I just returned from donating blood at the American Red Cross. I have been a regular blood donor for a long time. I usually donate blood two or three times a year. Unfortunately, I have been deferred as a blood donor for two of the last four years. I was deferred as a blood donor twice for one year each time, both due to traveling to an area where there may be some malaria risk. The first time that I was deferred as a blood donor was because of travel to Haiti. The second time was due to travel through rural Colombia. In my case, these deferrals resulted in a loss of 4 to 6 units of donated blood to the American Red Cross.
The American Red Cross is constantly trying to recruit new blood donors and to get previous blood donors to donate again. From the regular calls and advertising campaigns, I get the impression that the US blood supply may be low at times and that my blood donations are greatly needed. However, I am struck by the huge range of reasons for deferring willing blood donors. It seems to me that the threshold for deferral is very low. The willingness to accept any nonzero risk is very low. This approach is insane, or least pretty darn close. The vain quest for absolute security and zero risk is a dangerous fiction. I understand the reasons for wanting to avoid blood transfusion related adverse events. However, deferring extremely low risk willing blood donors and potentially depriving someone of a needed blood transfusions is not a zero risk enterprise either. As stated by Richard Benjamin, MD, PhD, chief medical officer for the American Red Cross, “The most dangerous unit of blood is the one we don’t have. Not having blood for someone who needs it is worse than giving someone a unit of blood that carries a 1-in-5 million chance of disease.”
I am not your average blood donor. I have a master’s degree in public health, so I have training in epidemiology, the scientific study of the distribution of disease, health and their determinants. Also, in the 1990s I worked in a health department managing an HIV-AIDS program. I am familiar with the political and cultural forces that can distort our scientific assessments of risk management. However, you don’t need a graduate degree to recognize that our culture has great issues around security and fear of losing or risking most anything.
Less than 38% of Americans are eligible to donate blood according to the American Red Cross. Today, as I read through the pages of reasons for which you could be deferred from donating blood, I was struck most profoundly by the deferrals based simply on where one has lived. If, in fact, the scientific basis for avoiding such blood donors is sound, then the entire continent of Europe should refuse blood donations from virtually its entire population. This cannot be sound scientific reasoning.
In the last decade or so, there’s been a lot of hysteria about mad cow disease. According to the federal Centers for Disease Control and Prevention (CDC), there have been 22 cases of mad cow disease in the United States since 2003. Three of these cases originated in the United States. Most of the other cases were from Canada, which you may note is not one of the restricted countries that will put you on the blood donation deferral list by the American Red Cross. The United Kingdom was the epicenter for the mad cow disease epidemic. While in the United Kingdom there had been thousands of cases of mad cow disease in years past, in 2010 there were only 11 cases reported. Maybe it’s time for the American Red Cross to relax its deferral requirements related to mad cow disease. Or, maybe we should come up with a new diagnosis for this irrational insanity, and declare that the American Red Cross has Mad American Disease. You are literally dozens of times more likely to be killed by being struck by lightning in the US then getting mad cow disease. I’m not sure what the chance is of lightning striking the American Red Cross, but I would settle for a light bulb above the head of somebody who makes these crazy decisions.
Over the decades that I have donated blood to the American Red Cross, I have noted the quickly changing and almost always growing list of reasons to defer a willing blood donor. As a personal example, I had malaria when I was an infant in Haiti where I was born. During the ensuing 50 years I’ve not had any symptoms of malaria. However, how the American Red Cross deals with this distant case of malaria changes back and forth. Many years ago, the American Red Cross simply asked whether you have ever had malaria, and if you indicated yes, the nurse would ask more specific questions. This always made for an interesting blood donation visit as I suspect there were few Ohio blood donors who had ever had malaria, and the nurses often had to consult with other professional healthcare staff to figure out what to do with me as a blood donor. Although sometimes it took a while for them to figure it out, it never prevented me from donating blood. Then, at some point later, they changed the question as to whether you had malaria in the last three years. I can answer no to this question, and this streamlined my visit quite a bit. Now, in recent years, they are back to the more general question of have you ever had malaria. Fortunately, there seems to be better training among the nurses during the screenings and they do not seem to need to consult anyone else to determine that I am, in fact, eligible to donate blood.
The American Red Cross’ quest for zero risk seems to be marching on. Since I last donated blood less than three months ago, they have added yet another safety precaution. Now, when they stick your finger with a needle to get a drop of blood to check your hemoglobin, they place a plexiglass barrier between your finger and the nurse. Really now, how often does anyone ever got blood splashed in their eyes from giving a finger prick? More importantly, does this represent any risk worth worrying about. If it does, I’d hate to see what such risk assessment would do to health care workers in hospital settings. Perhaps we should expect nurses in hospitals to soon be wearing spacesuits just to be sure. According to the CDC, “Health care workers who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection…the estimated risk for infection after a needlestick or cut exposure to HCV-infected blood is approximately 1.8%. The risk following a blood splash is unknown but is believed to be very small…The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be, on average, 0.1% (1 in 1,000).” For instance, for hepatitis C, “the risk is considered to be less than 1 chance per 2 million units transfused.” That’s for a blood donation recipient who has an entire unit of blood transfused into them. The risk of the nurse getting infected by pricking the finger of a potential blood donor would be on the order of that one in a million TIMES the chance of getting a drop of blood splashed in their eye when pricking a blood donor’s finger TIMES the chance that such an event could cause disease. You can do the math yourself. For the example of hepatitis C, conservatively, we are talking about one in a million times one in thousands times one in a thousand. In the end, we are talking about no more than a chance of one in many billions of getting infected by hepatitis C by pricking the finger of a potential blood donor without having eye protection . For the number of blood donations every year in the US, it would take centuries for this practice to expect to prevent even one case of blood borne pathogens. The risk for hepatitis C is the highest and adding in hepatitis C and HIV would not substantially change this basic calculation. From the resource perspective, the question becomes how many billions of times do you want to place a plexiglass barrier between you and a potential blood donor to prevent a single case of infection?
I am well aware of the emotional place from which the quest for zero risk comes. Unfortunately, the emotional experience of wanting to live in a zero risk world does not match up with a simple costs and benefits calculation of going very far down that road. It quickly leads to unjustifiable contradictions. Why defer blood donors due to a nearly incalculably small risk for mad cow disease from people who spend significant time in Europe but not Canada, where most of the US cases have originated from? Well, I’ll tell you. Starting a deferral process for people who spend significant time in Canada would expose the insane balance between actual risk and actual costs in trying to avoid the risk. It seems that we can “afford” to ban, for example, military servicemen who were stationed in Germany or England from donating blood in order to “buy” some unscientific sense of security in our blood supply. I recognize that plenty of people are willing to pay such prices. I just ask that we don’t fool ourselves into thinking that these choices are based on scientific evidence and well-reasoned analyses of risk management.
Another example of blood donor deferral that rests more on cultural biases than scientific and well-reasoned risk management, is The Lifetime Ban on Blood Donations from Gay Men, where policy analyst Robert Valadez writes:
“So where did this policy come from? And why is it still enforced despite advances in technology that can identify HIV in a unit of blood within days of infection?
The policy dates back to the early days of the HIV epidemic, when knowledge of transmission was nonexistent. Recognizing the disproportionate incidence rates among gay and bisexual men, the FDA responded by enacting a policy that prohibited all men who had sex with other men from donating blood. The year was 1985. Twenty-six years later, the policy remains unchanged.
Current blood donor eligibility criteria are largely inconsistent, imposing significantly less restrictive deferrals to heterosexual men and women who engage in high-risk sexual behavior. For example, a heterosexual person who has sex with a partner who is HIV-positive is eligible to donate blood after only 12 months. Yet the policy permanently bans all gay and bisexual men, even those who are HIV-negative, consistently practice safe sex, or in monogamous relationships”
Like many experiences in my life, I find that even the wonderful experience of saving lives by donating blood, comes with the collateral costs of having to participate in the system that is driven by an insane quest for zero risk. This insane quest has costs. It has costs for the blood supply and the people who depend on it. This insane quest for zero risk has costs for those who are subjected to its unscientific cultural biases, and for all of us who live in an environment that unnecessarily models for us this insanity and vanity. Life has risks. There are reasonable and scientific ways to reduce these risks. We should pay attention to these. However, we should not be driven and reduced by unreasonable fears, unfounded fears. As is often the case in life, that which we feel threatens us gets a disproportionate amount of our attention. Nonetheless, we should look at the full range of costs associated with trying to avoid some threat, and realize and accept that risk is an integral and unavoidable part of life. I would hope that the entrepreneurial spirit of Americans, in its broadest sense, would kick in as we live into the fact that taking and accepting risks can far outweigh the costs of those risks. Maybe even the American Red Cross will take a risk and pare down its blood donation deferral list. We can always hope — though this entails some risk…