Medicine is Public Health - Blood Supply

Our supply of blood products is built almost entirely on altruism, and is one of the most sophisticated public health infrastructure we have built.

Donate some blood if you can!

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Transcript

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Welcome back to Everything is Public Health. I'm MJ. And I'm Cass. Cass, have you ever donated blood before? I have. I have donated blood and I have donated platelets. And I donated my liver, but that's a separate thing. Did you donate the blood separately from the platelets? Right. So I was a regular blood donor. And one time they were like, hey, might you consider platelets? We're running short. And I said, sure, why not? Turns out I have like a cubic ton of platelets. And so like they would run my blood and get like sometimes twice as many platelets from me as they would from other people. So then they were just like six times a year or four times, whatever the maximum number of times a year. Like they were asking me to come in and donate platelets. And I did. And they were like, Your blood is too common. Like we don't really need more of your kind of blood. And they're like, we would much rather have your platelets. The problem is donating platelets, they pull your blood out, whip it around to get the platelets, and then pump your blood back in. Correct. But it takes nine million years. Not really, but it just takes a it takes a very long time. It takes much longer. One of the last times, they just like blew out all the veins in both my arms, and I was like, okay, I need to take a break. So it's been a it's and then COVID, and I just haven't donated since. Yeah, there was a blood crisis when COVID happened because people either can't or don't want to go out of their house to donate blood, and they really had to scramble in certain areas to make sure that hospitals can continue to operate because of this blood shortage. So yeah, donating blood, I want to say is relatively common. Actually, I'm just gonna look this up right now. How many Americans have donated blood in their lifetime? You want to take a guess? Two million. Three percent of the population donate blood each year. Probably not a lifetime prevalence, but it's probably the same three percent that donates, though. So like a million-ish. Yeah, roughly. So a lot of people donate blood. Here's something that I'm quite ashamed of. I have never donated blood. I am scared of needles and blood loss, perhaps rationally so. So I've never done it. Go ahead and judge me. No, I mean, listen, I know people, my son included, who literally pass out at the sight of blood. My son gives blood at the doctor's office, and like there's a team around him ready to catch him because he just crumples. I don't know if that's exactly your thing, but I do know that some people are afraid of that. And it's okay. There are other things that you can do. Not quite like that. It's a psychological fear. The actual blood itself is fine, but it's something to do with my blood that makes me that makes me uh fearful. So you're selfish. Yes. You don't want to give your blood. You're okay taking other people's blood. You just don't want to give your own blood. I have yet to take other people's blood. Perhaps one day I will. Um, but yeah, uh something I'm quite ashamed of. Never donated blood before. Yeah, yeah, judge me. Never too late to start. So today's episode is about blood, specifically the blood supply that we have stored away in various blood banks and hospitals around the country and the world. First, we must answer the obligatory question: why is this public health? From the most basic sense, many trauma incidents involve blood loss, which means for the medical team to help you, you may need blood products to keep you alive. Many surgeries involve expected blood loss, which means blood products are needed to complete the surgery safely and make sure that you survive. It's not possible to achieve this by having fresh blood donated as needed. It just would be too hard geographically to keep up on an as needed basis. So a system of widely accessible long-term blood storage, aka blood banks, are necessary to supply blood on demand. This involves coordination, infrastructure, and investments. And this doesn't happen by accident. We had to be intentional in creating the system. Yeah, and we want hospitals to have a steady supply of blood. It's critical for them to save lives. Unfortunately, science hasn't found a good way to make blood, but they are trying very hard. This means blood donation is still the primary way to acquire blood products. Speaking of blood products, let's do some basic biology. What is blood? I love this so much. As a biology major, my little heart's aflutter. So there are three main blood products acquired from blood donations: red blood cells, that's the component that carries oxygen through your body. Platelets, I mentioned I had donated, these are things that clot your blood, but they also participate in various immune system functions, and they typically are given prophylactically and then plasma. This is not just liquids that can be mimicked by IV solutions. Plasma contains blood proteins like albumin, which leads to fluid balance and homeostasis, globulins, which is immune system stuff, and most importantly, the clotting factors. So platelets alone might not be enough. These blood products are critical for our health and healthcare system. Cass, if you had to guess, do you think we, on average, have too much, not enough, or just the right amount of blood in our blood supply? Well, I don't have to guess because I know we do not have enough blood. That is correct. In general, we don't have enough blood. This is part of the reason why science has been trying their hardest to find a way to manufacture blood products artificially, because if they could figure out how to do that, then the reliance on this blood donation system would be a lot less. I made a classic MJ blunder when looking into this. Oh god. I thought to myself, surely I could figure out the current bioengineering landscape for artificial blood in an hour. Listeners, I could not. It is so unbelievably complicated. The plot of Christopher Nolan's movie Tenant was less complicated than the landscape of artificially bioengineered blood products. That's saying a lot. Yeah. The best summary that I can give is that they are trying. They are trying very hard to find out a way to do this, and they have made amazing progress on this and had several breakthroughs in the last 10, 20 years. However, they have not broken the barrier of finding a solution that is more practical than our current system. Or to put it bluntly, they haven't found a solution that is cheaper than our current system. So the current system persists. Speaking of which, what is the current system requiring blood for our blood banks? So, as we alluded to, but to make more clear, our blood supply is almost entirely supplied by donations. You may have seen blood drives, organizations will host them. There are blood donation centers and hospitals to help gather this product. And um, that's pretty much it. Um, the American Red Cross is a widely known blood donation agency. And some stats suggest it supplies one-third of all blood products in the US. They are the most well-known one, but every hospital has a blood collection process. Every hospital has a blood bank. So it's really like a diffuse system of interconnected blood banks and agencies, which is very beautiful in a public health way that we have this diverse system of networks of blood supplies. Quick question here, Cass. Can you sell your own blood? You sure as heck can't. That is correct. In the US and likely in many other countries, I didn't look, but I'm just assuming it is illegal to sell your blood or any part of your blood to another person or private entity. There is one single exception to this. Do you know? Uh, something related to either platelets or plasma, you're allowed to sell that, but you can't sell your blood. Correct. The one single exception to this is some places they just collect your plasma and nothing else, and they may be able to give you some compensation for your time. It is not exactly a payment for your plasma, legally speaking. It is compensation for your time. But even then, we're talking about maybe a few hundred bucks a month if you max out the amount allowed. So in general, not really. You can't really sell your blood or blood products. Well, it's similar to the way we compensate human subjects research. Yeah, exactly. Right? If you have participants that you're gathering information from, you are compensating them for their time, not for the contribution to the study, because then that could be perceived as undue influence. Yes. Speaking of which, I won't get into the ethics space too much, but perhaps we will if our conversation goes there, because this is an important concept I think we need to discuss. We in general have a blood shortage. Why don't we have a system that pays people to donate a safe amount of blood? Well, it's the same reason that you can't sell other parts of your body like kidneys or other organs. You have two of them. There are people who may be in financial stress and having money attached to them doing a thing, like giving blood or donating an organ, may incentivize people to give more blood than is safe or to undergo a massive surgery that they otherwise wouldn't want to do. There's also a concern that with money, people may be dishonest about risk factors, and there may be certain conditions barring them from donating that they would choose to not be honest about. Quick side note, as we just said, you cannot pay for organs. And my dad, when we were going through the donation process, kept making jokes about buying my liver. And I was like, Dad, literally, like, I know you think you're being funny, no, no, no, no. But you are going to get banned. Like, this is not a funny joke. So let's, you know, let's maybe stop making jokes about you buying my liver. So if he wasn't clear that it was a joke, he might actually get in trouble. So yeah, there's definitely ethical concern because I mean you brought up the human subject research, and I think that's like a perfect example. At a certain point, the amount of compensation will affect people's decision-making process, and that is not something we want with blood or kidneys or anything related to our health and safety. This is why the process of donating blood is almost entirely donation-based. And this is something that I think is quite beautiful. Let's put a positive spin on this. Like, humans can come together and be altruistic. There is nothing outside of altruism, I want to say, that incentivize people to give blood. I can't really, unless you love free t-shirts, I guess that's like the one thing. But there's really nothing. The cookies aren't that great. Yeah. It is possible. Like, people do want to help each other out, even if it means getting almost nothing in return. Think of this the next time you're doom scrolling on your phone. Oh my god, everyone around me seems to be super evil. Like, no, like millions of people, not millions, more than a million people donate blood every year, and they get at best a t-shirt, maybe cookies out of it. I will say there is good research on doing things like donating blood or platelets or plasma or even donating an organ makes the person giving the donation happy. Yeah, it does. It improves your mental health and those sorts of things. So the recipients obviously are better because they can get the treatment that they need, but it feels good to do something for someone else even without any expected return. Yeah, it is possible. People are beautiful. We can work together if we try. Altruism is not dead. Now, regarding donating blood, there is another ethical aspect that we should discuss. These blood donation agencies collect your donated blood, which you give for free or for a t-shirt. You are not compensated for this. Are these agencies allowed to profit off of your donations by selling these blood products to hospitals? I'm gonna say there's some nuance. So I think there's a differentiation between covering the cost of doing business versus making a profit. So obviously, people are donating their blood, but all of the people that work for the Red Cross, for example, are being paid to be there. And then there's processing and transfer and all that kind of stuff. So, yes, I would argue they should be able to make money in order to cover the cost of doing business and maybe even to expand, like have the money go back into the organization like a nonprofit. I would argue they probably should not be able to make lots and lots of money. But I do know that hospitals, for example, who are transfusing the blood are charging a gajillion dollars to insurance companies for that. So somebody somewhere is making money, which is probably a little sus. Yeah, put a pin on this. This was years ago, but one of these factoids went viral about how the American Red Cross sells your blood at hundreds of dollars of unit per hospital, which in turn charges the patient thousands of dollars for transfusion. And these are the type of factoids that annoys me the most because it's technically true, but it's not spiritually true. Do you know what I mean? Yeah. Technically, yes, they do sell your blood for a few hundred dollars per unit. And technically, yes, hospital charges patients thousands of dollars per transfusion, but the way that this factoid was posed was like, oh, look at these greedy American Red Cross, right? And so it's a little dishonest. Some people pointed out that this is kind of messed up, which I guess you can certainly see of that way, like you're using people's altruism for profit. And this is not entirely true because the reality is much more nuanced, as you have said. Yeah, as I was mentioning, the process of collecting the blood donation is expensive. Labor, equipment, testing, storage, transportation, coordination, that all adds up to millions of dollars easily. And for example, just the American Red Cross, their annual cost for running their blood collection operation approaches $2 billion billion with a B. So without charging the hospitals for blood, these blood collection agencies simply could not be able to function. And the vast majority of them are nonprofit. So that's something. Yeah. To disparage that factoid that went viral, like yes, it's technically true, but to think of this system as like a profit-mongering system that makes money off of people's altruism is kind of dishonest. Yeah. But I think the difference in that point is how I read that was not the problem that the American Red Cross sells it for hundreds of dollars. It's that the hospital then charges thousands of dollars. Yes. Right. And so, you know, my hour of my time donating blood becomes X thousands of dollars of profit for the hospital, which hopefully is nonprofit, and then is returning that in to cover uncompensated care and providing community services and all that kind of stuff. I would be more concerned with for-profit organizations and hospitals engaging in those tactics. Yeah. For-profit organizations like insurance companies. Yeah. I don't know that we've ever explicitly said this on the podcast. So just so that everybody's on the same page. Not for profit companies, that does not mean they don't make a profit. The difference is what they do with the profit, right? They have to make money, otherwise, they wouldn't be an operator. But the not-for-profit profits go back into the organization versus the for-profit profits going into the hands and pockets of shareholders. Yeah. So that whole factoid made its rounds, and people have pointed out that it's a little dishonest. But I get how there's an uncomfortable part in this. Like the transaction of these blood products that are sold across this country are rather opaque. These blood units are not sold on a per unit basis, like how you and I would buy groceries. Like the hospitals don't go to the Red Cross and say, hey, can we have like a thousand units? It's not how that works. They're sold via contracts. So there's like a pre-existing agreement that hooks up the hospital with the American Red Cross, for example. And there are agreements, there's also reimbursement plans. So it can feel rather opaque to the general public and therefore can feel a little bit uncomfortable. What are these deals that are happening between hospitals, et cetera? However, as you pointed out, it costs money to run this operation. And the real culprit that we should be looking at is why are hospitals charging patients thousands of dollars for blood that people donated for free? And that is insurance. Pretty much boils down to that. Absolutely. Another aspect why blood supply is public health and is all the system that needs to be in place to ensure that diseases are not being transmitted via the blood transfusion process. Absolutely. So even before blood is collected, there's an extensive questionnaire to screen out people, even with the smallest chance of being unsuitable for blood donation. Do you remember the questions they asked you? Yeah, it's um do you use injection drugs if you're male? At the time I was doing a lot of donation, they would ask if you have sex with men. Hello, post-editing MJ here. As of 2023, this policy that previously barred gay and bisexual men from donating blood is no longer in effect. It has finally been repealed. Now everyone will get the same risk-based questionnaire to determine their eligibility. This policy started during the AIDS epidemic around 40 years ago and was criticized pretty much from day one, but it is now finally repealed. They would ask about like other blood-borne pathogens. Do you have HIV, hepatitis, any of those kinds of things? So it's a pretty long list of things that they would ask you for. And then after the blood is collected, it's rigorously screened for infectious diseases and anomalies, and then it's processed to reduce further risk of contamination. The FDA enforces a really stringent set of regulations regarding blood products and it conducts routine inspections of blood facilities. Importantly, blood products expire quickly. So it's not like we have an opportunity to stockpile a whole bunch and keep it around. Red blood cells last just over a month. Platelets last only days. This means as soon as the blood is collected and screened, there needs to be a swift and organized system that gets the blood to the hospitals who need them, or else they would be wasted. And even after it gets to the hospital, there are then layers to ensure the blood is being properly labeled and stored so the patients receive blood products that are compatible with them. Every hospital has staff dedicated to managing the blood products and also managing the supply to ensure there's as little waste as possible. Yeah, I looked a little bit into this. It really is a really delicate balancing act because platelets only last, what, five days? So you don't want to order so much that you end up having to waste a bunch of products that could have gone to another hospital, but you also don't want to order so little that when someone needs platelets, they don't have it. So it's a lot. And that's why all these things are so expensive because it's a lot of labor that goes into making sure that there's an adequate supply. If such blood supply does not exist in that area, there are alternative procedures that medicine has invented to deal with this. This discipline is colloquially called bloodless medicine, which, as you could probably guess, is finding ways to not use blood products in situations that typically calls for blood products. Why do you think this discipline was developed? I would guess it has something to do with the tenuous supply that we have, right? We were just talking about how quickly they have to be used. And I would guess, like many things in our country, the supply is not evenly distributed. And there are maybe places where it's even harder to get blood than not. Yeah. Blood banks charge us hospital money for these blood products. So there are definitely hospitals that may be, uh, shall we say, a little bit strapped. So it's for three reasons why this discipline organically developed. One is because our blood supply is constantly under stress, like you pointed out, and may deplete in theory. This is a problem in the US, but it's a bigger problem globally. There are so-called quote-unquote blood deserts, uh, which are serious public health issues as many hospitals operate on no blood. So there's a lot of times where they could save the person if they have blood products, but they simply don't have access to it. So many people die because of this. This is an issue also in the US in certain areas, but obviously a lot less serious. The second reason is simply medical reasons. Some people have rare conditions where they simply don't have the blood that can be safely transfused to them without their body causing some damage. So super rare blood type, some sort of autoimmune diseases, whatever. These people either have to wait for the super rare, super, super rare universal donor blood, or they may do something called autologous blood. They preemptively take blood from themselves and store them for later use on themselves, because you can always use your own blood. This is typically done in anticipation of a big surgery or for women giving birth. Because if you need to have an emergency C-section, you better have blood. The last reason is there is an increasing number of a small fraction of people who are refusing blood products outright. The obvious example is Jehovah's Witness, but also a rising number of patients who refuse blood for quote personal reasons. It is unclear why this group of people are on the rise. Perhaps it's due to recent anti-science sentiments. But what do you think? Oh, that's tough. I have had major surgery and had to have blood products provided, and I couldn't imagine how it would have impacted my recovery had I refused to receive blood products. So I don't know. Sometimes it's hard to try to understand why people do what they do. I would imagine anti-science, anti-public health, personal autonomy, you know, people going down the rabbit hole on the interwebs and reading things that aren't factually accurate. But just so that everybody knows, there's a lot of screening that goes into this. And in general, there are few risks associated with using blood products. It's so safe. We have many systems in place. This is both a medical endeavor and a public health endeavor. And generally, getting blood products in US is pretty safe. We don't know, but a lot of frontline practicing healthcare providers are noticing like a rise of people who say they either straight up don't want these blood products or are curious about whether they need these blood products. There's also that on the rise. Uh colloquial, of course. Like we won't get a real sense unless someone do one of those big surveys. But hard to find funding nowadays in science. Womp womp. I'm sad again. Sorry to end on that note. Okay, well, let's go to the microgrid section. Microgrid number one, obviously, donate blood if you can. Or platelets or plasma. Or platelets or plasma. I will try to do that. That's my goal for 2026. I will try to donate blood sometime in 2026. If you can't donate blood, you should definitely at least find out your blood type. It's important. If something ever happens to you, it's important that you can tell healthcare providers in an emergency what your blood type is so that you can receive blood. Or if there's some emergency and they are actively needing a particular type of blood and they're calling for donations, you should know your blood type. Also tell your partner or your family member what your blood type is. Very important. For sure. Thank you so much for listening to this episode of Everything is Public Health. New episodes every other week. If you like the show, please tell everyone you know about the show. That helps us immensely. Commenting, subscribing, and leaving us a review helps us a bunch as well. If you have any questions or think we missed an important perspective, you can reach out to us at everythingispublichealth at gmail.com. 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