Recently Neutral Source managing editor Richard Belzer attempted to donate blood, but was declined. Although the story is anecdotal and not empirical, it suggests good reasons why this particular blood bank seems to always be in short supply.
The requirements for blood donation are lengthy and complex. There are good reasons for selectivity, including the risks of contracting HIV, hepatitis, and Creutzfeldt-Jakob Disease (colloquially known as “mad cow”). Some bloodborne diseases can be tested for analytically, but analytical tests always have false negatives, and for some diseases no tests yet exist.
Prospective donors, who are motivated largely by altruism, often experience considerable frustration with the process if they are denied. Having one’s blood rejected as substandard can cause cognitive dissonance with the fact that his blood is just fine for personal use but not for sharing. There is also a utilitarian component because screening occurs immediately prior to donation rather than in advance, when it could be doing more cost-effectively from the prospective donor’s perspective. These procedures very nearly maximize the costs borne by prospective donors who are declined, which likely deters many from volunteering again. When blood banks use procedures that are cost-effective for them but not for prospective donors, they communicate that their time is more valuable than the time of the volunteers on whom they rely. Why volunteer if the blood bank communicates that your time is not valuable? It’s a lot of trouble to go through to get a cup of juice and a cookie.
This flowchart shows how prospective donors are interrogated immediately prior to donation. Even when they register in advance, however, prospective donors are not directed to this flowchart (or provided a paper copy) so that they can determine for themselves if they are likely to meet the conditions for donation.
In this particular case, two reasons were given for declining the donor’s blood: (1) current antibiotic use and (2) recent travel to a country where “malaria is endemic.”
According to Northern Virginia’s INOVA Health Systems’ blood donor program, any current use of antibiotics is per se grounds for declining a donor. The requirement for eligibility is:
24-hour wait after last dose, plus you must be well for at least 3 days
There is nothing magical about 24 hours or 3 days; both are rules of thumb. More interestingly, at the bloodmobile this policy was attributed to the federal Food and Drug Administration, which regulates blood banks. But according to the FDA, this is not the case; the blood bank has discretion to decide based on the reason antibiotic therapy is being administered:
The reason for antibiotic use must be evaluated to determine if the donor has a bacterial infection that could be transmissible by blood.
INOVA has chosen to exercise its discretion in a precautionary manner, but not to take responsibility for doing so. In any case, during the intake process INOVA could quickly exclude prospective donors taking antibiotics and save them the trouble of enduring the remainder of the screening process. It doesn’t. Only after the burdensome screening process is complete does INOVA inform the prospective donor that he is automatically ineligible.
TRAVEL TO A “MALARIAL AREA”
The disqualifying travel was to Mendoza, Argentina, and the vineyards located south of the city (i.e., away from the Equator) and at higher elevation. INOVA’s requirement for eligibility is:
1-year wait (symptom free) after return from visiting malarial endemic area for less than five consecutive years
What constitutes a “malarial area”? INOVA does not say on its web site, but at the bloodmobile it tells prospective donors that this restriction also is imposed by FDA mandate. That also turns out to be misleading at best because it ignores the discretion that FDA provides to the blood bank:
Donors who have been to an area where malaria is considered endemic will be deferred for 12 months after departure from that area regardless of whether or not they took anti-malaria prophylaxis. Malaria may be transmitted through blood transfusion. The donors shall be accepted or deferred based on the Malaria Risk Countries as designated by your institution.
INOVA does not publish these designations on its web site. The donor was informed that travel to “cities” in Argentina is permitted but travel outside cities is disqualifying. The INOVA staff member would not share the actual text of the policy with the donor.
According to the federal Centers for Disease Control, only very limited parts of Argentina are endemic for malaria:
Malaria risk area in Argentina: Rural areas of Salta and Jujuy province (along border with Bolivia) and Misiones and Corrientes province (along border with Paraguay).
The World Health Organization describes the malaria risk in Argentina as follows:
Malaria risk—exclusively due to P. vivax—is very low and is confined to rural areas along the borders with Bolivia (lowlands of Jujuy and Salta provinces) and with Paraguay (lowlands of Corrientes and Misiones provinces).
That is, not all of these northern provinces are malarial; only their rural areas are. Where is Mendoza?
It is 596 miles from Salta, 637 miles from San Salvador de Jujuy, 995 miles from Puerto Iguazu in Misiones, and 703 miles from Corrientes (distance calculator). The city is at an elevation of 2,300 feet in a location where annual rainfall is less than 10 inches. More than 100,000 people live in the city, and about a million people live in the metropolitan area. Neither Argentina nor the WHO report any incidence of malaria in this population.
INOVA is entitled to exercise its discretion in a manner that is more precautionary than FDA requires. However, it misleads prospective donors when it blames FDA for the stringency of its own rules. And, it should be understood that the more precautionary its self-imposed rules, the more prospective donors it will reject, the more prospective donors will be deterred from volunteering in the future, and the less blood will be donated.
When INOVA complains that it is short on blood, this prospective donor is unlikely to be motivated to volunteer.