With a system in turmoil, will there be enough blood?
Charlotte Gray
CMAJ 1997;157:778-80
[ en bref ]
Charlotte Gray is a CMAJ contributing editor.
© Charlotte Gray
In brief
In a short time Canadians won't be able to recognize their blood-collection system. With the Red Cross getting out of the blood business and the government and business moving in, what will the changes mean for Canadians and their physicians?
En bref
Bientôt, les Canadiens ne reconnaîtront plus leur système de collecte du sang. Tandis que la CroixRouge se retire de l'approvisionnement en sang pour être remplacée par le gouvernement et l'entreprise, quel impact ces changements auront-ils pour les Canadiens et leurs médecins?
Readers of the Report on Business section of the Globe and Mail could hardly miss the August announcement concerning the Board of Directors for the new Canadian Blood Bank Corporation (CBBC). The lineup of 5 collared-and-tied men staring gravely at readers -- the notice covered one-third of a page -- demanded attention.
In the text below the mugshots the CBBC noted that it had opened its first clinic and training centre in St. John's, and then gave the directors' qualifications. The list included 2 lawyers, a chartered accountant, a venture capitalist and 2 businessmen; strikingly absent was anyone with a scientific or medical background.
"The Canadian Blood Bank Corporation is the only private-sector blood bank in Canada providing services for the collection and long-term storage of autologous blood," the notice explained. The company received Health Canada's nod of approval Feb. 17, 1997.
Blood was much in the news as the corporation's notice appeared. That same week, in the Globe's front section, articles described the country's dangerously low blood supplies. Donors were staying away in droves, forcing hospitals to cancel surgery because of blood-product shortages; once again, doctors were appealing to Canadians to give the gift of life. Another article discussed the decision by federal and provincial health ministers (except for Quebec's) to curtail the role of the Red Cross in blood collection and distribution and to establish a new Canadian Blood Service, although federal Health Minister Allan Rock did ask the agency to continue to help recruit blood donors. A final article described how the Red Cross said "no thanks" -- it would prefer to walk away from the blood business altogether.
The juxtaposition of these business and political items, which spoke volumes about the disarray surrounding blood collection, made for ironic reading. Those businessmen in Newfoundland can hardly be blamed for seeing a market opportunity and grabbing it. At the same time, Canadians are confused and fearful about their public system. Over the past 5 years they have had to swallow one ghastly revelation after another about blood officials' roles in the tainted-blood scandal. Indeed, the existing blood system might be considered one more victim of HIV.
HIV and hepatitis have changed the way we look at blood, and that created a market opportunity. Today few Canadians would agree, without a twinge of apprehension and distrust, to letting a family member receive a blood transfusion. The CBBC offers a reassuring alternative: bank your own blood in case you ever need it, and then you won't have to depend on unreliable strangers to save your life -- or perhaps take it.
An end to altruism?
Yet this private-sector entrepreneurship is undermining the implicit contract that between donors and recipients. Up to now, blood donation has been a purely selfless act in Canada. Since 1947, when the Red Cross's blood-supply program was launched, donors have given blood for no reward other than altruism. However, the private, for-profit initiative has no room for altruism; it depends on the personal survival urge to recruit clients.
"I don't see the private blood bank as a serious threat," says Durhane Wong-Rieger, the high-profile spokesperson for the victims of tainted blood who now chairs a consumer group that is advising the government on the new agency. "But it is the last thing we need right now. The public is confused already about who is collecting blood and what safeguards there are. A new player like this just raises the fear level and detracts from the solution. And none of the people on the Canadian Blood Bank Corporation board have any expertise in blood products."
She says there is a real danger that support for the public system will evaporate, making the job of the new Canadian Blood Service even more difficult. The service is already having a difficult birth. Since Justice Horace Krever began his enquiry into the state of Canada's blood system 4 years ago, it was obvious there would be a shake-up. But what would the Red Cross's eventual role be? Until now it had monopoly rights over the blood that flowed from its thousands of donors. How soon could a new system be put in place? Should it await release of the Krever Commission's report?
Krever may have been more thorough than was anticipated. He was determined to pinpoint those responsible for the infected blood that left 1200 Canadians infected with HIV and at least another 12 000 with hepatitis C. On Dec. 21, 1995, after 2 years of hearings, he notified dozens of people that he might name them in his final report. Most chose to take legal action rather than rebut allegations. The Red Cross was particularly hard-nosed in its response and less sympathetic to the victims of tainted blood than the public could swallow. Its autocratic behaviour shocked observers and convinced governments that it would be incapable of running a blood service tailored to different principles.
However, it was not until after the Liberals' re-election last June and the appointment of Allan Rock to the health portfolio that the fate of the Red Cross was sealed. In consultation with his provincial counterparts, Rock decided that a new agency was required. He also decided that to wait for the Krever Commission's final report would put the blood supply at serious risk. One reason donations have dropped precipitously may be that blood donors have been offended by Red Cross behaviour toward Krever. At the end of July, the health ministers announced they would establish a new agency by this month.
Reaction to the announcement was generally positive. "I am optimistic that a revamped system will provide the service required for the next millennium," said Dr. Gail Rock, chief of hematology at Ottawa's Civic Hospital. She worked for the Red Cross for 14 years and has been critical of its inflexibility. "We must have a system that is modern, responsive to new developments and regional needs, and has medical people in the loop."
Wong-Rieger is also confident that governments made the right long-term decision and that they were correct to move without waiting for Krever's report, which will probably be released in October or November. "It will be the first time that an agency is in place to implement the recommendations of a royal commission," she said. "It will be able to act fast on directions concerning donor tracing or physician education on the use of blood."
However, Wong-Rieger soon became frustrated by the inertia that followed the July announcement. Details were scarce about how the new agency would function and each passing week brought a further decline in blood donations. By early August reserves of blood in Montreal and western Quebec had fallen to 26% of normal levels. "The transition period is unnecessarily difficult," Wong-Rieger said. "There has been no attempt to explain that the Red Cross remains responsible for blood collection right now and that donations are urgently required. Even the Red Cross personnel themselves are confused and busy looking for new jobs."
Three major challenges face the new blood service. In order to gain public trust and support, it must be clearly accountable to its users, both transfusion recipients and health care professionals. One of the most shocking revelations in the past few years is that financial concerns came before respect for human life when crucial decisions affecting the safety of the blood supply were taken. Second, the management of the new national agency must be less centralized than the old Red Cross and sensitive to regional concerns. "We need a system that will respond fast to regional requests and initiatives," says Gail Rock. However, the new agency must remain at arm's length from provincial governments even though they will fund it. Third, its top executive levels must include health care professionals and scientists. The old Blood Transfusion Service run by a Red Cross top heavy with lay committees took a long time to absorb new information. This may have been one reason why Canada was 7 months behind the US in testing blood donations for HIV.
Wong-Rieger feels confident that the outline of the new system has taken account of all these requirements. For instance, the new service's 12-member board includes 2 consumers and provincial representatives. "I am sure that eventually we will have a good service."
Still, there remained some outstanding issues when health ministers met earlier this month. These included the start-up costs for the new agency and the question of liability when the agency takes over the Red Cross's blood-processing operations. The new agency must also deal with class-action lawsuits launched against the Red Cross in June by those infected by hepatitis C during blood transfusions. Allan Rock is expected to give the new agency a boost by announcing that Ottawa will offer an out-of-court settlement to anyone in this position. However, the uneasy alliance between Ottawa and the 9 participating provinces could break down if any province starts believing that it is taking on too large a financial responsibility.
Meanwhile, the Canadian Red Cross faces some difficult questions of its own now that it has bailed out of the blood business. It answered one of them in August when it replaced its former secretary-general, Doug Lindores, who had been ousted in March, with Quebec physician Dr. Pierre Duplessis. He will have a difficult job because the beleaguered organization has lost the program and funding that accounted for 60% of its activities. It already has funding problems, because it ran up a deficit of $18 million last year and $27 million the year before. Its financial health is further jeopardized by the uncertainty surrounding the blood-fractionation-plant project in Bedford, NS. The Red Cross had used its investment portfolio to guarantee loans totalling around $35 million, and now the project is unlikely to go ahead.
Both the new agency and the Canadian Red Cross have one crucial challenge in common. Against a background of tragedy, uncertainty and institutional politics, how can each organization build (or rebuild) public trust? How can the Red Cross continue to attract volunteers and funds for all the humanitarian work that it continues to perform superbly? How can the Canadian Blood Service move quickly into the current void with an all-out campaign to recruit not just donors, but also organizations to recruit donors. Fast action is required if the dwindling supplies are to be replenished.
The most important need may be to remind Canadians that the strength and quality of the old Blood Transfusion Service, in pre-HIV days, depended on the collective altruism of all citizens. If the new agency can rekindle that spirit, it will thrive. If it cannot, look for more notices in Report on Business.
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