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Henrik H. Bendixen
Chair, Forum on Blood Safety and Blood Availability
I will make just a few comments and then share the podium with Harvey Klein, who had a lot to do with putting this program together. My most important visual experience having to do with blood, undoubtedly, was watching television the day of the explosion in Oklahoma City, seeing the enormously long lines of people who insisted on donating their blood. This took place not only in Oklahoma City but also in other parts of the country. This brings to mind also the comment that the best place to store the blood reserves is in the body, and with modern transport possibilities, it would seem that in this country our reserves are fairly safe and adequate.
What is striking is how closely the need is being met, and with a relatively small reserve capacity at any given time. What came across was the considerable pride that many of you have in having learned to manage, predict, and meet the changes in demand.
The discussion about importers and exporters was very interesting. Again, it is a question of learning how to manage. At this point it still has the component of competition as far as I can see, but which, at least in the eyes of some, should and will lead to collaboration rather than competition.
I asked about cost because it is very tempting to consider the high cost of establishing modern blood processing centers. You can't help but ask how many such processing centers this country needs. The more we learn to manage the import-export business, it seems to me the fewer such processing centers we shall need.
It would be very interesting to know a great deal more about donor motivation. Clearly, one sore point is donor management. To use a bad metaphor, a blood donor is a gift horse receiving the most extensive dental examination imaginable. There is a contradiction built into the gift relationship, and the necessary concern about the safety of a unit of blood,
which increases the need to manage that interface in the best possible way.
The military's capability of storing many units is very important for its purposes. We can all join in the fond hope that the ultimate use of this reserve will be as a backup for civilian catastrophes rather than military operations.
About blood substitutes, only one comment: blood and blood products have become, if not perfectly safe, yet so relatively safe that it is not going to be easy for blood substitutes to compete because these substitutes will be held to the same standards as the current product.
I would like to close our workshop by reiterating a few of the important points we heard today. For example, we heard about the current status of the blood supply. Doug Surgenor reported on the most recent data, those available from 1992, which indicated that more than 12 million units were collected by regional blood centers and hospitals in the United States. It was a little distressing to hear that major changes took place in both the collection and transfusion practices from 1989 through 1992, but no one sitting in this room can really tell us what the trends have been from 1992 through 1995. Clearly, that is something we need to work on because we can't address the problems unless we know what the trends are.
We heard about a 7 percent drop in allogeneic collections between 1989 and 1992, but a 9 percent drop in transfusions and a 70 percent increase in autologous blood collections. Only about half of that autologous blood is used, something that, again, should be somewhat distressing for most of us.
That is the story for red cells. We know far less about the other blood components, although we do know that during that same period of time single-donor platelet collections increased 75 percent. We also know that there are about 1.9 million units of blood that are unaccounted for in the United States. It would be nice to account for those units and to know whether those are units that actually could be recovered for transfusion somehow or whether those are units that are inevitably lost by breakage, by outdating that can't be addressed, and perhaps by mismanagement or units that are of the wrong blood group.
Dr. McCullough then carried on this theme, telling us that inadequate supply leads to danger to patients, and perhaps increased costs due to longer hospitalizations and postponed surgeries. However, excess collection of blood also leads to increased costs. Dr. McCullough also showed us data concerning the fluctuations of blood collections and blood use both at the University of Minnesota and nationally. He pointed out that with data collection by month to month, one couldn't really say much about the fluctuations except that
perhaps there were some. I thought it very interesting that while the average weekly usage at the University of Minnesota was 264 units, the range was 195 to 395 per week and that one couldn't really predict what collections would be. He also speculated on why there might be problems with collections, and it was impressive to me that there were no data as to what these reasons were.
Dr. Carson addressed the impossible question, which is whether blood is being used appropriately in the United States. He told us about mortality and morbidity during surgery and questioned whether they could be changed by transfusion. He discussed the increased morbidity and mortality in the Jehovah's Witnesses that one sees with falling hemoglobin concentrations and with cardiovascular complications. We don't know whether transfusion would correct mortality, and this cries out for controlled studies. We can only hope that those might be carried out, given the current financial situation of some of our sources of research funding. That, too, appears to be somewhat of a problem.
Dr. Westphal cautioned us not to treat donors as "reagents." And he pointed out some of the differences in the blood systems in Western Europe and those in the United States. Although his data go back to 1989, it was certainly interesting to see that the Swiss have 100 donors per 1,000 population, while in the United States we have 54. Perhaps that is all we need, but perhaps we need to do better than that if we are to have an adequate blood supply. Dr. Westphal also pointed out that in Switzerland small towns and villages have a sense of community. In the United States, we hear that it may be better to move away from a community responsibility and perhaps move to a more central idea of a national blood supply.
Mr. Bonk told us about the very impressive Delaware Plan: 30 years of no appeals and no shortages. It is a replacement-type plan. Others felt that while that might work in Delaware it probably would not work in Los Angeles or New York City.
Professor Cohen reminded us that if something is valuable the best way to acquire it is to pay for it. There is no such thing as a free lunch, only lunches that others pay for.
Professor Drake told us, again, based on a fair amount of data obtained over a long period of time, that the American blood donor is a marvelous individual. They are out there to donate, if only we need them, and perhaps we don't need them in any greater numbers. Perhaps we are getting as much as we need and we are maintaining a very narrow supply over demand because that is the way our system works. However, the donors are out there. Every year, 10 percent of eligible donors give about 1.5 times a year and that is 3 percent of our population, but, in fact, more than 50 percent of eligible donors have given at some time.
I thought one of the more interesting sessions was the panel on
distribution, where first we heard about the Red Cross's Hub system and some of its problems, along with some of its successes. We also heard about the efforts to dissociate the concept of blood as a local community resource and make it more of a national resource. This contrasts with what Dr. Westphal found in a very successful system in Switzerland.
Dr. Simon described to us both United Blood Service's system and the national blood exchange program of the AABB, as well as the problems of providing blood to remote areas.
Dr. Gilcher turned the well-known "triad" on its head, telling us that today, perhaps, cost is more important than availability and more important than quality and safety. I think he didn't really believe that, but hoped to make us think a little bit about what is really important in the national blood supply. He also reminded us of the truism that if a blood center meets hospital needs in all three of those areas, the hospitals will not go elsewhere.
Dr. Bracey gave us the hospital's perspective and let us know that exchange of inventory information is not routine. I think that it was probably surprising to many of us to realize that many hospitals have no idea of what the inventory is for their city, their region, or their state.
I found Mr. Fields' presentation a very interesting one. Kroger buys and ships a billion pounds of perishables annually. That is about the weight of the blood that we ship around annually. His products have a shelf life of 3 to 45 days; again, our platelets outdate at 5 days, and our red cells outdate at 42 days. Perishables are collected locally but shipped and distributed nationally, and availability is controlled by a central clearinghouse. So there are a lot of similarities here between seafood and blood. Kroger has a quality assurance program, and they are, of course, regulated by the FDA, as well as by the USDA and state agencies. They are moving from a hub system to a general distribution system and hope to thereby reduce wastage to 5 to 7 percent. Finally, he told us how using a satellite-type system seems to be effective for moving their perishables around. I can see the large red satellite in the sky now, moving blood around the United States.
Dr. Valeri described cryopreservation of red cells for us. These systems have been useful in a variety of areas, but they do not appear to be very useful for managing the civilian blood inventory on a day-to-day basis in the United States. However, they certainly could be used for potential quarantine problems, for rare blood types, and for some rare medical indications in which freezing is important.
Colonel Ward pointed out to us that freezing blood is very important for the military, and I can only second Dr. Bendixen's thought that we hope that that does apply to the civilian world and we won't need to use those 67,000 units frozen and stockpiled around the world for military casualties.
Colonel Hess pointed out to us that we shouldn't forget about extended storage, refrigerated liquid storage, even though the research in that area has
almost disappeared in the last 15 years. A few persistent and successful researchers continue to work in this scientific area. It remains important research that could save several hundred thousand units a year. Extended shelf life certainly could be helpful for remote areas of the United States and for making autologous blood more effective for those individuals for whom it is indicated.
Finally, Dr. Fratantoni told us about the future of red cell substitutes, which may not be quite as close to the horizon as I recently read. We are likely to see such an oxygen carrier within the next several years, however, and perhaps it will find its niche in our blood supply.
In closing, I was most impressed by the diversity of the U.S. system, the systems of collection, of distribution, of inventory control. I think some might be surprised that it works at all. The others will say it works very well and, in fact, only needs a little bit of fine-tuning in order to work almost perfectly.
I thank you all for attention and your comments today, and I hope that we have at least raised a number of issues that will send you home thinking about how we can better make availability less of a problem in the United States.