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Yet Another Bloody Crisis

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In January 2022, the Red Cross in the US declared a “national blood crisis” in face of its greatest blood shortage in more than a decade. Yet, its source is not solely pandemic-related.
Though data on this very observation remains sparse, the demographic transition towards elderly societies in the Western world represents an imminent threat to the future blood procurement equilibrium – namely excess demand and scarce supply.
Some regard this as a wake-up call to widen the eligible population sample for blood donation. Can present blood donation deferrals with respect to sexual behaviour be eased without imperilling blood safety? Find out why there may or may not exist a dichotomy between social justice and data-driven policy.

The sheer abundance of crises in the past two years has exposed myriads of structural policy deficiencies in the public sector. Yet another one might be added to the list, as the Red Cross in the US reported its first national blood shortage in 10 years.

In the US, just as in Europe, hospitals have been facing critical shortcomings of blood supply: amid the pandemic, the number of blood donors has declined by 10% overall, while blood drives in schools and colleges recorded a decrease of 62% in the US. The situation in Europe has been comparable. As data by the European Blood Alliance and the European Centre for Disease Prevention and Control (ECDC) exhibits, public health care sectors in Europe have witnessed an overall decrease of 12% in blood components.

The reasoning behind this appears trivial: donors began avoiding blood donation opportunities, campaigns were canceled, capacities reduced within the health care sector, and unsurprisingly, supply chains were disrupted.

What supposedly eased the ongoing crisis, thereby leaving the latter in obscurity, was the decreased blood demand during the pandemic. Total blood use dramatically fell as patients’ treatments were delayed or attenuated, and surgeries were postponed. Despite this, 65.6% of physicians with transfusion-dependent patients suffering from myelodysplastic syndrome (MDS) declared that they had encountered supply shortages, affecting at least a quarter of their patients – an effect that was most pronounced in Italy with 31.6% affected.

The pandemic has therefore laid bare the vulnerabilities of the medical sector with respect to global blood supply – it blatantly exposed that it is not simply a transitory problem, but a structural one. Indeed, the equilibrium between the number of blood donations and the demand for blood transfusion is currently facing an imminent threat. Not least with the advancement of medical treatment in hematology and oncology, and subsequent surges in surgical procedures, the amount of blood requirements have soared in the Western world – and will not cease to do so.

On haunting demographics

Yet another rather insidious transition is underlying the rising demand for blood. In high-income countries, the greatest share of transfused patients is amongst the population aged above 60 years, accounting for 75% of all transfusions.

This renders the present situation all the more dire: if blood supply can be regarded as a transfer of blood between different population samples, then, inevitably, the demographic composition of Western societies has gained salience: in the midst of a transition towards elderly populations – that is, soaring life expectancy and reduced fertility rates – the current practice of a young and healthy population sample providing for vulnerable age groups above 60 years has been outpaced by demographics, and is now obsolete.

This presages a two-sided doom: not only is the eligible population of donors decreasing – the number of blood transfusion-dependent patients is rising too.

Hitherto, data on this very observation has been sparse. Yet, researchers have posited that, much rather than pathogen transmission-related risks, it is the demographic composition of Western societies that has revealed itself to be the greatest issue in high-income countries.

The Blood of the Unwanted

In this vein, questions on blood donation deferral policies have resurfaced in public discussion. Until 2000 in Italy, for instance, men who have sexual intercourse with other men (MSM) were banned from blood donation to effectively reduce pathogen transmission risk.

As exhibited by the table below, the pandemic has been an extraordinary accelerator for policy changes. Amid the present blood supply crisis, a great number of countries revisited their blood donation policies in the light of MSM deferrals to widen the sample of eligible donors amongst the population.

The rationale behind deferral

Many of the present MSM deferrals can be traced back to the 1990s: in the wake of the first HIV epidemic, legislators attempted to contain the spread of HIV through blood transfusions in the medical sector. Prima facie, it seems that this rationale still holds: evidence suggests indeed that MSM have a 27-fold risk of contracting HIV compared with the general population. In fact, in 2017, 57% of newly recorded HIV infections in North America and Western Europe were recorded by MSM.

Who is at fault?

According to a 2018 report by UNAIDS, in 33 of 87 selected countries, less than 60% of MSM stated to have used a condom the last time they had sexual intercourse. This can largely be attributed to governments’ failure to implement viable non-discriminatory prevention campaigns. Scarce financial resources, and “hostile conditions make it difficult, even dangerous, for nongovernmental organizations in many countries to provide services for this population group,” a report contends. This does not only apply to low- and middle-income countries, where legislation promoting LGBTQI+ equality is often non-existent.

The case of Italy

In the early 2000s, an Italian ministerial decree revised donation deferral policy for MSM, applying other criteria such as high-risk sexual behavior, regardless of the sex partner’s gender. Deferral henceforth referred to people with multiple sexual partners, unknown sexual behavior, sex workers and their customers, repeated sexual contacts with people, and of course, HIV, HCV, and HBV patients. Criteria for eligibility thus became gender-neutral in Italy and were merely based on “individual risk assessment.”

According to an Italian study in 2013, HIV prevalence in blood samples did not alter after the abolition of the lifetime deferral of MSM, supposedly countering the assumption that risk arises from MSM rather than incautious or negligent sexual behavior. Yet, according to a comprehensive 2021 report by the Robert Koch Institute, a subordinate research institute of the German Federal Ministry of Health, the Italian data sample was biased and incomplete.

And besides these statistical details, empirical evidence suggests that the two western European states with the highest HIV prevalence in blood supply, namely Italy and Spain, are also the ones that do not have permanent MSM blood donation deferrals.

According to another study, however, the case of Italy is a dubious one. HIV prevalence in donated blood had already been increasing before 2001. Further local data from Lombardy, for instance, did not show any significant increases in the HIV prevalence of blood donations after the enactment of laxer policy.

Hence, data remains ambiguous – and the opaque epidemiological prevalence of HIV does not allow simple deductions.

(Im)morality in scientific debate

This wide array of contradicting evidence leaves policymakers with a pertinent question: can safe, adequate, and pathogen-free blood procurement be reconciled with sufficient blood supply by easing restrictions for MSM?

Two moral imperatives oppose one another in this matter: one is that blood donation policy ought to uphold safety standards for recipients for the public good. The other, however, consists of non-discriminatory and scientifically reasoned donor eligibility for minorities. Governments’ reluctance to adapt resides precisely in this moral dilemma between “social harm” – as opposed to inclusion – and “public health.”

What renders scientific reasoning ambiguous is the paucity of data on MSM amongst populations. As LGBTIQ+ communities continue to be subject to discrimination, the reliability of surveys attempting to quantify the number MSM within population samples remains questionable.

Many LGBTQI+ advocates have, however, claimed that, before further evaluating MSM deferral policies in the light of HIV transmission risks, non-discriminatory donation policy began with appropriate language: that is, in lieu of distinguishing between gender, sexual orientation, or sexual preferences, legal provisions ought to distinguish between “risky sexual behavior” and other factors that reflect the individual’s reality of life; that is, gender-, and sexuality-neutral legislation. Yet, not only individuals affiliated with LGBTQI+ communities will argue in favor of the implications of symbolism: as another study contends, donor compliance may even be advanced by relaxed donation policies, which “may paradoxically reduce the risk of an HIV-positive donation entering blood supply.”

Fallibility is a virtue

On the other hand, the German Robert Koch Institute emphasizes that scientific discussion of blood donor eligibility should not be conflated with so-called political debate. Risk assessment was conducted independent from sexual identity and sexuality, the institute explained. Hence, placing this matter in a societal context was not coherent with the scientific intent of blood donation safety. In fact, blood donation policy should not be regarded as a parameter to measure society’s acceptance of diverse sexual identities and behaviour, according to the institute.

This poses a key question: can we distinguish between the dimensions of data-driven policy and social progress? Should policy be merely data-based, or should it also reflect presupposed social advancement with respect to non-discrimination – calls for social justice – to the detriment of scientific consensus, or more precisely, the lack thereof? Inevitably, allegations of political systems’ tendency to self-complacency arise. But such an attitude is a fallacy.

Indeed, if even data-driven policy has a certain virtue of fallibility – lifelong MSM deferrals from blood donations – so too should political debate. We can therefore reconcile the presupposed dichotomy between calls for social justice – easing deferrals – and scientifically assessed policy. As anticipated, the answer to this issue probably lies somewhere in the middle.

References

https://www.bloomberg.com/news/articles/2022-01-27/hospitals-face-blood-shortage-as-medical-groups-plead-for-donors

https://ekpf.eu/wp-content/uploads/2021/05/Blood-use-in-Europe-learning-from-the-impact-of-COVID-19_-May-2021.pdf

https://www.who.int/news-room/fact-sheets/detail/blood-safety-and-availability
https://www.blutspendezurich.ch/fileadmin/pdf/Weiterbildung/Journalclubs/2018/Goldman_et_al-2018-Vox_Sanguinis.pdf

https://www.sciencedirect.com/science/article/pii/S1201971213003081#bib0070

https://onlinelibrary.wiley.com/doi/full/10.1111/trf.15768