's blog is about paid plasma in Canada, but don't start snoozing, it focuses solely on the Final Report of Health Canada's Expert Panel on Immune Globulin Product Supply and Related Impacts in Canada (hereafter referred to as the Expert Panel). Goodness knows how much it cost Canadian tax payers. Suspect we'll never know.

Why the blog? Well, how many Canadian transfusion professionals have read the Expert Panel Report on their own time? Maybe inside CBS they've had a staff member précis the key points as its findings are critical to the blood supplier but wouldn't happen in busy, mostly under-staffed transfusion services where Report doesn't affect operations. So, in a way, it's my gift to colleagues who may never have the time to read it and reflect.

Just happens that in a one-day lull in the FIFA World Cup of football (soccer in NA)  - I'm a footie fanatic - I finally managed to read some of the Final Report entitled Protecting Access to Immune Globulins for Canadians (pub. May 2018). Oh, and initially folks had to write to Health Canada to get a copy as it wasn't online, but now is (Further Reading).

So far I've read mainly the Executive Summary, which is the longest exec summary I've ever seen totalling 3975 words over 8 pages. Supposedly, average readers can read about 200 words/min or 2 pages/min, both of which mean average Canadians would need 15-20 mins. to read just the exec summary. Now the Expert Panel was not tasked to make recommendations and perhaps this contributed to the long summary (or not).

What follows are a few things that stood out for me in the Executive Summary, which I've finally waded through. Are these the key points? Who knows after 3975 words? BTW, I've worked in Canada's blood system as a transfusion educator for decades. Granted, my neurons are aging by the minute, but identifying the Report's key take home messages based on the exec summary was difficult. The following jumped out at me.

Why read the blog? If you care about Canada's blood system, it's a summary of what Health Canada received from its Expert Panel. If you are not Canadian, it informs on the issue of the $multi-billion paid-plasma industry [Further Reading] and why it thrives, despite being inherently unethical and preying on the poor.

Page 6 - Who uses immune globulin (IG)

Patients receiving IG can be divided into 2 major groups: those for whom the drug is life-saving and for which there is no effective alternative at this time and those whose illness can be positively impacted by the use of IG but for whom there are other therapeutic alternatives also available. There are a relatively small number of conditions and patient groups for which IG has been definitively shown to be effective and they account for the majority of use of IG.

ME: Really? No third group? Those receiving IG for 'off label' uses for which few if any evidence-based studies exist?  Is all IG issued in Canada screened to prevent inappropriate use versus the physician wants it and gets it, especially if a 'biggie'? The screen has no holes? I'm surprised.

Page 7 - Audits of who uses IG

Given the high usage of IG in Canada, a number of audits have been carried out in different provincial jurisdictions to understand patterns of utilization of this expensive product. These audits show that a significant proportion of IG use falls outside established criteria and guidelines. Other jurisdictions, particularly the UK, have achieved more success than Canada in optimizing the appropriate use of IG for patients for whom it is indicated, and as a result have a much lower per capita utilization rate.

ME: Huh? Guess there is a third group of IG users in Canada.

Page 8 - Public view of paid versus volunteer donors

One of the important dynamics impacting the future of the global plasma supply is the strong public policy position for using volunteer unpaid donors for source plasma collection and a resistance to the use of paid donors. The rationale for this position includes concerns about safety of products made from paid donors, ethical concerns about the commodification of human plasma, and concerns that compensation for donating source plasma would diminish the commitment of volunteer donors of both whole blood and apheresis platelets.

ME: This sets out the 3 main reasons why some folks are against paid plasma. The Panel emphasizes safety is not an issue, indeed it's the only thing that's bold-faced in the exec summary (p. 9). Referring to fractionation of plasma derivatives:

The outcome of these changes has been dramatic: there have been no confirmed cases of disease transmitted through PDPs in over 2 decades.

To me, a transfusion professional, that's a no-brainer. What the statement did not say is that fractionation clearly kills all currently known transfusion-transmitted infectious agents. Regardless, plasma derivatives like IG have a good safety record, are safe for the time being, and for anti-paid plasma advocates to emphasize safety is non-productive.

ETHICS is all but unmentioned by Expert Panel: What I didn't see in the exec summary was a discussion of ethical concerns about the commodification of human plasma (Further Reading:The twisted business of donating plasma).

For this readers must go to p. 71:

Moral/ethical opposition to paying for blood or plasma due to the perception that it negates the benefits of a solely voluntary-based donation system, and that it targets vulnerable populations. These organizations declared their support for the CBS initiative to collect more plasma by opening 40 new voluntary donor plasma collection sites. They also called on the Government of Canada to halt licensure of paid plasma businesses in Canada, including CPR.  

In contrast to the other groups above, a group of >30 ethicists and economists submitted an open letter to the Panel expressing concerns about banning compensation for plasma donors and the resulting impact on the ability to secure a sustained and safe supply of IG for patients in Canada. This open letter also addressed key points frequently raised in the debate, including: wrongful exploitation, commodification, altruism, safety and security. Approximately half of the signatories were Canadian, while most of the rest were from the US (Appendix G).

ME: App. G is of course the letter written by Peter Jaworski (and others), author of Markets Without Limits, whose primary thesis is, 'If you may do it for free, you may do it for money' meaning selling body tissues and organs is moral because you can do it for free (voluntarily donate). And selling tissues / organs saves lives so must be good, conveniently ignoring and minimizing that it preys on the poor.

What's not said in the Report (did they know or care?) is the connection between Jaworski and others who have coincidentally written many letter and op-eds for Canadian media in an attempt to influence public opinion in favour of paid plasma. Jaworski co-founded the Institute for Liberal Studies and is an adjunct scholar at the [ libertarian ] Cato Institute.

Bottom Line: Expert Panel all but bailed in the issue of the ethics of paid plasma. There are many, including Canadians, who could have given an ethical perspective against paid plasma but they were not consulted. Shame on the Panel.

Page 9 - Self sufficiency requires paid plasma

Across Europe, Australia and North America, the only jurisdictions that have achieved 100% self-sufficiency for plasma collection are those that have permitted paid plasma donors. Jurisdictions that permit payment of source plasma donors have a significantly higher plasma collection capacity on a per capita basis compared to those jurisdictions where compensating source plasma donors is prohibited.

ME: Paying poor people increases donations/capita? Yes. Wonder how many nations, particularly Canada, might be closer to self sufficient if - CBS got funding to collect more plasma - and the main IG users were those for whom the drug is life-saving and for whom there is currently no effective alternative? Just a thought.

Page 9 - Volunteer plasma more expensive

In addition, the cost of collecting large volumes of source plasma utilizing volunteer donors is 2-4 times more expensive than the commercial plasma collection model and thus it remains more economical for jurisdictions to purchase IG and PDPs from the commercial market, all of which are made from plasma from paid donors. Finally evidence indicates that, notwithstanding the funding for blood operators to meet collection targets to achieve self-sufficiency, often source plasma programs based on volunteer donors just simply can't make their targets.

ME: Had to read further (search for it) on why volunteer plasma is 2-4 times cost of paid plasma. Found it on p. 64:

Different sources suggest that enhancing self-sufficiency through the collection of volunteer apheresis plasma by the blood service would seem to cost 2 to 4 times as much as that collected by commercial industry (Refs 36,114.)

NOTE: This statement of cost seems based on a submission by Canadian Plasma Resources (Ref. 36) and Ref 114, Noel S. How to reduce cost of apheresis plasma? First lessons of a benchmarking. Établissement. Français du sang. 2015. (no link provided). The Panel goes on to explain:

In part this relates to the limits on donation frequency which appear to be inherent in a volunteer donor based source plasma  operation –  for example: a commercial operator in the US achieves an average paid plasma donor frequency of 17.3 donations per year, while non-profit operators across Canada, the US, the EU and Australia average from 4-7 source plasma donations per year per volunteer donor.

The collection volumes per source plasma collection site run by non-profit operators range from 4,000 - 15,000 litres in Canada and the EU, while in the US and EU commercial sector the volumes per site range from 40,000 to 50,000 litres.

ME: So the increased cost of volunteer plasma is based ('in part') on 17.3 donations/yr for paid plasma versus 4-7/yr from volunteers. In other words, because paid plasma companies mostly operating in the USA suck the maximum volume of blood out of America's poor, paid plasma is cheaper to produce and plasma companies make $billions.

Page 9 - Notion of 'volunteer' is evolving

Other evidence revealed the evolving nature of a voluntary donor – data from the European Union reveal that in Europe, incentives for voluntary donors are diverse and in many instances have a value equivalent or even greater to what would be considered payment in Canada and other jurisdictions – thus the definition of a volunteer donor is shifting.

ME: Good point. Also think it's similar in most of USA's non-profit blood centers. They offer goodies ranging from Walmart gift cards to credits if friends and relatives ever need blood transfusion so they don't need to pay.

Page 10 - Self sufficiency in Canada

The question of whether Canada should increase its self-sufficiency in plasma collection and to what degree was a major focus of the Panel. The Panel had a strong consensus that Canada needs to make a much more significant contribution to the collection of source plasma – the Plasmavie program and the desire of CBS to increase collection of source plasma from their donors are an appropriate response to the significant dependency on the US as a source of plasma.  

On the issue of what level of self-sufficiency should be targeted, it is appropriate for Canada at a minimum to be able to provide sufficient plasma to meet the needs of the one group who are truly life dependent on IG –  those patients with primary immunodeficiency (PID). This would ensure that these patients are protected in the unlikely event of a severe shortage. Volume targets beyond this minimal expectation should reference priority clinical needs.

ME: Another key question un-addressed by the Panel: What percentage of Canada's IG supply do PID patients - who truly need it - use? If CBS greatly increased its collection of plasma could their needs be met? Versus just allowing non-evidence based 'off label' uses to grow, thereby enriching the paid plasma industry, as currently exists.

Page 10 - Solid business principles and partnerships with private sector

Importantly, the move to collect more source plasma by CBS and H-Q needs to be based on solid business principles and learnings and/or partnerships with the private sector who have significant expertise. Increased source plasma collection by CBS and H-Q cannot be undertaken at any cost. There is a significant premium related to the cost of collecting high volumes of plasma from volunteer source plasma donors (between 2-4 times more costly) –this is recognized by CBS and was reaffirmed by discussions with other jurisdictions. 

Given that there are a number of provinces in which commercial plasma operations are currently permitted, the Panel agreed that options could be carefully examined to ensure that all source plasma collected in Canada from Canadian donors (whether paid or volunteer) be made available for the needs of Canadian patients. There are a number of mechanisms whereby this could be achieved.

ME: This is the Expert Panel's bottom line - the recommendation that the Expert Panel could not make but did in its own way. Why is it on p.10 of 12 in the exec summary? Paid plasma is okay in partnership with Canada's existing voluntary blood system. And the Panel cautions governments: Do NOT spend too much tax money on increasing voluntary plasma donations.

Meaning, the Panel is advising the provincial/territorial funders of Canada's blood system not to give CBS too much of the extra funding it requested but give it some? Some funding is needed because the world should not be too dependent on the USA for plasma as it now is - discussed extensively elsewhere in the Report, mainly in 4.2 SECURITY AND SUSTAINABILITY OF SUPPLY OF PLASMA, pp. 59-64. Will be interesting to see how long CBS will need to wait to find out what funding it has and begin planning.

Page 11- Paid plasma has no effect on the blood supply

There is no compelling data to suggest that expansion of source plasma collection - whether with paid or unpaid donors - has negatively impacted the whole blood supply. However, we would caution that this is an issue which should be further researched and it requires ongoing oversight and vigilance. One particular issue worth monitoring is whether source plasma operations could affect recruitment of future volunteer apheresis platelet donors.

ME: What's with the focus on the whole blood supply? Why no mention of plasma donation, which can be done more often? And mentioning aphersis platelet donation also ignores the issue of targetted plasma donation.

Page 12 - Final page of Executive Report

In summary, much has changed since the release of the Krever Commission report in 1997. PDPs are safe...However, like most of the world, we are too dependent on one jurisdiction (US) for the supply of the vital raw material used to make these products.

Canada needs to do more to collect plasma and take other steps to enhance our self-sufficiency in meeting the needs of our citizens for PDPs. As discussed there are a number of decisions to be made and strategies to be considered. In the implementation of the strategies, there needs to be transparency for the public and stakeholders, adherence to good business principles with flexibility in the approach where appropriate, due consideration of the taxpayer, and ongoing attention to the outcomes with the capacity to adjust where necessary.

ME: The Panel correctly stresses that much has changed since the 'tainted blood' tragedy of the 1980s-90s in Canada and elsewhere. Most notably, the fractionation process of plasma derivatives such as IG kills all known infectious organisms. To me, one thing that hasn't changed is the certainty blood experts have that all is safe now, just as they had in the early 1980s before AIDS was proven to be transfusion-transmitted, something they resisted.

Also, the Panel re-affirms the long-standing blood supplier emphasis on cost-effectiveness seen in all CBS reports. Emphasize safety up front then pivot to the real emphasis - saving money.

BOTTOM LINE
To me the biggest fail of Health Canada's Expert Panel was not dealing with the ethics of exploiting the poor. Maybe that's because to me it's the main reason to be against paid plasma, especially as the plasma industry gets rich on the blood of the poor and needy.  Frankly, the Panel was set up this way, given its four members.

Did it never occur to any of them to independently solicit Canadian ethicists who didn't sign a letter promoting paid plasma? Guess not. Not part of their skill set? GIGO comes to mind and I suspect Health Canada is fine with this.

But the Report would be significantly enhanced - and provided a valuable educational service -  with a frank discussion of balancing the needs of patients with the reality of exploiting the poor. Examining in-depth all the options to increasing plasma donation without feeding the plasma industry's ever growing profits would also make the Report more informative. Instead the Panel concluded volunteers (however defined) cannot supply the need to be self sufficient, only paid plasma donors can, albeit the world needs to wean itself off the USA's poor.

Second fail: See above for the Panel's sloppy treatment of 'Who uses immune globulin (IG)' and 'Paid plasma has no effect on the blood supply,' focusing on whole blood donation vs plasma donation.

Third fail? Given the Panel's composition it would be expected that they would emphasize private sector involvement. Perhaps unfair for the two Canadian transfusion experts of the highest quality on the Panel but it crossed my mind and I offer it to you as food for thought.

FOR FUN
Again I chose a favorite Simon and Garfunkel ditty as it fits Health Canada's Expert Panel, specifically the lyrics: Still a man hears what he wants to hear / And disregards the rest.

• The Boxer (Simon and Garfunkel, benefit concert in Central Park, NYC, 1981 before 500,000) 

I am just a poor boy
Though my story's seldom told
I have squandered my resistance
For a pocket full of mumbles, such are promises
All lies and jests
Still a man hears what he wants to hear
And disregards the rest

As always, comments are most welcome.

FURTHER READING
Final Report of Health Canada's Expert Panel on Immune Globulin Product Supply and Related Impacts in Canada

Plasma fractionation market forecast to exceed US$ 26 billion by 2022

The twisted business of donating plasma (28 May 2014)

Tidbit: Since 2008, plasma pharmaceuticals have leapt from $4 billion to a more than $11 billion annual market.

The sound of silence (Musings on why it's key to criticize TM professionals / organizations)

Updated: 25 May 2017 

(Major revision from the blog initially posted.)

May's blog was stimulated by recent experiences I've had on a transfusion Twitter account. It deals with concerns about professionals speaking their minds versus being silent. As such it's a personal blog but I hope transfusion professionals everywhere will be able to discern the issues involved and how they may relate to their professional lives.

The blog's content is the type of thing folks don't usually discuss except perhaps with their trusted best friends (or in social media speak, their BFF).

Executive version: The blog is about decisions made on Twitter and on transfusion-related blogs like this one, which occasionally make me persona non grata with fellow tweeps and colleagues. The blog's focus is about the need for transfusion professionals to speak out and discuss the things that bug them, instead of remaining silent.

The blog's title comes from a Simon and Garfunkel song, circa 1965.

BACKGROUND
So readers can appreciate the context of where I'm coming from and what has shaped my views, some background.

In brief, I'm a lifelong medical laboratory technologist who began my career as a 'kid' at Canada's then national blood supplier (Canadian Red Cross) in Winnipeg in the pre-AIDS era that blood bankers often call the 'golden age of serology'. CRC is where I grew up professionally and the Canadian Red Cross Blood Transfusion Service (CRC-BTS) staff became my beloved blood banking family. The learning opportunities were abundant because Winnipeg's CRC-BTS was, and remains, the only combined blood supplier-transfusion service in Canada. Many of the staff became lifelong pals.

Later I lucked out by getting a teaching position as a lecturer, then professor, in the MLS program at the University of Alberta in Edmonton and a clinical instructor for the UAH blood bank, positions held for 22 years. I called these positions the best transfusion science teaching job in Canada, maybe the world, before choosing to give up a tenured university position to embark on new adventures.

With this background I've seen many changes, some I judge as good, some as bad, and been a keen observer of our profession for decades. Transfusion medicine remains a lifelong love affair.

It's obvious, but please be aware that what follows is my perspective and, as such, shows my biases.

CRITICIZING A RESPECTED ORGANIZATION
As noted earlier, my TM career began with Canada's blood supplier CRC-BTS, now CBS. After being a med lab tech, lab supervisor, and clinical instructor at CRC-BTS, decades later I was privileged to obtain many consultant jobs with CBS - I loved them all - and briefly served as a lab manager of a CBS patient services lab. It's an organization Canadians can be proud of but, like any large organization, is not perfect.

Over the years I've criticized CBS on Twitter and in blogs for what I perceive as deception, hypocrisy, use of hackneyed business jargon, and more.

Some tweets I've made often occur on the spur of the moment and constitute errors in judgement. Some are because, as a bit of a contrarian, I see things differently than many or choose to reveal my true feelings on issues that others do not for whatever reason.

Reminds me of advice I'd give to Med Lab Science students:

Explaining how feedback is an indispensable tool to help both instructor and learner improve, and modelling appropriate responses such as, "Thanks for telling me that." When MLS students enter their clinical internship year, I'd explain that constructive criticism is their best friend. They can improve only if supervisory staff tell them when they are doing something wrong or doing something that needs to be improved.

That said, does CBS even want feedback from the likes of me, especially when it's often critical of their practices or constitutes a send-up? Perhaps not.

Sad but tweets about CBS could potentially cause folks I respect to unfollow me on Twitter. I know of at least one in the UK who has done so.

The blogs are a different matter. They're not spontaneous but a way to get something that bugs me off my chest. In a way they're therapeutic. I blog about an issue and feel better because I've said my piece and haven't remained silent. Often I wonder how the heck I've had the chutzpah to criticize a respected organization and its leaders.

So the question arises, is it preferable to keep silent or continue to challenge CBS to be even better? Or are blogs and tweets similar to pissing in the wind?

Fact: Most transfusion professionals choose to keep silent and not criticize organizations such as national blood suppliers for several reasons. First and foremost, the organization may be their employer. Or perhaps they interact with the blood supplier as a hospital client and want to maintain a cordial relationship. 

But the result is that the blood supplier often never knows where they need to improve because no one dares to tell them. Certainly rank-and-file employees usually don't. Reality is many employees outside an inner circle at head office, or not in management positions in blood centres, have long since given up offering feedback about policies because it's invariably ignored. At least it seems that way to 'trench workers'.

Directives and self-congratulatory missives emanate from CBS head office that staff in the far flung regions sometimes consider a joke, often so hypocritical that the missive is the exact opposite of reality. I could write a lot more on this from my experiences as a CBS lab manager but won't now.

LEARNING POINTS
Why should we offer honest feedback to TM colleagues and organizations? Because it's the only way they can improve. If we only promote what a great job they do, they will NEVER improve. And I want the organization I grew up in and love to improve.

As to errors in judgement, those mistakes are what I must learn from. If I've inadvertently offended colleagues, I apologize unreservedly. Being passionate about a subject can sometimes push me to say dumb things.

Does any of this resonate with your experiences? Are you deep into the 'sound of silence' as many, perhaps most, transfusion professionals are? Food for thought that I hope is palatable and doesn't cause you to choke.

FOR FUN
This Simon and Garfunkel song fits this blog. TM professionals and organizations who might improve - if only colleagues would speak inconvenient truths - never can improve if the Sound of Silence reigns in the TM community.

• The Sound of Silence (Simon and Garfunkel, Madison Square Garden, NTC, 2009 )  

I will remember you (Musings on TM colleagues past)

Updated: 30 April 2017 (Fixed typos)

April's blog focuses on a friend and colleague who recently died. How to write about Kathy Chambers after she so suddenly and unexpectedly died? Celebrate her life with a series of anecdotes on how she affected Canada's transfusion and quality community and beyond and especially those she closely worked with. 

Kathy's was the first blog in the CSTM's 'I will remember you' series (Further Reading). This blog allows me to be more personal and intimate.

For those who didn't know Kathy, I hope the blog has interest and value as a narrative on the complex interpersonal and mentoring relationships that exist in the transfusion workplace, indeed, any workplace. As you read it I encourage you to think of your own colleagues and how you interact.

The blog's title derives from one of Canadian Sarah McLachlan's songs.

ANECDOTE 1
Upon first meeting Kathy when she worked as a senior in the transfusion service of UAH, Edmonton I was struck by how she was so no-BS and down-to-earth, true to her Saskatchewan roots. She told it how it was, without the soft edges of political correctness. 

My gawd, I thought, this is the hard-nosed technologist I must collaborate with to develop the students' blood bank rotation experience? She was confident and a bit intimidating. If intimidating to me, an experienced transfusion professional, how would she appear to the 'kids' (as I call them to this day). 

Well, I needn't have worried. Kathy turned out to be the proverbial 'egg', hard on the outside and soft on the inside. She truly wanted the vulnerable neophytes (students) to have a good experience, to learn and grow during their clinical rotation. Kathy's confident exterior was intimidating, but she was warm and caring too, a trait that became increasingly clear the more I got to know her. 

Someone you could treasure as a lifelong friend no matter where life's divergent paths take you. 

ANECDOTE 2
At the CSTM 2000 conference in Quebec City, 10 years after she'd left Edmonton, Kathy introduced me to the then BC PBCO medical director and put me forth as the webmaster/content coordinator of its TraQ website. The offer came out-of-the-blue, totally unexpected, and was very kind given that we hadn't kept in close touch over the years. 

That conference generated many laughs. Kathy had such joie de vivre, always smiling and sharing an unspoken joke. 

TraQ was a dream job because I'd recently left a tenured position in MLS at the University of Alberta. After 22 years it was time for a new adventure and to give some of the 'kids' I'd taught a chance to transmogrify the job into the 21st C.

On subsequent trips to Vancouver for TraQ, and later on a CBS educational website project, Kathy always picked me up at the Vancouver airport (a chore in itself, given the traffic) and I stayed at her home and got to know her up close and personal.

One tidbit I recall is how we'd sit on her back deck each morning over coffee and she'd laughingly point out the neighbours who were suspected drug dealers.

To my surprise, I learned that Kathy gave me significant credit for something I took as normal. During her time in Edmonton she'd undertaken an ART (Advanced Registered Technologist), no longer offered by the now CSMLS. The ART was a way for Canadian medical technologists without BSc degrees to qualify for supervisory and managerial positions in clinical laboratories. 

Part of the ART requirement, besides a research project and oral examination, was a literature review. Kathy's lit review needed quite a bit of work and, as an experienced instructor, I gently suggested how she might improve it. Goodness knows who had taught her in the past because she inexplicably credited me for being a kind mentor and never forgot it. 

I suspect it formed the basis of her many acts of kindness to me over almost 40 years.

Fits with my experience that what we remember in life is mainly a series of small events (sometimes even seconds long) that strongly affect us positively or negatively and that we recall for the rest of our lives. 

I'm so glad that Kathy saw a small act in a positive light because her resulting kindness made my post-Med Lab Science career.

ANECDOTE 3
In 2000, Kathy and I were approached by Heather Hume, who had a vision to create a CBS educational website, which we did (2000-2003). Still think the site was a vein-to-vein masterpiece but impossible to maintain without considerable resources. Today, it's morphed to CBS's Professional Education site.

We had so much fun creating the original website. And I learned a lot from Kathy. Her breadth of experience was incredible. 

Towards the end of the project, Kathy and I had a parting of the ways, so to speak. The details are not important but, in retrospect, the fault was all mine. Indeed, Kathy went out of her way to rectify the situation and soothe my feelings but I was the stupid, hurt-feelings, hard-headed one. Keep this in mind for what comes next.

ANECDOTE 4
In 2007 I formed a consortium that was eventually hired by Alberta Health & Wellness to develop a Provincial Blood Contingency Plan to deal with severe blood shortages from pandemics and other causes (July 3 - Nov. 30, 2007). Folks I asked to form the Consortium included Penny Chan, Maureen Patterson, Dianne Powell, and Maureen [Webb] Ffoulkes-Jones, and yes, Kathy Chambers. 

As it turned out, Kathy Chambers became the 'de facto' lead under difficult circumstances and led the project to its successful conclusion. Quite an accomplishment and one that showed she had the 'right stuff', which I never doubted for a moment. 

Those of us involved refer to it as the 'project from hell' and Kathy was its saviour.  We can laugh about it now but not then.

ANECDOTE 5
When CSTM asked me to do a series of 'I will remember you' blogs, the first person I thought of was Kathy Chambers. She agreed without hesitating and, as was typical of her, quickly delivered the 'goodies' needed for the blog. 

Kathy was so talented and efficient throughout her entire career. How the heck could she have such focus? Amazing woman! A force of nature, a 'oner'. Like many in Canada and beyond, I'm fortunate to have known and learned from her. 

My best memories are of the many laughs we shared. Cannot see Kathy's face without a smile. I hope readers will recognize themselves and colleagues such as Kathy who have affected their lives for the better. 

FOR FUN
Naturally, I've chosen Sarah McLachlan's song for this blog:

• I will remember you 

I will remember you, will you remember me? 
Don't let your life pass you by 
Weep not for the memories.

FURTHER READING

• CSTM 'I will remember you' blog: Kathy Chambers

Don't worry, be happy (Musings on decreased government funding as a TM disruptive force)

Updated: 2 Jan. 2017 

Last December I got a bit mushy and wrote

• Islands in the Stream (Musings on how love of transfusion medicine unites us) [Further Reading]

This year I'm not as sentimental and am okay with being a grinch who stole Christmas. Besides Dr. Seuss's tale has a happy ending. Not saying it applies to this blog, though it may. You decide.

Continuing the series on disruptive forces that affect, or will affect, the practice of transfusion medicine (TM) is hard. Why? Mainly because of all TM health professionals, to date the ones who have been most affected by disruptive forces are medical laboratory technologists / biomedical scientists (whatever they're called in your country). I suspect that an in-depth discussion of laboratory realities would cause many nursing and physician eyes to glaze over.

Including the three main TM professionals is part of the challenge of writing TM blogs. For the most part I try to write about big picture 'poop' that affects all so lab techs, nurses, docs can relate.

So what is December's blog about? It's about the disruptive force of DECREASED GOVERNMENT FUNDING of health care in those nations where universal health care exists, and to a lesser extent in the USA.

USA readers may think the blog is not as relevant because you don't have government-funded universal health care like the rest of the developed world (Further Reading). But from what I've read on medical laboratory and clinical laboratory educator lists, similar things happen in the US, perhaps for different reasons. For example, consolidation is rampant in the blood industry. (Further Reading)

The blog was stimulated by a seemingly odd source:

• How physicians can keep up with the knowledge explosion in medicine (Further Reading) 

One suggested solution was to create the equivalent of 'paralegals' for medicine. Yes, my mind works in strange ways. More later.

The blog title derives from an 1988 ditty, which I've used before, by 10-time Grammy award winner, Bobby McFerrin . 

In an effort to keep the blog short and sweet, well at least shorter, I'll muse on Canada and leave it to you to judge if similar events apply to your country. References for many of the points will not be provided because they are available by doing simple Google searches. For example, in writing a literature review, you do not need to reference facts taken as a given and available in many resources, e.g., Donald Trump will become the 45th US President.

December's blog was also partly motivated by the economy currently tanking in my Canadian province of Alberta because prior governments made us depend on the price of oil to provide government services, including health care. Unfortunately, our economy regularly tanks. Suffering from boom and bust cycles is normal if you depend on others for prosperity, others like Saudi Arabia and the nations that make up OPEC (Further Reading).

The blog reflects on the disruptive force and effects of governments deciding to save money on the backs of health care professionals and the health system, including patients. First I outline the immediate effects in general of decreased funding, then present long term consequences for transfusion medicine.

DECREASED GOVT FUNDING - IMMEDIATE EFFECTS

CLINICAL LABORATORIES
Decreased health care funding began in a big way in Canada in the 1990s. Driven by right wing ideology, provincial governments (responsible for health care in Canada under our constitution) decided to save money in many ways, including by cutting funding to health care, particularly clinical laboratories. 

The result was a concurrent move to regionalize and centralize laboratory testing because it facilitated saving money by eliminating laboratory administrative staff and 'trench workers' alike (See Dianne Powell, Further Reading).

Management gurus tapped into the big government money available to consultants by propounding catch-phrases such as 'right sizing' and 'working smarter, not harder'. All in the belief that 'BS baffles brains', which it apparently does when it comes to governments to whom bafflegab is second nature.

'Working smarter, not harder' particularly rankles because it led to managers of transfusion labs trying to do more with less  - in effect, being guinea pigs to government experiments - and considered failures if they couldn't.

Staffing
For example, if five labs became one lab, the first to be axed could be four lab supervisors, now that only one was needed. Similarly, the five trench workers who covered the midnight shift as the sole technologist on duty could become one worker. You get the idea. What happened in Canada due to this disruptive force was many lab technologists, mainly middle managers and trench workers, lost their jobs.

Education programs
Concurrently, med lab technology/science programs closed across Canada, since far fewer graduates were needed. 

In Canada in the 1990s only two programs survived in the 4 western provinces (constituting ~31% of Canada's population) and both were in Edmonton, Alberta, perhaps due to the programs' strength, since Alberta was the province hurt worst by funding cutbacks. I taught in one (MLS, University of Alberta) and was a clinical instructor for the other (NAIT).

Medical lab technologists/clinical lab scientists
Under NAFTA, those with university degrees were lucky to get clinical laboratory jobs in the USA, where shortages had become extreme. Others had to give up the career they loved and had worked at for up to decades when laboratory jobs disappeared.

Clinical placements
Another factor was that government cutbacks resulted in clinical labs becoming under-staffed. Staff could barely keep up with doing core work (patient testing), let alone train students. As a result no one wanted to, or even could, train students, even though it was in their best in interest for succession planning.

Automation
Semi-automated and fully automated lab instruments found great favour and prospered in the era of decreased government funding of clinical laboratories. Instrument manufacturers promised their impressive looking instruments would decrease staff numbers, a tempting advantage since staff had costly benefits such as supplementary health insurance and pensions.

Companies also tried to take the edge off axing technologists by claiming now they could concentrate on more interesting skills and let the instrument do the 'grunt work' (my phrase). Cue a kumbaya moment. Except those without a job wouldn't be singing.

But, oh how pathologists' eyes would light up at the thought of becoming less of a cost centre in the hospital hierarchy. Of course, the more bells and whistles the gizmos had, the bigger the eyes.

No one seemed to care that

• Government money was sucked outside Canada to multinational for-profits, rather than to staff who worked in Canadian communities, paid taxes and raised their families here. 
• Lab automation operates on a razor-blade business model. 
• Despite promises of smooth integration with lab information systems, automated instruments often had a hidden cost - the need to buy middleware so they could 'talk' to the LIS. And then the fun begins.

NURSING
Perhaps nurses can add to this discussion, at least I hope so. In Canada, decreased government funding of health care led to unemployed graduate nurses being recruited to the USA, Australia, NZ, pretty much everywhere outside Canada. More than 20 years later, Canadian hospitals still suffer because there are not enough nurses to staff operating rooms, emergency departments, etc.

Indeed, the nursing shortage is growing because of an aging workforce (Further Reading). Impending baby-boomer retirement affects all health professions.

MEDICINE
In Canada, decreased government funding did not affect physicians as much as med lab techs and nurses, mainly because physician numbers are much lower. However, in Alberta in the 1990s lab physicians lost jobs and, as might be expected, were compensated much more than other health professionals.  See 'History of 1990s Laboratory Restructuring in Alberta':

•  $7M Fund for Docs in Distress 

DECREASED GOVT FUNDING - LONG-TERM EFFECTS
In a way the long-term consequences of decreased government funding are the same for lab technologists, nurses, and physicians. Here I'll focus on transfusion medicine tidbits.

LABORATORIES
How have TM labs coped (saved money), and with what effect on medical laboratory technologists/scientists, post-government funding cuts?

Regionalization and centralized testing laboratories and increased automation all led to decreased staffing needs. But more than that, automated instruments led to a decreased need for well trained transfusion specialists.

Less educated and specialized staff
Hospital transfusion service labs are more than happy to decrease costs by hiring lab assistants (some with formal educational qualifications but also those trained on the job). Generalist technologists who work in other labs such as chemistry and hematology also play a key role, especially in labs beyond the centralized transfusion service lab and in rural areas.

The result has been fewer and fewer transfusion specialists with more and more staff relying on the few specialists to problem solve and keep transfusion service laboratories functioning safely. When TM specialists retire, who can fill their key role?

Dummy-proofing
For decades, some TM educators have referred to hiring less well educated staff as the 'dumbing down' of the profession. That sounds harsh but does not mean that lab assistants or generalists are dumb because they clearly are not and deserve respect. Rather it means that with the advent of automation and 'mistake-proofing' tools, many staff no longer need to be as educated and trained as before. For example:

Tools
Mistake-proofing is designing processes and devices to help prevent errors and make them obvious at a glance. Synonyms include error-proofing, fail-safing, and the politically incorrect idiot-proofing. Mistake-proof devices are common in daily life. Ex:

• Beeping alerts when keys are left in cars or headlights are left on
• Computer dialogue box that asks, "Do you want to save the changes you made...."

Mistake-proofing tools are also commonly used in transfusion processes and include:

• Checklists for specific processes;
• Inspection checklists for receiving blood into inventory;
• Pretransfusion nursing checklists;
• Colour-coding of ABO antisera;
• Cross-checking work done by others;
• Barcodes on donor bag labels;
• RFID for release of transfusion units from refrigerators and more (Further Reading)

Bottom line - Labs: To make a transfusion lab run safely, some staff  must be well educated transfusion specialists.  How many depends on the locale, test volume, patient mix, etc. My experience is there are too few specialists and they're aging, about to retire in large numbers.

NURSING
How have hospitals and blood suppliers coped (saved money), and with what effect on nurses, post-government funding cuts?

Hospitals
In hospital wards across Canada there are fewer and fewer RNs, also fewer LPNs. Instead we have a new category of health worker, called by various names, including heath care aides and nursing attendants.

In Canadian hospitals, such workers usually have formal qualifications taking about a year to complete, including an internship. They often are the main care givers, especially to the elderly in long-term care.

Besides being short-staffed, the big nursing change within hospitals, discussed in the first 'disruptive force' blog, is the advent of transfusion nurse specialists/safety officers and blood conservation nurses. But they arose from the tainted blood tragedy and government regulation, not government cost-saving measures.

Blood suppliers
In Canada, as a cost saving measure, CBS decided to axe the number of expensive nurses it employs by hiring cheaper on-the-job trained 'donor care associates'.

* Health Canada approves new blood donor screening model (10 Feb. 2013)

This correlates to how USA blood donor centers operate, where  phlebotomists are trained on-the-job to draw donor blood and perform other functions. Having a Certificate of Phlebotomy helps since employers would rather get trained staff to decrease their costs.

Once I joked that CBS may do the same with its transport staff.

Bottom line - Nursing: I've no idea how well 'donor care associates' work at CBS and what effect, if any, their employment has had on nurses, other than fewer jobs available. On hospital wards, nurses suffer from short-staffing and a different mix of staffing, which is stressful.

PHYSICIANS
How have TM labs coped (saved money), and with what effect on medical staff, post-government funding cuts? With regionalization and centralized testing labs, fewer transfusion service medical directors exist because one physician fulfills the role for an entire health region. 

And, although all staff have responsibility, transfusion service medical directors are ultimately responsible for keeping patients safe, which becomes more challenging with staff shortages and a different mix of staff.  

In the health care system in general, several strategies have been floated to decrease physician costs, and some have been tried. 

For example, in Alberta a system of primary care networks exists (Further Reading). They work well (I've accessed one myself) and consist of physicians and other health professions, including nurse practitioners, dietitians, respiratory therapists, exercise specialists, etc.

The cost saving derives from the benefits of preventative medicine and using less expensive health professionals as appropriate. Now that Canada has assisted dying legislation, the Alberta government expanded the list of medical professionals authorized to assist patients with their deaths to include nurse practitioners. (Further Reading) 

The news item that caught my eye dealing with physicians:

• How physicians can keep up with the knowledge explosion in medicine (Further Reading)

The article proposed interesting solutions:

• Create 'paralegals' for medicine (para-medicals)
• Meaning let nurses and junior doctors do more
• Build a learning medical information ecosystem
• Wow, what a bafflegab mouthful! At first it seemed to mean teamwork between health professionals (always a great idea), but then the authors pivoted to information technology. 

Always the technological solution, eh? Makes me laugh because I know physicians who have difficulty using their office computer system to renew a prescription easily. And some of these docs are not that old.

• Mutter, mutter...Why won't it let me select renew? Aaargh! (Then writes it in pen on the computer print-out)

And how many physicians resist Twitter as a huge waste of time and don't see it as a valuable tool? Yet they attend medical rounds for the sandwiches (and to be seen) and chitchat or snooze or check e-mails throughout? Or perhaps, just to show how clever they are, ask the presenter an obscure question?  Perhaps I'm being too cynical but that's how it seems sometimes.

Bottom line - Physicians: On a personal level, transfusion physicians have been more successful than lab technologists and nurses in fighting job loss caused by government cutbacks. Or maybe it just seems that way because their numbers are fewer. Of course, medical directors of transfusion service labs feel the full staffing effects of having fewer specialist lab technologists/scientists.

I cannot but smile imagining physicians being told they must concede a significant percentage of what they always considered their health care role to others. But don't worry about it, docs, it's to your advantage. Others will now do the boring 'grunt work'. And you'll be able to concentrate on the interesting, complex stuff you were educated for. Don't worry, be happy.

SO-WHAT? 

LOW MORALE AND MORE

With cost cutbacks, low morale affects all health professions to varying degrees. My experience is morale falls mainly due to uncertainty, lack of control, and feeling devalued

When government cutbacks occur, health systems are stressed to the max and are forced to change. You might think of it as tough love. The change includes finding innovative ways to keep functioning safely. What often results is a series of experiments, experiments in which both staff and patients are the guinea pigs. 

Often outside consultants are brought in to push and implement what is often the hobbyhorse that's become their cash cow. Sorry, couldn't resist the mixed metaphor. They implemented 'the solution' elsewhere and now they're the experts, commanding big money. It's led to the joke

• 'We're consultants and we're here to help you.' [Sure you are.]

➽In this system-wide experimental laboratory where cost saving rules, the biggest impact on staff is uncertainty and loss of morale. Change is always hard but even 'keeners' can soon become unhappy when they learn that they have no control over events, including job loss. Competent, skilled staff are let go because their positions are eliminated. In a unionized environment sometimes the 'best and brightest' lose jobs due to lack of seniority.

Moreover, staff who survive the cuts often feel guilty. The 'Why me, not them' syndrome. Suddenly folks you've worked with for years are gone, perhaps needing to change careers they love, and you're left for no apparent good reason. Some may even need a job to care for their families away more than you do but....

In such an environment staff invariably begin to feel devalued. Unfortunately, this is one of the most long-lasting invidious effects of cost restraint in which it matters not how capable someone is, how dedicated or how loyal. Staff begin to feel like checkers being moved around a board, where any checker will do. 

Effects such as low morale take a long time and much effort to reverse. It seems that some feelings are branded into people's souls, and not in a good way. 

The other long-lasting invidious effects are mistrust and cynicism about the intentions of governments, that with a limited money pot, make choices that cripple a health system and leave it with a lasting hangover. This happened in Alberta, Canada in the 1990s.

Similarly, where massive funding cutbacks lead to significant job loss, internal disruption and re-organization, distrust and cynicism invariably extend to the administrators who lead the health system, whether those at hospitals or the blood supplier. 

The health care system becomes similar to a dysfunctional family with some of its characteristics

'One or both parents exert a strong authoritarian control over the children. Often these families rigidly adhere to a particular belief (religious, political, financial, personal). Compliance with role expectations and with rules is expected without any flexibility.'

In the case of health care, the de rigueur belief system includes cliches such as 'do more with less', 'work smarter, not harder', the lean business model and its many variants rule. Oh, and by the way, no dissent allowed. 

➽One final tidbit: The long-term effect of decreased government funding leading to less educated and trained staff is disconcerting because 

• A little knowledge is a dangerous thing. 

The most dangerous folks in any profession are those who do not know what they don't know. And that plays out daily on hospital wards and in transfusion services labs, where we can only hope there are enough well educated specialists to catch errors leading to patient harm. 

SUMMARY
In this blog I muse about the short- and long-term effects of the disruptive force of decreased government funding for health care and transfusion medicine in particular.It's happening everywhere.Will governments have a

• Come to Jesus moment?

It's doubtful. Today governments still do not consult frontline workers enough, or at all, about coming cutbacks and give them an opportunity to participate fully in a transparent change process.

Changing government policy is difficult and analogous to Newton's First Law of Motion:

A body at rest will remain at rest unless an outside force acts on it, and a body in motion at a constant velocity will remain in motion in a straight line unless acted upon by an outside force.

A sufficient outside force hasn't acted because professionals in the health system tend to accept whatever poop falls on their heads and do everything to make it work. Don't rock the boat, yes, this worries us, but let's wait and see. Somehow we'll muddle through, even if it creates much stress to us.

That's the thing. Physicians, nurses, lab technologists/scientists in transfusion service labs make the system work, regardless of the personal cost to their health and well being. And those in charge, physician-administrators (⧭see below), bureaucrats, politicians alike, seem happy to let them. 

FOR FUN
This song has been used before because it fits some of the blogs and, face it, I obviously like it.

For interest, in 1988 McFerrin's song was used by 'Bush 41'  - a one term President - as his official campaign song without McFerrin's permission. McFerrin protested, stated he'd vote against GHW Bush, and dropped the song from his performances. Ouch!

Anyway, given recent political events in the USA, you can likely guess my take on Donald Trump. Similarly for the long-term effects of government cutbacks, I could slit my throat (figure of speech) or sing this song and I choose the latter.

• Don't worry, be happy (Bobby McFerrin and friends) 

Here's a little song I wrote
You might want to sing it note-for-note
Don't worry, be happy
In every life we have some trouble
But when you worry, you make it double
Don't worry, be happy Don't worry, be happy now

As always comments are most welcome.

FURTHER READING

CSTM blog: I will remember you: Dianne Powell on lab restructuring

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

How physicians can keep up with the knowledge explosion in medicine (19 Dec. 2016)

⧭The rise of the hospital administrator [Reality is that hospital administrators railed at in the article are often physicians who've become 'suits'.]

Alberta's Primary Care Networks | Edmonton Southside PCN

Alberta government expands medical professionals authorized to assist patients with their deaths, by including nurse practitioners (12 Dec. 2016)

Truth about the nursing job market

USA blood industry consolidation

Blood industry shrinks as transfusions decline (2014)

Blood centers should position themselves to be agents (not victims) of change (2014)

U.S. health care from a global perspective

U.S. spends more on health care than other high-income nations but has lower life expectancy, worse health

Middleware revolution bridging automation gaps

UK health agency plans RFID trial to staunch transfusion errors (2006)

The case for RFID in blood banking (USA perspective, 2016)

Saudi's destructive oil freeze (March 2016)

Simply the best (Musings on paid plasma & TM colleagues I've know)

Updated: 23 Jan. 2016

January's blog is a two-fer, derived from a news item in TraQ's monthly newsletter and a blog series written for the Canadian Society for Transfusion Medicine (CSTM).

The title derives from a 1989 Tina Turner classic. And it relates to the CSTM blogs, not paid plasma. But I suspect you could figure that out. Paid plasma and its Canadian players are the antithesis of the best.

Although this blog and the CSTM blogs are from a Canadian perspective, I'm confident you will see how the content and issues relate to you, no matter where you practice.

For links to news items and resources, see Further Reading at the blog's end.

#1. MUSINGS - HONORING COLLEAGUES / RECORDING HISTORY
I encourage readers to read this new series of blogs on the Canadian Society for Transfusion Medicine site. To date there are two blogs, with many more to come.  As I wrote to introduce the first blog:

Each blog begins with my musings on the individual, followed by a brief background on the person's career, sometimes with my comments throughout. 

If you're looking for a rah-rah, rosy view of Canada's transfusion medicine field, this ain't it. Why? Although all participants enjoyed their careers and love the transfusion profession, they also speak honestly about both the ups and downs. Perhaps their reflections will resonate with your experiences.

Take a peek. Blogs present real experience with honest opinions that challenge the 'powers that be'. I encourage you to comment on the CSTM website and give your experiences, whether similar or different.

Now for the NOT BEST. 

#2. MUSINGS - PAID PLASMA REDUX
Oh, no, I can hear you scream. Not paid plasma in Canada again! Yep, because it's in the news again. To me, it's like whack-a-mole or the gift that keeps on giving, blog-wise. So much to learn from this Canadian saga, and most of it BAD.

Don Davies, a federal MP with a centre-left Canadian political party (NDP) has called on paid plasma clinics to be banned. Already not allowed in 2 provinces (Ontario and Quebec), a company, Canadian Plasma Resources, now has plans to set up in the Canadian province of Saskatchewan and has the approval of its right-of-centre government.

Party characterizations are mine. Feel free to disagree. Note that in Canada's political system, jurisdiction over health care belongs to the provinces.

Bottom line, and one reason why I think writing about this again is useful:

• MP Davies bases objections on safety. Since Canada has one of the safest blood systems in the world, this is a hard sell. More credible arguments against paid plasma are nuanced.

Safety
In a nutshell, the safety risks of paid plasma are exceedingly small but not zero. Any remaining risks are rare and relate to the 

• Poor and needy potentially lying on blood donor screening questionnaires to get the money, combined with 
• Reality of window periods of negativity (even short ones), such that screening tests may not detect early infection.

Another risk factor is that of unknown new and emerging infections that may be transfusion-transmissible. You can bet they exist, just as death and taxes are sure things.

In both cases, the infections would need to escape existing donor screening questions and tests, as well as current processes in the manufacture of plasma derivatives (e.g., albumin and immune globulins such as IVIg and Rh immune globulin), including

• Plasma quarantine
• Technology to inactivates viruses
• Purification steps

Can transfusion-associated risks happen with plasma derivatives? Yes. Likelihood? Extremely low. One unknown is the human factor. Humans make mistakes, otherwise known as 'shit happens'.  

But, similar to winning the USA's Power Ball $1.6b lottery (odds are ~1 in 292 million), eventually someone will do it. If you're the unlucky patient  who gets a transfusion-transmissible disease, no matter how unlikely, it matters not.

Moral/philosophical
Canada, like many nations, adopted an altruistic view of blood donation, meaning paid plasma donation is an anathema.

But paid plasma donation has existed since the 1960s in Canada, something paid plasma advocates love to point out:

As far back as the 1960s, the Rh Institute in Winnipeg paid Rh negative women with potent anti-D causing severe HDN and fetal death a small honorarium for their time in donating plasma by plasmapheresis. 

Side-Bar: Never mentioned in the literature - something that fell under the radar: In the 1960s Canadian Red Cross Blood Transfusion Service (CRC-BTS) bled employees for blood typing antisera and paid us. How much? A whopping $5/donation.

As a group A CRC-BTS medical lab technologist employee, I donated plasma for anti-B antisera and was injected with soluble B antigen to increase my anti-B titre. My group B co-worker had her anti-A similarly boosted and plasmapheresed for anti-A. 

Such donations ceased when my co-worker's first child had severe ABO-HDN. Physician in charge realized it was not a good idea to boost the strength of ABO antibodies in young women of childbearing age. Doh!

Back to anti-D: Donation initially occurred at CRC-BTS (now CBS). As someone involved I can testify that the 'Rh ladies', many of whom had fetuses stillborn due to severe hemolytic disease of the fetus and newborn (HDN or HDFN) did not donate for the small honorarium. 

• See Dr. Bowman's obituary and note the comments.

Rather it was to help other woman not have to suffer their pain and in gratitude to Dr. John Bowman, who donated his own group O Rh-negative blood for exchange transfusions, pioneered inter-uterine transfusions (IUTs), which gave them living children, as well as pioneering antenatal Rh Immune globulin manufactured from their plasma, which prevented HDFN in others.

• So, please, don't buy the guff that today's poor who donate for money are in any way similar to these women donating anti-D in Winnipeg. 

Since then a commercial company (Cangene, now defunct and part of Emergent Biosolutions) expanded to paying not only the 'Rh ladies' with potent anti-D, but others with special antibodies to manufacture plasma derivatives such as hepatitis B immune globulin (HBIG). 

Canada's approach to commercialized, private medicine
To some extent Canadians have looked our collective noses down on the commercialization of blood donation (and health care in general) in our U.S. neighbour.

Ignoring the ethics of paying the poor for plasma and charging those unfortunate enough to be sick for health care, many Canadian medical lab technologists/scientists who work in the USA are astounded at the bureaucratic nightmare associated with hospital transfusion services charging patients for each and every pretransfusion test.

• Need a type and screen? Ka-ching!
• Have an antibody to identify? Ka-ching! 
• Need antigen-negative red cells? Ka-ching! 
• Need multiple red cell, plasma, and platelet transfusions? Ka-ching! 
• Require special blood products like irradiated red cells? Ka-ching!

Patients can be billed $1000s of dollars. Many don't have private insurance associated with employment or are not poor enough to get Medicaid or are elderly (Medicare).

For more on USA's system of paid blood donation and private healthcare, see Further Reading (Domen and AABB and Deciphering USA's Health Insurance System (an information page I created with significant help from a MEDLAB-L subscriber).

What does 'paying' donors mean?
Today USA's so-called 'non-profit' blood banks do not directly pay whole blood and plasma donors money. It's done via various incentives. 

Sample 'non-profit' blood bank incentives (via Oklahoma Blood Institute):

• Chance to win a cruise
• Donor rewards (Ex: Up to 100% of OBI-related, blood processing fees covered to a maximum of 100 units of RBCs)
• Redeemable merchandise
• Ability to Track test results

Paid plasma collection centers, some operated from abroad, e.g., Australia's CSL, are different. They prey on the poor and make a lot of money doing so. Even they now have sense enough to shy away from the filthy lucre ($$$) and do not pay donors directly. It's usually done by prepaid debit cards, as explained here:

• How Plasma Donors Got Stuck With Prepaid Card Fees and Why It Matters (3 Nov. 2015)

BOTTOM LINE: Many Canadians think this is the way to go. I do not.Those promoting paid plasma lay on the fear and guilt: people will die without a sufficient supply of plasma derivatives. Then they play the hypocrisy card, noting that CBS buys products made from paid plasma donors. 

What they don't say is 'Let's build the plasma collection centres next to homeless shelters so we can get our supply 'on the cheap'. Renting or buying a facility will also cost less. Value-added! Let's leverage the location to improve our bottom line and pay higher dividends to our investors.' Because it's all about the money, stupid!

For interest, someone sent this as a comment to an earlier blog and it's never been more relevant:

"Regarding Paid Plasma and the potential go ahead in Saskatchewan (SK):
We have had no public consultation in SK. and we are still don’t know what happened to the results from the Health Canada Public Consultation on the Safety of Paid Plasma Donations.

The CBS doesn’t collect as much as they could because of cost not donor availability but this reality gets stood on its head to appear that there are not enough donors and we actually need this. 

CHS and CBS support the deal adding credibility not to a Baxter or Octapharma but instead to a bunch of guys that really do not appear to be very credible. 

It's all incredibly interesting. Can't help but wonder who will be handling the testing of samples for CPR?"

MY TAKE. Health Canada and CBS both come across as a joke in this sorry saga:

• Health Canada: Backgrounder: Plasma donation in Canada
• 2014 blog: Day tripper (Musings on HC's instructions to the jury on paid plasma)

Can HC make a decision that doesn't ebb and flow in the wind depending on how key stakeholders lean? And if profit-motivated Canadian Plasma Resources opens for business in SK, who will do the transmissible disease testing?

Can CBS please stop with the weasel words that they support voluntary blood donation but, hey, paid plasma is safe and, by the way, we REALLY need it?

FOR FUN
When I write about my colleagues, I always think of Tina's song:

• Simply the best (Tina Turner, Barcelona. 1990)

As always, the views expressed are mine alone. 

Comments are most welcome (you can do so anonymously). See below. 

FURTHER READING

My 5 prior bogs on paid plasma (Some internal links to news items may not work but you'll get the idea)

Paid plasma clinics must be banned: NDP (15 Jan. 2016)

AABB: Billing for Blood and Transfusion Services: Frequently Asked Questions and Answers

Deciphering USA's Health Insurance System  (Generous help with links supplied by James Pusavat, a MEDLAB-L subscriber from the USA)

Domen RE. Paid-versus-volunteer blood donation in the United States: a historical review. Transfus Med Rev. 1995 Jan;9(1):53-9.

What is USA's Medicare vs Medicaid? / Also see Investopedia

This next paper is a beauty. Gives all you need to know about paid plasma in Canada, and its advocates:

• Ethical and legal issues in the supply of blood products (Study paper for Bayer Advisory Council on Bioethics,1999)