The inequities in blood safety and availability between rich and resource-poor countries represents a world transfusion crisis. Each year, hundreds of thousands of deaths occur that could be prevented if blood were on hand to enable transfusion. Women in childbirth and young children with anemia are disproportionately affected.
As with most crises, there is no single causal factor. Many blood centers operating in low-income countries face multiple challenges in serving local patients, ranging from the lack of a coherent national policy framework to shortages of money and appropriately skilled staff. But visit any blood center or transfusion service in the United States and compare it to the equivalent in many African, Asian, and Latin American countries—particularly outside of major cities—and one aspect of inequality is immediately apparent: the basic equipment necessary to collect, test, and process blood safely and efficiently.
Given international financial disparities, this might, of course, be expected. But this particular aspect of inequality is especially regrettable since U.S. blood banks routinely dispose of hundreds of millions of dollars-worth of equipment each year. Much of this discarded material is perfectly serviceable and is simply being displaced as part of routine upgrade programs created to acquire the latest and best technology. And what happens to the no-longer-needed equipment? Some is recycled; more ends up in landfill. Sadly, very little finds its way to struggling overseas blood banks.
Fortunately, there are relatively easy ways to re-home used equipment and surplus supplies. While barriers to exporting these still-valuable goods exist, resources are available to overcome such challenges. The old adage states that charity begins at home, but there is no reason why blood bankers (and other laboratory professionals) cannot extend that spirit to their workplaces.
Overcoming barriers to re-homing
The first obstacle is lack of awareness about existing inequalities. In transfusion care, too many blood bankers assume that transfusion medicine across the globe is experienced by practitioners in much the same, effective ways. Worse, in the course of regular business little thought or discussion is devoted to these matters. It is not surprising, therefore, that scant consideration is typically given to how to mitigate global inequities. A long-term education effort—of which this article seeks to be a small part—is required to increase understanding of the gulf between rich nations and poor.
Another barrier is the informational gap that impedes successful matching of gifts to recipients. The principle that there are those that have and those that need is easily established: identifying that blood center A has something that is required by blood center B (on another continent) is much harder. Some blood collectors have developed exclusive relationships with overseas collectors; for example, England’s NHS Blood and Transplant has a long-term support arrangement with the national blood transfusion service in Uganda. This can work well in many ways, such as skills transfer, but less so in relation to equipment when what the better-resourced partner has to give may not meet (in type or quantity) the immediate needs of the other center. Conversely, what the intended beneficiary requires may not be available from the donor institution. A better idea is an international equipment exchange network where detailed information profiling can match donor institutions with potential recipients. Such a tool exists in https://www.gbfeqxchange.org/exchange/, a cloud-based portal that connects donors and recipients.
Another set of challenges exists in researching and resolving the many technical variables in play when contemplating equipment donation. It is necessary to ensure that the equipment is a good fit across many parameters. This applies at a most basic level (voltage of electrical equipment, for example) but also pertains in relation to the availability of skills required to install, operate, repair, service, and maintain the donated equipment. Likewise, there needs to be assurance that sufficient resources are available to purchase consumables and meet any other costs of ownership. Some equipment—donation beds for instance—can be readily received by most blood services. Others, such as component collection systems or sophisticated testing technology, place demands on the receiving organization such that they can rarely be re-homed successfully without the involvement of the manufacturer, or at least co-operation from an engaged local distributor.
The remaining barriers are experienced most directly by those who work at the front line of donation: time and money. Re-homing equipment is usually far removed from the core business objective (although, with imagination, it can successfully engage staff, local media, and other community stakeholders), and there is often little institutional slack to absorb additional costs and duties. But donation requires resources: freight charges need to be met and logistics need to be managed (with specialist knowledge). Even if potential donors have the necessary money and staff, they may have minimal experience in exporting and be easily daunted into inaction. Partnering with experienced non-profits that are committed to getting valuable equipment into the hands of new owners in developing countries, such as Global Blood Fund, Matter and Afya Foundation, can relieve many of the logistical burdens and costs.
To adequately gauge your decision to pursue re-homing opportunities, it is worth considering some ethical dimensions. Three arguments against donation are often levelled.
The first of these is that the donation may undermine growth of indigenous capabilities. If, for instance, there is a local centrifuge manufacturer and donation of “pre-loved,” no-cost equipment of this type will impact its sales that foster self-sustainability, then the donation, however well-intentioned, would potentially be unethical.
The second argument centers on sustainability: will a donation change operating procedures in a manner that can be maintained over the longer term, or will it be necessary (at the end of the useful life of the donated equipment) to revert to former practices? This is important, because the loss of something previously enjoyed is always more keenly felt than the absence of something never experienced, and the long-term progress of the resource-challenged blood bank is of paramount importance. Opinion is divided on this point, although many argue that in an uncertain future, where equipment is expected to provide at least several years of service, this concern should not be used as an excuse for inactivity.
Although it is true that older, less-sophisticated technology is sometimes more appropriate for resource-poor settings, a third ethical contention centers on the quality of equipment being donated. By shipping pre-used items, blood banks from prosperous nations risk being accused of pushing sub-standard—or at least less desirable—goods onto poorer neighbors.
Most times equipment will have been operationally deployed up to the point of availability/donation and rarely goes from serviceable one day to unfit for purpose the next. However, care must be taken that donated equipment is, indeed, still serviceable and can be supported on location by the supplier or its agents. It is incumbent upon the donor to assess the quality of the gift and not to off-load equipment that offers only marginal benefit.
Impact of re-homing successes
Encouragingly, there are numerous success stories to build upon in global blood banking. Over the past few years millions of dollars worth of equipment has been re-homed. Dozens and dozens of organizations have collaborated to expand the reach and quality of transfusion care.
Bloodmobiles have found a second lease of life in Africa, Asia, and Latin America, where they add greater flexibility to blood drive deployments and allow access to previously inaccessible communities. Portable beds are providing more comfortable donations in Nigeria, Mexico, Cambodia, and Lesotho. A better experience is especially important to encourage new donors to return to give again. Blood mixers are helping make every donation count, by preventing needless losses due to clotting in the collection bag in places as far apart as the Democratic Republic of Congo and Peru.
This equipment is not only providing huge benefit; it also is creating significant economic leverage. Bloodmobiles that might otherwise have been sold at auction, stripped, and used as recreational vehicles, and beds that could have been sold as scrap for salvage parts, would return only minimal funds to the disposing center. On the other hand, for a relatively small investment—often just five percent to 10 percent of the depreciated value—the equipment can be given to under-resourced blood centers that would otherwise be unable to afford it. Gratifyingly, such donations continue to provide their designed value, improving the lives of donors and patients.
Call to action
As blood bankers and laboratory scientists we are, of necessity, experts at multi-tasking. When it comes to the disposal of equipment that is being retired from service, a new task you should add to your protocols is determining its potential to be re-homed to a blood bank in need. As with so many of your duties, lives hang in the balance based on your care with this step.
John Armitage, MD, is President and CEO of Oklahoma Blood Institute, the ninth-largest non-profit blood center in the United States. Dr. Armitage also chairs the Global Blood Fund and Blood Centers of America boards of directors.
Gavin Evans, MBA, serves as Executive Director of Global Blood Fund, an international charity that supports blood collectors in low-income countries. Previously, he worked for 15 years as the senior executive responsible for donor recruitment and management for
England’s NHS Blood and Transplant.