Beyond the Pale: the Ethics of Gifts

Professor Andrew Zolani Cakana (FIBMS; MB ChB; CTM; M Med Sc.;

FRCPath).

The recipient was Arthur Coga, "the subject of a harmless form of insanity." Sheep's blood was used because of speculation about the value of blood exchange between species; it had been suggested that blood from a gentle lamb might quiet the tempestuous spirit of an agitated person and that the shy might be made outgoing by blood from more sociable creatures. Lower wanted to treat Coga several times, but his patient refused. No more transfusions were performed.

Blood donation in Zimbabwe.• Voluntary:– Free– Altruism vs egalitarianism?

• Only 5 - 10% of the population gives blood, (higher among the Swiss and lower – 1% for Zimbabwe?)

• Why give of your blood free?– Is our tokenism outdated?

• Super donor characteristics:– How then do we find such people in society and retain

them as donors?

Blood Transfusion in Zimbabwe.

• Centralized collection and processing.– Cost effective testing vs wide participation?– Local community transfusion activities outlawed.

• Testing for HIV, Syphilis, HBV & HCV– cost increased by sensitivity of methodology.

• Fractionated to red cell concentrates, platelets, fresh frozen plasma and cryoprecipitate.– Essential or cosmetic?

Blood funding and cost of blood in Zimbabwe.

• Traditionally funded by MoH, with low private addition. Now the reverse.

• Unit cost of red cell concentrate $250.• Some Health Insurances and Hospitals run a

different tab for blood, requiring patients to pay for the blood directly to NBTS.

Anaemia and Clinical Practice: Parirenyatwa Hospital experience.

• Data collected from 15/05/2015 to 15/07/15 for patients with HB <5 g/dL.

• No cause of anaemia was sought.• Patients searched for whether transfused or

not.• Outcome of death recorded if occurred within

the month.

Hb<5g/dL Hb<4g/dL Hb<3g/dLTotal 276 135 (49%) 45 (16%)Transfused 175 (63%) 90 (67%) 31 (69%)Not transfused

101 (37%) 45 (33%) 14 (31%)

Deaths 58 (21%) 31 (23%) 9 (20%)

Limited conclusions from this study.

• Anaemia of CTCAE grade >3 is very common in a referral hospital in Zimbabwe.

• Decisions on transfuse or not transfuse are beyond clinical judgement.

• At least one third of the patients cannot afford to pay for the necessary blood support.

• At least a fifth of the patients with Hb <5g/dL will die of their anaemia within the first month of admission.

What are the drivers of the cost of the free gift?

• Centralization of collection, remote areas don’t collect their own blood.

• Over testing, the perpetuation of the virophobic environment and demand for purer blood products.

• Limiting donations to voluntary non-directed. • Limitation of options.

Epidemiological context (HIV)..cont

17

Summary of annual averaged residual risk estimates (three models)

•HIV: 1 in – 6250 [7143; 5556] – 5263 [5882; 4545] – 6667 [7692; 6250]

18

Survival Following HIV Infection of a Cohort Followed up From Seroconversion in the UK: AIDS. 2008;22(1):89-95

• In 2000-2006, the proportion of individuals expected to survive 5, 10 and 15 years following seroconversion was 99%, 94% and 89%, respectively.

• Conclusion: In HIV-infected individuals on ART, with a recent undetectable viral load, who maintained or had recovery of CD4+ cell counts to at least 500 cells/μl, we identified no evidence for a raised risk of death compared with the general population.

Risks of & in Life.

Risk of Dying next year by accidental drowning (UK).

• All causes: 1 in 83 534• In bath tub: 1 in 81 0815• In swimming pool: 1 in 452 738 • In natural water:1 in 217 314

Zimbabwean patient blood needs.

• Affordable blood product.– Incomes vs cost of blood (SHO $289 vs $250 for one unit).

• Red cells in majority of peripheral cases.– Is whole blood cheaper?

• With no ‘blood generics’ from India we need home made solution for current crisis.

Ethical issues to be addressed.

• HIV patients survive much longer than grade >3 anaemic patients. How do we explain the risk of death to patients: anaemia vs TTIs such as HIV?

• Whereas the HIV prevalence in the public is around 30% and new donors is 5%, is screening new directed donors a justifiable risk as source of blood?

• Are we not justified in introducing ‘generic blood?– Less tested – Less processed– Directed donations– Local Community sourced.

Epidemiological context (HIV)

26

Conclusions.

• Debate should occur on ways of accruing ‘safe’ and affordable blood.

• Patients must be given options (just like for all other drugs) to buy the ‘generic’ version.

• Minimal testing using hospital based technology should be reconsidered at provincial and remote hospitals.

• Does post exposure prophylaxis have a role?