|Safe Blood in Developing Countries - The Lessons from Uganda (EC, 1995, 151 p.)|
|Section One - Introduction and summary|
|Chapter One - Safe blood and HIV/AIDS: The Uganda achievement|
AIDS in the World also says that:
'The key concept in modern transfusion medicine is the integrated blood transfusion service. The integrated system seeks to ensure a timely supply of adequate amounts of safe blood and blood products, where needed and at an affordable cost... The global reality is stark: while the integrated system is a reality in industrialised countries (albeit with residual problems) the people of the developing world rarely receive the full benefits - and often suffer the risks - of blood transfusion.'
This books shows how one African country, Uganda, did achieve an integrated blood transfusion service. But it also shows how, in doing so, Uganda had to face up to some of the special characteristics of health and the blood supply in Africa. What are those special characteristics?
First, much of the health infrastructure on the continent has been destroyed by civil war and civil strife (as it had been in Uganda).
Second, some regions of Africa have a high rate of HIV infection (and of other infections) in the general population, leading to a basic probability that the blood supply will also be heavily contaminated, unless stringent precautions are taken.
Third, blood is frequently and routinely given by doctors in Africa in cases where sometimes blood transfusion could be replaced by other measures.
Fourth, African economies are generally too poor to import 'safe' blood supplies or blood products from abroad
Fifth, African health budgets are generally tiny when expressed in terms of health expenditure per head of population, so a full-scale safe blood service is often considered quite beyond their means
Sixth, the occasions when blood is given differ quite radically in Africa, compared to, say, Europe or the USA. There, it is typically a case of high trauma, say, major surgery, a motor accident or an industrial injury. In Africa, it is more likely to be a mother in childbirth, or a child suffering acute anaemia as a result of malaria. Such a child, tragically, runs the risk of swapping malaria-related anaemia for the deadly HIV infection. Overall, a much greater percentage of blood in Africa goes to women and children than in industrialised countries
Seventh, Africa, (like many parts of Asia) has professional paid blood donors, who make their living out of giving their blood, often as a result of extreme poverty. These people and their behaviour are hard to keep track of, and they tend to have abnormally high rates of HIV infection
Eighth, most donations of blood are given at the level of the individual hospital, that is, blood transfusion is hospital-based. So it is hard to enforce consistent standards over many scattered sites, and personnel skilled and trained in blood transfusion are thinly spread
Ninth, in the absence of a national or regional safe blood policy and blood transfusion service, much blood donation and transfusion is done 'on the hoof, with relatives of the sick or injured person giving their blood to the doctor to use there and then. This means that there may be no time or facilities to test the blood for HIV or anything else, and the well-meaning attempt to restore a sick or injured person may end in an even worse outcome.
The effect of all this is that you cannot (even if you have the money) just take a blood transfusion service from an industrialised country, where none of these characteristics apply, and plonk it down unaltered and unmodified in an African (or other developing) country. Nor can you just assume (as some donors have done) that simply financing a supply of blood bags and HIV test kits to hospitals will be enough to solve the problem. Nor is a purely medical approach enough. It is much more complex than that.
The study entitled AIDS in Africa, published in 1994 in New York, remarks that: 'Even more frustrating from the public health point of view is the realisation that the experiences and strategies of developed countries for preventing bloodborne HIV transmission are not useful in Africa. If the American blood donor screening programme were implemented in Zaire, for example, almost all Zairian donors would be ineligible to give blood.'
So the choice of standards has to be realistic in the light of African conditions. The choice of blood donors has to be adjusted to the rate and age profile of HIV infection in Africa, and the infections to be screened against have to be chosen in the light of the epidemiology - the main diseases prevalent - in Africa. For example, in Zimbabwe, about 10 per cent of the adult population carries the Hepatitis B virus, about the same rate as the HIV virus. The prevalence of malaria and malaria-induced anaemia, poses special problems for Africa. This study of how Uganda developed a national safe blood programme shows how the idea of an integrated blood transfusion service was both adopted from industrialised countries and adapted to the specific circumstances of Africa. There are of course other EC-supported projects to develop blood transfusion services in Africa. Angola, Benin, Cameroon, Congo, Cote d'Ivoire, Guinea Conakry, Lesotho, Madagascar, Rwanda, Zambia and Zimbabwe are cases in point. These examples are discussed in more detail later. But the case of Uganda is unusual because
a) Uganda had a shattered infrastructure
b) from the ruins, a national blood transfusion service has emerged
c) with quantified results and costs
d) it was the first and is now the longest-lasting EC safe blood intervention in Africa.