II
ENHANCING COLLECTIONS



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--> The Delaware Plan David Bonk I am here to tell you about the unique system of blood procurement, called the Delaware Plan, that has been developed in my area of the country. In the way of background, you should know that the Blood Bank of Delaware is a medium-sized blood bank, serving 19 hospitals on the Delmarva Peninsula, which includes the state of Delaware and the Eastern Shore of Maryland. We annually draw about 55,000 units of whole blood and platelet apheresis products and distribute approximately 90,000 units of blood and blood products to those 19 hospitals. We are very proud of the fact that in over 30 years we have not had a blood shortage or a cancelled surgery for lack of blood, or an emergency appeal for blood donors. Hospitals in our area set their own optimal inventory levels. They get whatever they want whenever they ask for it. Compared to the national strategy of having donors give three to four times per year, we ask our members to take a turn approximately once every two years. Of the one million residents in our area, nearly 700,000 are covered by our membership plan. Compared to the national average of 3 to 5 percent of the eligible population giving blood, in our area 20 to 25 percent of the eligible population gives blood. We don't conduct community blood drives. We never hold blood drives at businesses. Anytime more blood is needed, even Type O, that need can be met quickly and without alarm or additional cost. We have a blood program that works very effectively at the one thing that blood banks are supposed to do and that is provide a reliable supply of high-quality blood products to the hospitals we serve every day of the year, no exceptions, no excuses. We also have the lowest processing fees in our area of the country, and the savings to those hospitals in terms of lower fees, reliable supplies, and the elimination of cancelled surgeries for lack of blood have been enormous. All of this has been accomplished through our membership blood assurance plan, the Delaware Plan. It is an unusual way for a blood bank to function, so I will tell you a little bit about the way it works. We ask people to join our membership plan as a means of providing blood for the community and coverage for themselves and their families. Each

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--> membership is a family plan, providing coverage for the member, the member's spouse, and all tax dependents. Each member family is asked to do two things. First, we ask them to pay a small annual dues to keep the membership active. That is either $2 or $5, depending on age. Second, we ask them to provide a pint of blood when it is their turn. In return, people who join and support our program pay reduced fees when they or their family members use blood. This is a credit system. The 19 hospitals we serve charge a replacement deposit fee (RDF) for the patients who use blood and are not members of the blood bank's plan. This fee, which is $30 for a unit of red cells and $15 for a unit of platelets, could be paid or the charges waived if the blood is replaced. For example, if a nonmember uses 10 units of packed cells, the processing fee at $57.50 per unit would total $575. The replacement deposit fee at $30 per unit would total $300. The total bill for this patient, who is not a blood bank member, would thus be $875. Generally, health insurance does not pay the RDF. That same patient as a blood bank member would be charged the processing fee at $57.50 per unit, but would not be charged the replacement fee for a total bill of $575, or a savings for that member of $300. That is the incentive for people in our area to join and support our program, and that is why the majority of the population has joined. In exchange for this coverage, they are asked to take a turn providing an acceptable pint of blood. Since we have such a large membership base, that turn is infrequent, approximately once every two years. When it is a member's turn to provide a pint of blood, he or she has three options: either give blood himself, if eligible; provide an eligible substitute donor; or pay the $30 fee to replace one unit of blood. For those members who cannot fulfill any of those options, we provide a donation credit from a high school donor. We don't want to lose a member because they can't donate, don't know someone to donate for them, or cannot afford to pay that fee. Of course, our overall marketing goal is to make sure that everyone in our region is covered. The key to our success is the support of businesses and organizations. As I mentioned earlier, we do not conduct community blood drives and we don't ask businesses to sponsor blood drives. This is expensive for businesses in terms of lost worker time and productivity. We simply ask businesses and organizations to be group sponsors of our membership plan. Currently, there are over 2,700 businesses, corporations, and organizations on the Delmarva Peninsula that are group sponsors with us. Their responsibility as group sponsors is to do three things: first, recruit new members into our blood bank plan; second, provide member addresses and telephone numbers; and third, collect the $5 or $2 annual dues for each group member. Most of our groups gladly pay those dues as a fringe benefit of employment. We deal directly with the member when it is that member's time

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--> to give blood, and he or she can donate during nonworking hours on evenings or weekends. We estimate the annual cost to a business at under $10 per blood bank member. This compares with the estimated cost for a business to conduct a blood drive at somewhere between $20 and $50 per donor in lost worker time and productivity. Between 80 and 85 percent of the blood drawn in the United States is drawn at places of business or at organizations such as churches or clubs. The remainder is drawn at fixed sites. In our plan, 94 percent of the blood is drawn at fixed sites. None is drawn at businesses. This keeps our costs down and significantly reduces the cost for each business. It encourages businesses to support our plan by recruiting members for us. Currently, we have over 182,000 members, and those memberships provide coverage for nearly 700,000 people. We are actively working to recruit the nonmembers. Another significant difference in our area is that we are able to prescreen 95 percent of the donors before they ever come into our donor centers. When it is a member's turn to give blood, we contact him or her at home with a postal notice that contains a list of options and some of the information about who generally qualifies as a blood donor and who generally is disqualified. We include a list of the high-risk behaviors for AIDS, so that they have time to read it at home, not sitting in our waiting room. We ask members to call to make an appointment if they plan to give blood. When they call, we are able to prescreen them over the telephone to eliminate those who would obviously not qualify. It saves a tremendous amount of time for them, which they appreciate, and it also saves time for us. That is how the Delaware Plan works. It is based on individual responsibility. This is an extremely equitable system in that every person is asked to play a small role in ensuring the community's blood supply. We spread that responsibility over a larger base than is common among most blood programs. Those who choose to not participate are asked to pay for or replace any blood that they use. The system has been working extremely well, but it is not without problems. One of our biggest problems is that our members are asked to donate when it is their turn, which results in a random supply of blood types donated each day. Because we have a greater need for Type O generally, and other types from time to time, we created our Lifesaver Club. It is for people who want to donate more often than every two years. Over 12,000 of our members have joined and have agreed to be on call should we have an extra need for their type of blood. We can project that need several days in advance, and when we expect our in-house inventory to go below optimal levels, we will call and ask those next on the Lifesaver Club list if they can come in during the next few days so that we can avoid having an emergency. The donor receives an extra credit that can be used at a later date or given to a friend or relative. That system provides for nearly all of our type-specific

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--> needs. Another concern that has come up in national forums is the safety of the blood from replacement donors compared to that from the general population of donors. In recent years, the practice of using the RDF has been under increased scrutiny. Consequently, we conducted a study to see if replacement donors are less safe than the general population of blood donors. The results were presented at the AABB annual meeting last year. We did a comparison of test marker rates between member donors and replacement donors, to see if replacement donors had a higher incidence of test marker rate. The major hurdle was that in our system, since the majority of the population is covered and participates by donating, there are relatively few actual replacement donations. We had to review the records for two full years of donations to achieve a statistically significant sample size. TABLE 3 Comparison of Viral Markers in Blood of Delaware Plan Members and Replacement Donors Marker Number (%) Member Donors (N = 67,338) Number (%) Replacements (N = 1,354) Hepatitis B core antibody 660 (1.0) 19 (1.4) Hepatitis C antibody 457 (0.7) 12 (0.9) Alanine aminotransferase 875 (1.3) 23 (1.7) Syphilis (STS) 5 (0.01) 0 HIV-1 antibody 9 (0.01) 0 HIV-2 antibody 0 0 Hepatitis B surface antigen 4 (0.01) 0 Human T-cell lymphotropic virus antibody 4 (0.01) 0 The database was the test results from all blood donations made during the years 1992 and 1993 at our donor centers. Chi-square analysis was used to compare the repeatedly positive test results in the two groups with p greater than 0.05. Of the eight screening tests we were performing at that time, only ALT, HBcAB, and anti-HCV occurred at sufficient frequencies to be meaningfully analyzed. The difference in the incidence rate among the replacement donors compared to that among allogeneic donors was not found to be statistically significant. The study did show that replacement donors were more likely to be giving blood for the first time, 18.5 percent, and their test marker rates were similar to those of other first-time donors. Our results

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--> indicated that the blood given by replacement donors is statistically as safe as that given by the general population of donors. The next question that often comes up when other blood bankers look at our system is whether it is fair. The replacement fee has been called a penalty fee, while others say we use the fee to coerce people to give blood. This is not how we administer the program. As I have noted, we have less than 2 percent replacement donors, and there are ways around the fee. For example, we actively recruit ongoing blood users, so that they will be covered. Someone who is added to one of our group accounts will be covered immediately, even if he or she uses blood that same day. We have group accounts with the local heart association and the cancer society that will accept as a member anyone who is affected by heart disease or cancer. We also discount our replacement fees to the hospitals by their annual bad debt ratio so that the hospital will not try to collect from the poor and the indigent. For example, if Hospital A has a bad debt ratio of 10 percent, we reduce the amount of the replacement fees that we charge that hospital by 10 percent. For those who cannot afford to pay our membership fee or cannot fulfill the obligation to provide blood when it is their turn, we have programs to provide free memberships or student donations for those people. I submit to you that the Delaware Plan is one of the most equitable in the nation, and I ask the following questions for the Forum to consider: Is it fair that 95 out of every 100 people in the United States who could give blood do not? Is it fair to overdraw in some areas of the country to subsidize blood programs that cannot provide for their local needs because they can't motivate their local population? Is it fair to the people who give blood four times a year that they receive no advantage over those who never give blood? Finally, is it safe to have a predictable major shortage of blood every January, every July, and every September and not attempt to change the system? To summarize, for over 30 years, the Delaware Plan has eliminated blood shortages, eliminated surgeries cancelled for lack of blood, and eliminated emergency media appeals for blood donors. Hospitals in our system set their own optimal inventory levels for blood. People in our area are asked to give blood every two years instead of three to four times every year. Of the eligible population, 20 to 25 percent give blood under this plan, compared to 3 to 5 percent nationally. The costs to business sponsors and to our hospitals is significantly lower than those in other areas. Spreading the burden for the blood supply over a large population through this blood assurance plan is more

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--> equitable for all. It reduces the costs and provides for a steady predictable supply of blood without compromising safety. That is the Delaware Plan, and that is our approach to it. Questions/Comments Alvin Drake: I question those statistics gravely. For reasons I will talk about, 3.5 percent of the U.S. population gives blood every year. If 25 percent of the people in Delaware gave blood in the same time period, you wouldn't know what to do with the blood. It is measured over different time periods. David Bonk: You are correct, but we are talking about the number of people who actually participate as blood donors in our system. Arthur Bracey: There is a notion that there are a number of people in the population that are at risk for having infectious diseases. What do you think is the desirable level of participation? What is the index for donation or participation in the donor program? David Bonk: For our donor program, we make a great distinction between the people who we want as members and the people we want as donors. We want everyone to join and support the program in some way or other. We certainly don't want anyone who is at risk for any of the diseases to donate blood, and we are very careful with that. Our test marker rate overall in our donor population is lower than that in the other areas of our region. We are making that distinction, but our approach is to try to recruit everyone in our area to support the program in one way or another. This is not necessarily through their donation of blood, because, clearly, a lot of people don't qualify to donate and we don't want them, but we do want their support. Thomas Zuck: How do you recruit platelet apheresis donors? David Bonk: We do that more traditionally. Our apheresis program is separate from our membership plan. There is certainly no requirement to participate. It is more in the line of altruism, although our platelet apheresis donors do receive two credits when they make donations. We generally just recruit them by mail from among our regular blood donors or recruit them in the chair as they are giving their allogeneic unit of blood. Ann Chinoda: In Florida, there is an outside firm which has visited all of the hospitals and has spoken with them on the diagnosis related group (DRG)

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--> reimbursement issue, showing hospitals why they should move away from the replacement deposit fee because of the three-unit deductible in Medicare. Have you not run into that problem at all in Delaware? David Bonk: The question comes up periodically, but the system works extremely well at recruiting blood donors and maintaining one thing that we absolutely need, enough blood on the shelves every day of the year. You saw the fluctuations in some of the presentations made earlier, the highs and the lows. We don't experience any of those lows, and our outdate ratio is very low as well. The question of the replacement deposit fee almost becomes moot as you approach the level of the population that is covered that we have. Celso Bianco: How do you deal with specific high-risk populations, for instance, gay men or with minorities? How do they have access to this plan? David Bonk: We recruit them as members the same way we recruit any other member, and, of course, when the questions come up, we very clearly tell them that there are extensive restrictions as to who can actually donate a pint of blood, but we welcome everybody regardless of medical condition to be a member and support the program in one way or another. William Sherwood: We have admired the success that you have had and have benefited from it. I wonder if you have given thought to how that kind of system would work in large cities, such as New York, Chicago, Philadelphia, and Los Angeles, where there are large, inner city populations. These are people who are very difficult to contact and as a group have extremely high blood usage. Do you think this could work in those kinds of environments? David Bonk: We have thought about it, and the question has come up many times. We don't have an example of how this system would work in a large metropolitan area. We would certainly like to see if the numbers would lend themselves to trying this plan in an inner city situation, although it is impossible to say.

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--> Markets and the Blood Supply Lloyd Cohen I was initially very surprised to be invited to speak here, but when I found out that Art Caplan was responsible for inviting me, I knew why I had been invited and what I was expected to say. He and I are on opposite sides of a debate having to do with organ transplants. I favor markets. To some people, I may even seem like a caricature of an economist, who, as the famous old saying goes, knows the price of everything and the value of nothing. The position that I will assert here is the extraordinarily unexciting position that if something is valuable, the best, most efficient way of acquiring it is to pay for it. That is my view with regard to ambulances, scalpels, operating rooms, bread, housing, and clothing. There are exceptions to the general principle that simple markets in which one pays for the goods in question are the most efficient. Let me suggest three possible kinds of exceptions that might come to mind in the case of blood banking. I will dismiss two of them and then discuss the third a little bit more. The first is a kind of general moral exception, that somehow it is elevating of the spirit that people give blood and that this all is part of the great donative act, which draws us together as a community. I think that is largely nonsense. First of all, I suspect that the people in this room think they do valuable things for other human beings and don't feel any less that way because they earn a living doing so. So, too, with providing blood to others. I don't think in any important way the act is morally elevated by not paying people rather than by paying them. Certainly not to the extent that we should prohibit, prevent, or discourage people from selling it. Beyond that, if any sacrifice to the health of innocents is entailed by our insistence on somehow keeping this a donative procedure rather than paying people, then it is truly bizarrely immoral; that is to say, if we are condemning people to mortality and morbidity, there is certainly nothing moral in doing that on the altar of encouraging the great charitable, altruistic act of donation. The second possible exception to markets is cost. Some people may think that donation is a less costly system than paying people. It may seem odd to you, but, in fact, donation is a more costly system than paying people. Now,

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--> the illusion is that it is more costly if you have to pay money to those who sell blood. Well, indeed, it is more costly to you who must pay, but if we are looking at this from a social perspective, there is no such thing as a free lunch. Someone is gaining from the price you must pay, and someone is paying when you get the blood for free. From society's perspective, the person who is donating rather than being paid is suffering a cost. If we count his costs as part of the whole social mix, then the fact that you haven't paid him is no cost saving at all. It is simply a transfer. This is dedicated to the proposition that there is no such thing as a free lunch, but there, indeed, are lunches that other people pay for. You are concerned with "your cost," but from a social perspective, the money that you pay for blood is not a true cost. It is just a transfer of money. The true cost is the cost of the donors who suffer discomfort, lost time, lost earnings, and travel expenses. Those are true costs. The dollar valuation of those costs is merely a measure of the value of those sacrifices of time, comfort, and resources. From a wider perspective, donation is more costly than sale. How is it more costly? Precisely because you don't pay people in cash you frequently must compensate them in a more inefficient manner if you are going to compensate and encourage them at all. Another notion is that if you collect through blood drives at work, you are taking away time from work. It used to be the case that employers would give half a day off from work. Again, this is a payment in kind, more costly than it would be to simply pay people in cash, at a much lesser amount, to induce them to sell their blood. So, from a variety of perspectives, donations are a more costly means of acquiring blood than paying people in one form or another. The final issue is that of monitoring. I am going to give you examples, having nothing to do with blood, to show you the generality of this problem—a number of areas in which it is difficult or impossible to pay someone for what you want because you can't measure whether you have received it or not. You can't measure it directly when you are getting it. You may not be able to measure it later. Sometimes, even if you can measure it later, the measurement comes too late to be helpful. So, you must either supplement a simple cash market or substitute something else. So, for example, you throw in bonuses, retirement plans, and stock options as a supplement to simple wages or salary. The hope is that in this way one can induce employees to be productive when you can't measure productivity directly. The general rule is you can't get precisely what you want if you can't measure and reward precisely what you want. Another interesting illustration I came across the other day is of a man who owns supermarkets in Northern California, in low-income areas. He needs to hire reliable employees. Some people are honest, some are dishonest, and he has a real problem sorting. It does him little good to ask them if they

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--> are honest. We have a similar problem with blood. It is not all that useful to ask people if they are HIV positive. So, what do you do? To the extent that we have this problem that we cannot very well directly measure and monitor the safety of blood, we want to sort the population in such a way that we don't get blood from high-risk groups. We also don't want to encourage people to lie about whether or not they fall within this high-risk group. The supposition was made that when you pay people for blood, you suffer from both of those problems: you attract people from a population more prone to falling into this high-risk category and that for that population and for other populations in general, you encourage people to be deceitful in revealing whether or not their blood is hazardous. Now, under those circumstances, if one could find a means of getting the blood, other than paying for it, then one should give some weight to that. First, let me separate out the lying problem and the sorting problem. The lying problem is not all that much a function of whether you are paying people; that is, there is as much an incentive for people to lie if they are under peer pressure of one sort or another. So, it is not clear that paying people for blood, particularly if we are talking about amounts of $20 or $30 per pint, is a crucial factor in whether they will conceal a health problem. If I am wrong, though, that is a point in favor of not paying for blood. As for the sorting problem, that is an entirely separate problem. If we are trying to sort people because we don't want derelicts and we don't want gay men, that is a problem that exists independent of whether we pay people or don't pay people. I suspect that in North Dakota and in Minnesota there are fewer people who are HIV positive or have hepatitis and, so, those end up being rather safer sources for the blood supply. This leads to a particular advantage of markets. The general pattern in the United States has been to encourage widespread donation, again, part of this whole donative ethic. From the perspective of trying to get a safe, secure, reliable, continuous supply of blood, it seems to me that we should be going in a very different direction: trying to reduce the number of people who provide blood, not increase the number. From that perspective, again, we would be paying people for blood and paying more for blood the second and third times that they give, when we are more secure that their blood is safe and healthy. With regard to finding ways to solve the problem of monitoring blood, much of the problem would have been corrected by making blood suppliers strictly liable for any problems with their blood. Then the incentive is on the blood supplier to monitor and sort in whatever manner they think is appropriate. I will conclude by saying that these last notions with regard to monitoring

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--> are all very interesting. They all suggest different ways in which you would use different kinds of incentives and sorting devices under certain circumstances. An example might be getting donors or vendors through their employers. People who work are generally healthier, more reliable sorts than derelicts. There are many incentives that you can use in which you make use of the market. My understanding, though, is that all of these concerns now with regard to monitoring are past, that this is something of a dead issue now. My understanding is that over the last 20 years, our ability to lab test the blood has moved to a level where the blood that we actually use is quite safe, regardless of its source. If I am wrong with regard to that, then the monitoring issues come up again. I believe, though, that the safety of our current blood supply is not a function of all of these intrusive prescreening questionnaires that people have come up with, but rather a function of the fact that we can now effectively test for the various forms of hepatitis and HIV. With regard to the letter from the old man that Dr. Westphal read us, that is the reaction you will get from somebody who is donating, who is making a gift. It is not likely to be the reaction you will get from somebody who is trying to sell you something. That is another argument in favor of a market. Questions/Comments Jane Piliavin: I like the way you separate out the selection problem from the lying problem. That is something that is very difficult to do with the kind of correlational data that we have. I do want to point out that consistently to this day, plasma apheresis donors, who are routinely paid, have three times the risk of infectious diseases, as compared to people who are giving their blood. We don't know whether that is selection, lying, or some combination of the two. Jeffrey McCullough: I would agree with Mr. Cohen about the similarity in the costs of volunteer donors and paid donors, but for a different reason. I think the direct cost to our operation for a paid donor system would be no greater and maybe less than that for the volunteer system because it is a lot easier to call somebody up and get them for pay, so you don't have to shift the cost to the rest of society. David Jenkins: Red Cross data show that it only costs us about $10 in direct cost to the blood supplier to recruit the donor. That is not taking into account the cost to the companies, which I think is a very important concern. We would have to increase that substantially.

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--> Blood Donor Attitudes and Behavior Alvin Drake My involvement with blood donation attitudes and behavior began about 25 years ago, when the Titmuss4 book, The Gift Relationship, appeared. As you may know, it was a book with limited circulation but enormous impact in this country. A rather critical look was taken at our blood collection procedures compared with practices in Great Britain. It described our donors as people, many of whom donated blood for money, and most of whom exhibited a less noble attitude toward social welfare than was the case in Great Britain. As best as I can tell, Titmuss assessed the blood supply in Great Britain by talking to few people and probing not at all deeply into actual donor and blood allocation practices there. The blood supply in the United States was in part assessed by misusing data that I supplied. That certainly got me concerned, curious, and involved. My earlier work on the blood supply was with technical issues in inventory control, decision making with regard to frozen blood, data handling, and regional sharing. About 20 years ago, we had the days of the American Blood Commission (ABC). People were comparing individual responsibility versus community responsibility. They were really talking about the American Association of Blood Banks versus the Red Cross and were just beginning to recognize blood supply problems that could not be blamed on the public. I was among the early people to contend that much was right with the American blood supply. My claim was that any of us, as patients, should worry a lot more about getting clobbered by triage at an emergency room than about encountering a significant problem meeting our needs for blood. The ABC Donor Recruitment Task Force wondered, among other things, about how much cash and "insurance" incentives compromise the quality of the supply. We could establish that a lot of active, desirable donors said they were much less likely to give blood if they or most other donors were paid. Ten years ago, we were looking more at significant issues in blood testing and utilization. My research had made me claim that difficulties in places like 4   Titmuss, R (1971). The Gift Relationship. New York: Pantheon.

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--> New York City should not be attributed to the contention that New York residents are chronically different from people in Delaware or Minneapolis or Oklahoma. Blood supply problems can result from union contracts and poor recruitment practices, sometimes making collection so expensive that it can't possibly succeed. Today it is nice to hear people emphasize management issues, realizing the blood supply system can be controlled and can perform astoundingly well. Along the way, some friends and I did a book called The American Blood Supply.5 I would like to tell you a little about that research and its conclusions. With ample funding from NIH, we set out to learn how people feel about the blood supply and to understand the bases of their impressions and decisions about participation or nonparticipation. We picked Hartford, Houston, and New York as cities with very different kinds of blood supplies, from total community responsibility in Hartford to all kinds of things in the other cities. We went after carefully controlled sample populations (using interviewers skilled in seven languages) to learn what we could. We also studied work environments that made it astoundingly easy and routine to be a blood donor, places where you couldn't avoid thinking about blood donation. For this, we went to the big insurance companies in Connecticut, where the odds were that somebody known to an employee would call four times a year to solicit a blood donation. To be a nondonor there, a person would have to have thought out his or her rationale for not donating. That is different from the situation for most nondonors. We also looked at what happens to high school students at their first opportunity to donate. In addition, we studied samples of very frequent donors, committed nondonors, and ex-donors, to see how they explained their behavior and what may have happened to change it. Our conclusion was (and is) that it is awfully hard to blame the major problems of the blood supply on the general public. We can manage collections better each year to smooth out the supply. But the popular notion that there is a huge crowd of eligible but determined nondonors out there just doesn't hold. Let me say just a few things about the blood collection task. What is required to meet the needs for whole-blood products, short of what goes into the commercial plasma market? We need every eligible donor in today's population about once every seven or eight years. Of the large population of eligible donors, collections are naturally focused on those who are easily reached and economically drawn. If too many people were to give their blood, we wouldn't know what to do with it. The number of donors and donations is limited primarily by the 5   Drake, A, S Finkelstein, and H Sapolsky (1982). The American Blood Supply. Cambridge, MA: MIT Press.

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--> actual need for blood for transfusion. The issue is how to organize and make collections efficient and predictable, not how to significantly increase the donor base. There may be a larger percentage of active donors in some other countries, but some of their blood can be used for other purposes, maybe providing part of the plasma supply or being drawn for other markets. I doubt that the people in those countries are more or less nice than Americans, though in some cases their collectors may be more organized and/or more subsidized. In the United States, each year about 10 percent of the people who are eligible to give blood do so. Our donors give an average of about 1.5 donations in a year. That turns out to be around 3.5 percent or so of the total population, including both eligible and ineligible people. It makes no sense to ask why so few people give blood in any one year. We get about what we need. The issue is the hassle, interruption, and economic inefficiencies of the various ways we get the blood we need. What fraction of the people presently eligible to give blood in the United States have ever given blood? Somewhat better than 50 percent. Over a four-year period, probably 25 percent of the eligibles have given at least once. How do people respond to their blood donation opportunities? They respond generously if they are solicited and drawn with respect and convenience. Many will be baffled if you ask them why they donate, so obvious is the need. If you ask donors to select their reasons for blood donation (other than the obvious fact that there are patients who need blood), they will respond with whatever their collector tells them—credits, basic humanity, etc. How do people become ex-donors? Either because of a bad donation experience (long wait, inattention to their treatment, etc.—all fairly rare) or, more usually, either the person moved or the recruitment organization stopped reaching them. Asking for blood donation reasons can achieve strange results. There was a person at a blood bank who gave blood frenetically, four times a year, maybe five when the number of weeks worked out right. We asked why he did that. He said he gave it for his insurance plan. We replied that he had given eight times as much as required in his blood assurance program. His answer was that people need blood all the time. What did we expect him to do, donate less than he could? Most people don't enjoy blood donation but they are very happy to have participated. We should be careful not to provide potential donors with motivations less solid than those they already have. How do we convince people to give blood? It is good to sustain an intelligent, continued general awareness of the need. Other factors are invisibly at work favoring the blood supply. For example, by the time a person is 25 years old, the odds are already 50–50 that he or she knows that a personal acquaintance has received a blood transfusion. At age 35, there are three chances out of four that a person is aware of a friend, relative, or other personal acquaintance who has received blood. Collectors sometimes undermine the natural awareness of the need with well-intentioned but

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--> personal acquaintance who has received blood. Collectors sometimes undermine the natural awareness of the need with well-intentioned but misleading and sometimes ineffective ads. I'd like to mention one example. There was a big promotion in Massachusetts done by a well-meaning public relations firm that asked too few questions first. Incidentally, it was successful because anything that reminds people to give blood will probably help in the short term, though I believe the long-term costs of misinformation are considerable. The ad went something like this, at least in my unforgiving caricature. "Thump, thump, thump." Heart beating. "Blood is vital for life." Lots of drama and you hear all kinds of noises in the background. "You lose too much of this stuff and you could die. Thump, thump, thump. Nobody will give blood. Thump, thump, thump. So, why don't you?" It is easy to think of more positive messages. A lot of the ads emphasize that there is a tiny segment of the population—something like 3.5 percent—that gives blood, so why don't you be as heroic as they. There was one campaign with a picture of President Jimmy Carter lying on a table giving his 58th unit of blood. On newsprint, it looked like he was dying. This was part of one of the few national public service Ad Council campaigns. Big stuff. The material gets to be seen and heard by millions of people. But in some of these, there may be 11 sentences in the ad and 10 of them are dead wrong. They would scare me out of giving blood also. People are generous with their blood. People feel good about giving their blood. Treated well and solicited regularly, they will return to give again. If you want to feel good about people, study their attitudes and behavior with regard to blood donation. You'll find them astounding, uplifting and neat. Questions/Comments Lloyd Cohen: The economist reaction generally to the notion that you ask people what they would do under certain circumstances and you take that as a guide is just not a proper way to discover what they are actually going to do. People say all sorts of things. The way to find out what they are going to do is to give them choices. As for the observation that you ask people if they would give blood if they were paid and they say "No," I would have to see it before I would believe it. If it were true, though, my suggestion would be, don't pay those people. Pay other people. Alvin Drake: I agree that the test is obviously needed. In many cities over long periods of time you did have the choice. The value of the gift to the individual will be significantly undermined if they know that you can go and

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--> buy this stuff elsewhere, but I agree that the test isn't being run now. It was run in many places for many years in this country, with some very bad results. Harvey Klein: I think what you are saying to us is to determine whether or not this is a management problem. Alvin Drake: I think some excellent things were said earlier about the level to which we delegate recruitment and retention and the way we treat those professionals. I believe it is a management problem. I don't think it is a huge management problem, because if you go around looking for surgeons who say they would have done this and that but they didn't have the blood, you are going to have trouble finding them. We deliver what is needed. Nevertheless, I think that the recruitment and retention function is pushed way down the system where relatively unempowered people try to talk to powerful organizations and get in trouble. Arthur Bracey: You talked a lot about recruitment. What about the role of public education? Are we trying to educate the public too late? Should we start earlier in school? Alvin Drake: We have a lot of information on that, but I believe that the most crucial thing for the future of the blood supply is to go after those high schools and colleges tenaciously with people trained to concentrate on those populations. There are problems there. You can get less staff continuity in drive organization. Students are interested in all kinds of things. I saw our blood drive at MIT, which was about the national leader or close to it in per capita units, become just another blood drive when the Red Cross chapter around it collapsed, the chapter having sustained, fed, and paid attention to the students who organized the drive as well as to the donors. I think any system is going to require getting a bunch of blood from young, healthy people and giving it to mostly older people who need blood. One other thing, though. The general notion that blood donation is important, that you are likely going to need it someday, and that we all have it is good to stress to young adults. We need to tell them that they will feel good for doing it, even though it is somewhat creepy the first time. I think the younger the better. A high school campaign pays off long-term dividends beyond belief. What I remember is that a quarter of the kids eligible in a high school will give at their very first chance. That is amazing. You get in the habit, and I like best that you get in the habit of giving and receiving nothing in return.

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