We are the world (Musings on COVID-19's impact on the world's blood supply)

Stay tuned: Revisions are sure to occur

March's blog derives from the ongoing worldwide shortage of blood due to the coronavirus (COVID-19). Of course, because this is a transfusion medicine blog, I'm preaching to the converted. But I hope it gets wider distribution among all healthcare colleagues and the public beyond. 

Specifically, I ask all transfusion heath professionals to speak to colleagues, family, friends, neighbours about the ongoing need for blood donation, made even more crucial because of the COVID-19 pandemic. 

The blog's title is based on a 1985 song written by Michael Jackson and Lionel Richie for  'USA for Africa.' 

BLOOD SHORTAGES
For TraQ's newsletter, I've collated some of the ongoing blood shortages across the globe (Further Reading). Fact is, the need for blood transfusion is ongoing despite the COVID-19 pandemic. Yet blood donation has dropped off significantly in many nations for numerous reasons explained in the news items in Further Reading. 

TRANSFUSION NEEDS
Despite the ongoing efforts of the Transfusing Wisely initiative (Further Reading), implemented in many nations, regular need for transfusions still exits for many patients. Transfusing Wisely's general goals: Reduce the rate of unnecessary blood transfusions with the goals of lowering the risk of complications for patients and supporting the judicious use of valuable resources. 

For the general public, just some of the ongoing needs for blood transfusion include the following (not all inclusive):

Patients who need blood transfusions

• Mothers who incur significant bleeding during delivery, including those with placenta previa

• Gastrointestinal bleeding (if massive can be life threatening) with many causes such as hemorrhoids, peptic ulcers, tears or inflammation in the esophagus, diverticulosis and diverticulitis, ulcerative colitis and Crohn's disease, colonic polyps, or cancer in the colon, stomach or esophagus  

• Kidney disease, sometimes secondary to type 1 diabetes, that requires dialysis

• Any surgery that involves significant blood loss

• Trauma patients including those in car accidents who experience blood loss and victims of knife attacks or gun shot wounds

• Blood disorders, including
• Thalassemia major patients need regular red blood cell transfusions to raise their hemoglobin level and deliver oxygen to body tissues
• Sickle cell disease patients need regular red blood cell transfusions to provide normal red blood cells, lessen anemia and reduce the blood's viscosity, allowing it to flow more freely and ease disease symptoms and prevent complications
• Leukemia patients who develop thrombocytopenia need platelet transfusions to control bleeding 

The need is real and ongoing. Please encourage colleagues, family, friends, and neighbours to donate blood and save a life. It's one thing folks can do during the pandemic. Further Reading includes questions about donating in Canada and blood systems in all nations have similar information. 

FOR FUN Naturally, I chose We Are The World, originally written for 'USA for Africa' in 1985 by Michael Jackson and Lionel Richie, produced by Quincy Jones and Michael Omartian, and sung by many fabulous American  artists.  

• We Are The World 

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

As always, comments are most welcome and appreciated.
FURTHER READING
Australia: In the face of coronavirus pandemic, Australian Red Cross Lifeblood’s stocks are threatened (24 Mar. 2020)

Canada: Top doc says Canada still needs people to give blood amidst social distancing (17 Mar. 2020)
      Canadian Blood Services: Message by CEO Dr. Graham Sher
      CBS answers COVID-19 blood donation questions

Pakistan: Experts urge volunteers to donate blood as thalassaemia patients face shortage (22 Mar. 2020)

Spain: In COVID-19 emergency blood bank stocks in Costa Del Sol hospitals are alarmingly low (18 Mar. 2020)

UK: Blood donors needed after 15% drop, says NHS (23 Mar. 2020)

USA: Coronavirus fears threaten America's blood supply (12 Mar. 2020)

Transfusing Wisely Canada

Nessun dorma (Musings on anti-paid plasma blogs over the years)

Updated: 14 Nov. 2018

Below is a list of the blogs I've written so far on paid plasma: 23 blogs over 6 years as of 14 Nov. 2018. Some blogs focus on it entirely, others touch upon it along with related issues. In total 2004-2018 I've written 174 blogs, and paid plasma constitute about 13% of them. This blog's sequence is different than others. The main content (list of earlier blogs) will come at the end.

INTRODUCTION
The blog's title comes from a famous aria for tenors in Puccini's opera Turandot, which premiered at La Scala in Milan in 1926 after Puccini's death. Like many, I love the classic for many reasons. One is my spouse and I heard Pavarotti sing it in person in Edmonton in 1995. The face of every person on the LRT ride home from the concert radiated with joy.

I chose Nessun Dorma for several reasons. The title and first lines translate as 'None shall sleep' and builds to the final, victorious cry of 'Vincero!' (I will win!). In the battle over paid plasma in Canada, and it is a battle, I'm against paid plasma, as explained in the 23 blogs below. We don't know who will win and what the win will look like.

I hope the eventual winners (Vincero!) will be

• Patients who need plasma derivatives and are prescribed products like intravenous immune globulin (IVIG) for evidence-based reasons, not because Big Pharma promotes it relentlessly to physicians. VERSUS patients being scared into panic by BIG Pharma, which supports their associations financially and is not beyond creating fear the world will end if paid plasma clinics cease to grow exponentially. 
• Blood donors in financial need, who will no longer be exploited at the risk of their health by Big Pharma, which makes $billions off their body tissue. Yes, not all see themselves as being exploited, but many, if not all, are exploited and it's unethical.
• Volunteer blood donor sector, which will recruit and be able to retain young donors, instead of having them slowly siphoned off to paid plasma, from which they are unlikely to return as they age.
• Canada's blood supplier CBS (outside Quebec), which can concentrate on ways to encourage more volunteer young donors, perhaps with token incentives as happens in the USA system, or maybe not. Hope that CBS gets funding to open plasma collection clinics to get Canada closer to meeting its plasma needs.
• Canada's government funders of the blood system, which should fund CBS plasma clinics, encourage voluntary donation, VERSUS now needing to spend megabucks to regulate ('police') the use of IVIG due its ever-increasing usage, as done by the BC PBCO and others, including for primary immunodeficiency. 
• Health Canada should do its duty to regulate blood safety as a win-win strategy for patients and blood donors, VERSUS encouraging Big Pharma to promote endless iffy uses of plasma derivatives by supporting its exploitative paid plasma growth in Canada. 

FOR FUN

• Nessun Dorma - Luciano Pavarotti, 1994 (3:14 mins)

PAST PAID PLASMA BLOGS (n=23)

2018

The sound of silence (More musings on paid plasma pros and cons) 

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

2017

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

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

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

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

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

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

2016

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

Sweet Dreams (Musings on a recent transfusion-related nightmare) 

Heart of Gold (Musings on donating the gift of life)

2015

Heart of Gold (Musings on sucking $ from body tissues)

2014

Don't worry, be happy (Musings on the safety of our blood supply) 

If you could read my mind (Musings on hard-to-believe TM news) 

C'est si bon (Musings on TM news that is so good and not so good) 

Hey Jude (Musings on why paid plasma makes it worse, not better) 

I heard it through the grapevine (Musings on paid plasma's PR campaign) 

Bridge over troubled water (Musings on what to be thankful for as TM professionals)

2013

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

Heart of Gold (Musings on pimping for paid plasma) 

Stop children, what's that sound (Musings on commercialization of our blood supply) 

We are the world (More musings on commercialization of the blood supply) 

Still my guitar gently weeps (Yet more musings on commercialization of our blood supply)

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)

Heart of Gold (Musings on donating the gift of life)

Updated: 24 April 2016

April's blog was stimulated by a flurry of news about organ and tissue donation in North America due to 

• Canada: National Organ and Tissue Donation Awareness Week, April 22-28;
• USA: April is National Donate Life Month;
• Other nations have similar days, weeks, months throughout the year.

Recently, many news items have appeared on selling a body tissue, namely the introduction of paid plasma collection centres in Canada. Be aware that this is NOT another blog on that contentious issue. Rather it's about awareness of 

• What we can donate;
• Why we should donate;
• How we can donate;
• Why we don't donate. 

The blog's title derives from a 1972 ditty by Canada's Neil Young.

STATISTICS ON  DONATING BLOOD VS TISSUES AND ORGANS
The blog will mainly present Canadian statistics, which are not that different from statistics elsewhere in the world, except where noted. The focus will be on tissue and organ donation, not blood donation. OMG, statistics! Not to worry about being flooded with numbers. Statistics are great fun. 

About blood donation, ~4% of Canadians voluntarily donate blood. As to tissue and organ donation, 80-90% of Canadians support organ and tissue donation but less than 20% make plans to donate.

Donating tissue and organs is in many ways different than donating blood, especially if the former applies to the future once you're dead, something you put in a Will or indicate on your driver's license. 

Organ donation is a complex process, which involves identifying potential donors, getting consent from families and procuring organs around the time of death. Donating tissues and organs after death is something that won't affect you personally as you're dead. 

But donating will affect your family at an emotional time, so it's essential that you frankly discuss your wishes with them. If your family objects, regardless of your wishes, your donation will not happen. 

Canadian STATS - Organ Donation (2014)

• Over 4,500 people waited for organ transplants (77% needed a kidney); 
• 2,356 organs were transplanted;
• 278 people died waiting for a transplant (one-third needed a kidney).

TIDBITS

• The number of tissues and organs that can be donated is large

You can register to donate your organs and tissues and even donate certain organs while you're still alive: a kidney, part of the liver, and a lobe of the lung. See, for example,

• Organ, Tissue and Eye Donation  (Most locales in the developed world have similar registries and opportunities to donate.)

An estimated two-thirds of deceased patients who are eligible to donate organs in Canada do not make it through the complex organ donation process. 

Only 2% of people who die meet the strict criteria for organ donation. But 90% can donate tissues, including corneas, heart valves, tendons and skin. 

Each deceased donor provides 3.4 organs on average.

Quebec had the highest deceased organ donor conversion rate in Canada, at 21% of eligible deaths, nearly double that of all the Prairie provinces.  

Transplant BC has 988,740 registered organ donors but only 422 organs were transplanted in 2015 due to strict medical requirements that rule out 99% of donors. Most deceased donors are declared brain-dead in intensive care but their hearts are kept beating until surgeries can be performed. 

Donation after Cardiac Death (DCD) is an emerging phenomenon in Canada that has forced the health care system to confront ethical issues on what constitutes death. Canada has adopted neurological criteria (“brain arrest”) to define death but some provinces do accept DCD.  

MUSINGS
Why don't more people donate?
So why don't more people take steps to give the gift of life after death? It's complex but here's why I think many good folks don't think about donating tissues and organs and plan for it:

• Simply because it doesn't enter their consciousness;

• Unless they know someone whose life depends on a transplant, they're unaware;

• If they think about it, cutting up their bodies, even if dead, to remove parts may seem creepy;

• For some, religion plays a role:
• Oliver M, Woywodt A, Ahmed A, Saif I. Organ Donation, Transplantation and Religion. Nephrol Dial Transplant 2010
• Includes positions of many religions on organ donation and transplantation
• Bramstedt KA. Transfusion contracts for Jehovah's Witnesses receiving organ transplants: ethical necessity or coercive pact? J Med Ethics. 2006 Apr; 32(4): 193-5.
•  Why don't more Muslims donate?

Legal trade in tissues and organs
In many nations voluntarily donation is honoured but, depending on the body part, you may be able to sell it legally. For example:

• 10 body parts you can legally sell for big bucks (TheRichest.Com, 27 May 2015)

• How much can you get for selling your body parts? (The Guardian, 31 Jan. 2014)

Some argue we should be able to sell organs, not just plasma, hair, etc. 

• Give a kidney, get a check. (The Atlantic, 27 Oct. 2015)

 'A recent survey of Americans by researchers from Argentina, Canada, and the US. ...found that while barely half of respondents initially favored a system that would pay organ donors, the number rose significantly—to 71 percent—once those surveyed were given information about how the system would actually work.'

And some use arguments similar to those used to justify paid plasma. Paying helps the economy (the poor have more disposable money to spend) and recipient lives are saved. 

Black market in tissues and organs
We volunteer to donate body tissues and organs, we sell some legally, then there's the dark side, and it's very dark indeed.

• Illegal kidney trade booms as new organ is 'sold every hour' (The Guardian, 27 May 2012)
• WHO estimates 10,000 black market operations involving human organs take place each year
• Body organ 'medical tourism'

As well, there's another shady, hidden body organ market that seldom sees the light of day:

• Human corpses harvested in multi-million dollar trade (Sydney Morning Herald, 17 July 2012)
• A must read. Truly incredible!

You can search the Internet and find MANY similar - and even more gruesome - real-life, true reports.

LEARNING POINTS 
To me paid plasma is the thin edge of the wedge, the slippery slope that leads to hell, a hell where the poor sell their body parts in the open market to the highest bidder. Paid plasma and 'kidneys for sale' are on the same continuum.

My view is that voluntary tissue and organ donations are an incredible opportunity to make a real difference in the lives of fellow humans, whether 

• Skin for burn victims; (2 min. video)
• Corneas for blindness;
• Lungs for cystic fibrosis (or idiopathic pulmonary fibrosis);
• Kidneys for diabetes;
• and many more conditions and diseases.

Please take the time to indicate you want to donate tissues and organs, put it in your Will, and and explain your reasons to your family. Donating tissues and organs is a wonderful way to live after you die. 

• In Canada, How to donate
• In your country, search for 'organ donation' plus your nation, e.g., 
• Organ donation UK, organ donation Australia, etc.

FOR FUN
Neil Young's song fits this blog:

• Heart of Gold (Neil Young)

FURTHER READING
A selection of resources used to develop this blog and ones well worth reading.

• Canada: Blood, Organ, Tissue Donation

• Organ donation practices in Canada could do more to improve health and save lives

• Canada’s organ donor rate lags behind other countries. How do you fix it?

• Becoming an organ donor not such a simple process

• ‘Skin saves lives’: burn patients need skin donation

• Organ Transplant in BC

• Donation after cardiocirculatory death (DCD) 

• Dead enough (Cardiac arrest vs brain dead)

• The Canadian Bioethics Companion. Chapter 7 - Organ Donation

All you need is love (Musings on national blood supplier HR woes)

Updated: 11 Jan. 2015

January's blog derives from news about unionized employees of Canadian Blood Services in Ontario considering strike action and the public rancor that occurred between employer and employees. The strike is apparently off, as is often the case, but what happened bears comment.

Suspect no matter where you live, what your transfusion health profession, staffing issues in blog are relevant. Do you think your employer focuses on decreasing costs? Saves money by hiring less well educated and trained staff? Cares more about the bottom line than staff welfare? But spouts rhetoric to the contrary? Then this blog's for you.

The blog's title derives from a 1967 Beatles ditty, All you need is love. 

Disclosure: I worked for ~13 years as a medical technologist, supervisor, and clinical instructor for CBS's predecessor, Canadian Red Cross, before becoming an instructor in MLS, University of Alberta and since then have been hired by CBS as a consultant on many projects.

BACKGROUND
1. Ontario's CBS employees, belonging to the Ontario Public Service Employees Union (OPSEU), claimed the CBS management wanted to lay off skilled health-care professionals and replace them with lower-paid workers:

• Strike at CBS looms for 800 staff in Ontario (5 Jan. 2015)

2. The union wrote a letter to CBS staff about CBS's intention:

• CBS wants a new part-time casual workforce (OPSEU letter to CBS staff, 6 Jan. 2015)

3. OPSEU published ads in 14 newspapers across Ontario and made videos that claimed that CBS's HR policies threatened the safety of Canada's blood system, as in the earlier AIDS/HCV tragedy:

• Blood supply workers set 8 Jan. strike deadline
• OPSEU on Canadian Blood Services

4. CBS strikes back in the form of Ian Mumford, CBS's chief supply chain officer's e-mailed statement:

• Blood services boss attacks OPSEU safety ads

MUSINGS
Be aware that I am a staunch union supporter, despite their shortcomings. Love Pete Seeger and all he stood for.

Was in a union as a tenured professor at University of Alberta. Yes, it was the Association of Academic Staff, but a union all the same. 

When I worked for Canadian Red Cross's Blood Transfusion Service (BTS) in Winnipeg, we worked ridiculous hours at low pay. When I mentioned staff couldn't continue to work long weekend shifts (~24 hrs) and whatever it took to process huge blood donor clinics, the medical director, a man I respected until then, kindly said the equivalent of, 'You can always quit. I'll be glad to supply a reference.'

Also, I believe that CBS has a policy to hire the cheapest possible staff, to train them for specific jobs, and claim they're 'safe' with documented competency assessment.

This is exemplified by CBS's 'donor care associates' program, approved by Health Canada:

• 'Multi-skilled clinic employees' will oversee blood donor screening instead of registered nurses

Of course, CBS's 'cheapest staff' policy was vetted by Health Canada.  Why the cheapest possible? Because the federal government and its regulatory agency, HC, as well as the provincial governments responsible for Canada's healthcare system, are invested in reducing costs. I've blogged about this often.

And I well understand, but strongly disagree with, how public health and government employers under cost constraints prefer to hire casual and part-time staff. I lived it in the 1990s when the Alberta government cut ~40% from the laboratory medicine budget.

The result was massive lab technologist job losses, followed by years of casual and part-time employment, all so employers did not need to provide various staff benefits. Despicable. Also, many transfusion medicine experts lost jobs as transfusion services hired 'generalist' technologists who were supervised by fewer and fewer transfusion specialists.

Many transfusion medicine laboratories face succession planning issues as older transfusion specialists retire. The crunch may occur in 10-15 years when more and more specialists retire.

BUT....
To me the OPSEU ads are over-the-top and do the cause more harm than good. CBS's hiring practices are NOT admirable. Hiring less well educated staff and training them on-the-job puts more of a burden on busy, well educated and trained staff. Hiring practices that lead to long-time staff being without benefits are despicable.

Indeed, current CBS HR policies create real potential safety issues, to say nothing of staff discontent and workplace resentment. I suspect nobs like CEO Graham Sher and chief supply chain officer Ian Mumford do not have a clue about how staff in the trenches feel. And maybe those earning mega-bucks don't even care. 

But to imply CBS hiring policies threaten the safety of the blood supply, like the HIV/AIDS and HCV tragedies of the 1980s and 1990s did, is nonsense. Such claims make it easy for CBS to dismiss real concerns about their business plans that put cost above all else.

And yes, Canada's blood system has morphed into a business, not healthcare. None more so than Canadian Blood Services. CBS is not patient-centred, it's cost-centred. And staff is one of its biggest cost-centres. CBS gets rid of staff without a thought. Indeed, CBS congratulates itself for how much it cuts costs on the backs of staff.

But, please, those concerned should analyse each CBS policy rationally. Its policies may be sh*t on many levels, but they're NOT equivalent to the 1980s AIDs tragedy. False arguments that make it easy for CBS to dismiss legitimate concerns don't help.

My career path with two major employers (blood supplier, university med lab science program) seems antiquated. [I don't count consulting because it's a hodgepodge of 'jobettes'.] In contrast, today's workers can expect many employers with little job security.  

But despite conflicts, I considered both employers my family. I loved the organizations and believed we were on the same side, wanting to help and serve others. Canadian Red Cross BTS is where I grew up, literally. Teaching transfusion science in MLS at the University of Alberta was the best transfusion-related teaching job in the world. Hands down!

Reading the CBS-OPSEU rancor, makes me glad I'm a dinosaur of sorts. Are such HR issues between national blood suppliers and staff relevant elsewhere around the globe? You tell me.

FOR FUN
Always sorry to see animosity between union and employer (CBS) but I understand why. Yet to me, life is too short to be opponents. Surely, cooperating and understanding are better. My experience puts me on the union's side, despite its faults and hyperbole on blood safety. But I prefer cogent arguments to over-the-top claims, easily dismissed. 

Perhaps kumbaya, but I love this Beatles song:

• All you need is love (Paul McCartney, Stewart, Joe Cocker [now deceased], and many rock n' roll legends, Party at the Palace, 2002)

My edits to Lennon-McCartney lyrics:

There's nothing you can do that can't be UNdone
Nothing you can sing that can't be UNsung
Nothing you can say that can't be UNsaid
But you can learn how to play the game
It's easy... Love is all you need. 

As always, comments are most welcome.

The way we were (Musings on TM history and its lessons for today)

Updated: 11 Aug. 2014

This month's blog discusses 3 recent news items (and associated scientific papers) related to men who have sex with men (MSM), HIV risks, and blood donation, plus a paper written by Canadian transfusion medicine experts on Canada's perspective on donor criteria for MSM.

The blog's title is from a 1975 Barbra Streisand classic (one of my favorites) and theme from an eponymous movie starring her and Robert Redford.

Please read the news items and papers as they provide fascinating, useful details beyond the brief reports presented in the blog. Although the specifics involve North America, the content and learning points apply everywhere.

1. USA: HIV positive man arrested and charged after donating plasma for $30

A man admitted to police that he donated plasma at BioLife in Elkhart, Indiana even though he knew he was HIV positive. He'd lost his job and needed money. 

Biolife pays $30 for plasma via a debit card and is a division of Baxter Healthcare. 

The plasma donor was charged with three counts of attempting to transfer contaminated body fluids and one count of transferring contaminated body fluids.

2. USA: Activists fight MSM policy (lifetime deferral if even once since 1977) with National Gay Blood Drive on 11 July, 2014.

The blood drive involves gay and bisexual men who want to donate bringing proxy donors who are eligible to donate and publicizes what activists believe is an outdated discriminatory and unscientific policy. 

The news item outlines the key issues on both sides of the argument with quotes from Paul Strengers, medical director at the Dutch Sanquin Blood Supply Foundation (anti-changing the policy) and the American Medical Association (pro-change). 

Related: AABB, ABC, ARC Joint statement on National Gay Blood Drive

Among other things, the US organizations were concerned that the event might disrupt blood center operations but support "rational, scientifically based deferral periods that are applied fairly and consistently among blood donors who engage in similar risk activities."

3. USA: 5 reasons HIV is on the rise among young gay and bisexual men

In brief, according to HIV researchers at CDC, the reasons include young gay and bisexual men's partners are more likely to

• Have and transmit HIV

• Engage in risky sexual practices

• Use drugs

• HIV's stigma could make people less likely to get tested

• Younger men weren't around for worst of the HIV/AIDS epidemic and are less likely to know the dangers

Related: Johnson AS, Hall HI, Hu X, Lansky A, Holtgrave DR, Mermin J. Trends in diagnoses of HIV infection in the United States, 2002-2011. JAMA 2014;312(4):432-4.

4. Goldman M, Lapierre D, Lemay L, Devine D, Sher G. Donor criteria for men who have sex with men: a Canadian perspective. (Commentary) Transfusion 2014 Jul;54(7):1887-92.

With other jurisdictions considering a change in MSM policies, this paper was written by Canadian blood experts who thought it might be of value to share Canada's experience. It outlines CBS and Héma-Québec's extensive processes to consult interest groups / stake holders to achieve a consensus to support Canada changing its long-standing permanent deferral for MSM to a 5-year deferral from last MSM contact. 

The 'Commentary' begins by outlining the history of the HIV/AIDS/HCV 'tainted blood' disaster in Canada, which led to the Krever Royal Commission of Inquiry into Canada's blood system and its 'damning' (my word) 1997 report.  

As a result, in 1998 CBS and Héma-Québec were created; blood was regulated as a drug with blood centres considered biologics manufacturers, with more stringent regulatory oversight by Health Canada. 

I'll present only a few key highlights of the paper, those selected through my biased eyes. Also note [my Comments].

HISTORY: [One of the most explicit mea culpas I've seen from Canadian TM experts]:

* There was a lag between implementing measures to reduce transmission of AIDS/HIV in Canada compared to the US and others, including donor deferral criteria, HIV antibody testing, and sole use of adequately virus-inactivated factor concentrates.

* Delays contributed to infection of many transfused patients, with the hemophilia population particularly devastated by HIV. Delays also occurred in adopting measures to reduce HCV transmission. 

* Anger and bitterness over the (mis)management of HIV and HCV risk by the blood system cast a long shadow over the new organizations, CBS and H-Q. 

[Why did the delays occur? What's the root cause? A focus on cost over safety? A belief in evidence-based science that failed to consider what experts did NOT know? Or?]

STATISTICS: As of 2011 PHAC reports there were ~71,000 prevalent and 2250-4100 annual incident cases of HIV in Canada. MSM risk was high for prevalent and incident infections, accounting for about half of new infections.

* Large MSM studies demonstrate seroprevalence rates from 10% to 20% but generally recruit participants in gay venues and focus on currently sexually active MSM, often with frequent partner change (not those in longstanding monogamous relationships or those sexually inactive for a long time).

[Incidence of HIV seroprevalence in gays in long monogamous relationships is unknown.]

* With sensitive antibody detection assays and minipool nucleic acid testing (NAT), the window period for HIV is estimated at 9 to 11 days. 

* Residual risk for HIV is estimated at less than 1 in 8 million units at CBS and in the USA is 1 in 1.5 million units, due to higher rates of HIV+ donors. 

[FYI, residual risk is the risk of an infectious donation being present in the blood supply after all donor and donation screening activities occur and unsuitable donations are removed and discarded.  See Current information on the infectious risks of allogeneic blood transfusion - Residual risk. Put another way, it's the OOPS! factor.]

RISKS

* Risk modeling in Canada found the incremental risk of a 5-year deferral for MSM was less than 1 infected HIV unit entering the blood supply in 1000 years. 

* A 5-year deferral for MSM would not substantially increase transfusion-associated HIV in Canada. Similar modeling studies were done in France, UK, and USA. 

[Sounds great, eh? Almost as if we can crow, 'Don't worry, be happy'. But the fly in the ointment...] 

* 'Although modeling studies are useful to estimate small risk increments, they involve assumptions about many variables, where data are often sparse. Additionally, they do not provide information on novel or emerging threats.' 

[Modeling involves many assumptions based on minimal data – so much for evidence-based. Plus, obviously new and emerging threats (unknown) are absent from modeling studies.]

MUSINGS
I'm not going to report the guts of the Canadian paper, which outlines the processes used in Canada in 2001, 2006, 2008, 2009, 2011, and 2012 except to mention the Kyle Freeman court case.

But please read the paper if you have access because it explains the science and politics of MSM and blood donation as few resources have and the emotions and tension that marked the debate historically and still do.

In brief, the Freeman case involved a gay man who informed CBS via an anonymous e-mail that he donated and lied about his MSM status. To trace the anonymous e-mail and apply the appropriate deferral code, CBS sued for negligent misrepresentation as a way to obtain his identity from his e-mail service provider. He counter-sued, claiming CBS violated his rights under the Canadian Charter of Rights and Freedoms.

Freeman lost. Key elements of the judgment in favor of CBS were that blood donation is a gift and not a right and that MSM policy is not discriminatory based on sexual orientation.

Relevant reading:

• Gay Ontario man loses blood donation negligence suit 
• Canadian Hemophilia Society view of the case
• Court Case

LEARNING POINTS
MSM, HIV, and blood donation continue to be controversial and political. To me, key points from the Transfusion paper and related news items include 

#1. Goldman paper: 'Although modeling studies are useful to estimate small risk increments, they involve assumptions about many variables, where evidence is lacking. As well, they do not provide information on new or emerging threats.

In other words, models of HIV and other infectious disease risks to the blood supply are based on assumptions backed up with more or less zero data and do NOT consider new threats. So much for evidence-based decisions touted by TM experts.

#2. The role that student and gay rights activists play in changing blood safety policy is pure politics.

They claim discrimination (and a case can be made based on MSM vs engaging in risky behaviors regardless of gender) but ignore that HIV-prevalence of MSM presents a real risk to the blood supply. Moreover, HIV is on the rise among young gay and bisexual men, current HIV tests have a window period of 9 to 11 days, and donors may lie on blood donor screening questionnaires.

#3. Goldman paper: 'For patient groups, many of whom are chronic users of the blood supply, the change meant putting aside their fears of the past, assessing the available scientific information, and trusting in the system.'

To me, this is 'Don't worry, be happy' time (see earlier blog). Trust us. We've got your back covered based on science. Oh yah!

#4. All this aside, blood suppliers worldwide will cave to the political pressure of activist interest groups, claim it's evidence-based, and it won't affect blood safety until it does.

UK PERSPECTIVE

For interest, the UK's NHSBT donor policy on MSM:

• Why men who have sex with men are deferred from blood donation for 12 months (Position Statement: Nov. 2011)

The change means that only men who have had anal or oral sex with another man in the past 12 months, with or without a condom, are asked not to donate blood. 

Men whose last sexual contact with another man was more than 12 months ago are eligible to donate, subject to meeting the other donor selection criteria.

Other nations have permanent (indefinite) deferral or a 5 year deferral.              
FOR FUN
The blog's topic is not funny. The 'for fun' bit is just for enjoying the song. Looking back on the HIV tragedy and its impact on blood transfusion, I'm reminded of the innocent way we were before HIV appeared.

• The Way We Were (Barbra Streisand, 1975) 

Mem'ries,
Light the corners of my mind
Misty water-colored memories
Of the way we were. 

Scattered pictures,
Of the smiles we left behind
Smiles we gave to one another
For the way we were.

Can it be that it was all so simple then?
Or has time re-written every line?
If we had the chance to do it all again
Tell me, would we? Could we? 

Mem'ries, may be beautiful and yet
What's too painful to remember
We simply choose to forget.

So it's the laughter
We will remember
Whenever we remember...
The way we were...

As always the views are mine and mine alone and feedback is most welcome.