Blood: It’s complicated

An anxious mother stumbles into the clinic, carrying a fragile bundle wrapped in blankets and a faded kitenge. The baby boy – perhaps younger than one year of age – is breathing heavily and seems frighteningly pale for an African child. The MH triage nurse takes one look at the child and ushers them towards Maranatha’s version of an ICU, although it has none of the machines and gadgets one would find in an ICU in the west. As fast as can happen in a Ugandan setting, with a culture of people who cannot be rushed, the child is examined by a clinical officer, is cannulated, tested for their blood type, and then (with relief) the lab staff report that they have some blood available from the child’s blood group. The clinical staff let out the breath they were unaware of collectively holding, and everyone carries on doing the work that needs to be done.

In peak malaria season, this scenario may happen a few times a day. A common complication of severe malaria – especially in children – is anaemia.

I’m not a clinician. But basically, in this context, where severe malaria is really common, regular access to donated blood is essential. At MH, we sometimes transfuse several units of blood every day. Blood transfusion for these children is powerfully and phenomenally life-saving.

So, blood is important.

It is also frustratingly difficult to get our hands on sometimes.

The other day we had a call from Bundibugyo, a neighbouring district 60kms away. A child that had been taken to a hospital there needed a transfusion, and was extremely sick. Before the parents traveled, they decided to call ahead to the regional referral hospital, which is also in Fort Portal. They did not have blood. They then called another big hospital here, a Catholic hospital, which also had no blood. Then they called Maranatha. Our lab tech quickly checked the fridge and to our great relief, there was 1 unit of blood left, and it was the blood type of the boy. We told them to come. A rare win!

Every few months, MH invites the blood bank in FP to do a blood drive at the MH clinic, and we try to get as many units as possible donated. It’s quite a community day, actually, and fun.

The blood banks across Uganda, including the one in Fort Portal, were funded in part by some significant donors. But the donors have recently pulled out, and most of their funding is now from the Ministry of Health. With two old vehicles, and a small team of staff, they are expected to find enough units of blood to service about 8 districts – probably more than 5 million people. The blood bank is now expected to find this blood – miraculously – with no budget for transport and reduced staffing levels.   There are some pretty substantial challenges beyond the obvious time and resource constraints: there is not a culture or awareness in the general community around blood donation; there is no social pressure or reward for donation; with the majority of people poor farmers, people do not have time or resources to commute to give blood regularly; and with HIV (and other STDs) the highest in this region of Uganda, there is a substantial amount of blood that simply cannot be used, even if collected.

This epic wall of barriers to donation culminates in the variety of stressful situations we often have at MH, where there is just

Not. Enough. Blood.

When we are busy at MH, often our lab tech will find himself down at the blood bank a few times a week, begging for another unit. He will call the staff with the keenness of a 15 year old girl having her first crush, racing to the blood bank the moment there is a rumour of a few already screened life-saving-units ready to go. He knows all of the staff there by name. In emergencies, when there is really nothing left to do, we will send family there to donate and then wait around while the blood is tested and bring it back to MH. Of course, it was much more difficult in Kamwenge days, when collecting blood from the Fort Portal blood bank sometimes felt like an episode of the amazing race. We needed to send an esky with a public taxi from Kamwenge, with the request for blood signed by a certain MH staff. After bargaining on the price of this ‘service’, the taxi driver would take the esky to a supermarket in fort Portal town that had agreed to store a few icepacks for us, and then take it to the blood bank. Someone from the blood bank would pack the units for us (once they were available) and then organise another taxi driver to take the units back to Kamwenge, often tied on the roof of the vehicle. Once it arrived at the taxi park in Kamwenge, we would get a phone-call and go and pick it up, normally in a desperate rush knowing there was a child on the very precipice of life itself.

Basically, in a word association game, if someone mentions blood and Uganda, my immediate thoughts go to frantic phone conversations, empty fridges, the oxymoron of pale-black-children, and our shabby red esky that has been thrown into the work ute ready to collect blood from the bank on about a million occasions. Then comes to mind the afore-mentioned pale-black children’s chubby legs running around the ward a day-or-two later, defying the odds of the malaria gods by being an under-5-Ugandan-patient brimming with life.

The government referral hospital does not have the same record of transfusion as MH though. Their not-so-reliable transfusion record has been the focus of many a Ugandan’s frustration. To offer some context, the public health system in Uganda is broken. Staff often simply aren’t there, equipment is broken, drugs are often not available or shifted to ‘private pharmacy’s’ within the hospital, bribes are the norm, rooms are extremely overcrowded, health staff have low morale and some simply don’t care….

In this scenario, one can imagine there is much that could go wrong when a patient is in need of a blood transfusion. The stories that I have heard when quizzing friends and our own staff about their experiences when in need of blood are numerous and horrific: clinic staff demanding payment for blood, blood expiring in the fridge while people wait in the wards in need, patients being sent to private pharmacies in town to purchase the basic equipment lacking to give blood, unqualified staff overseeing the process or staff unavailable so the blood is never transfused…

All of these issues are of course irrelevant when there is almost no blood available, and so much demand, as has been the case in the past few months.

A few weeks ago, one of the Ugandan newspapers published a story reporting that recently at the Fort Portal referral hospital, 8 people died in ONE DAY due to a lack of blood. This, understandably, created a political storm of sorts, so much so that the Ministry of Health sent some high-ranking officials in expensive suits with shiny cars to Fort Portal to find out what indeed happened. Trying to understand what the problem is, so that it can be fixed.

But there are no easy solutions.

I wish there was.

The solution is for people to be free of poverty

The solution is for the government health system not to be broken.

The solution is for the Ministry of Health to take seriously their mandate to provide basic services to the population, and to be held accountable to this by an educated, politically engaged population.

The solution is for malaria to not be endemic in this population and take tens of thousands of children’s lives every year

The solution is for people to come to the health service earlier before they become anaemic, confident in the knowledge they will be looked after well.

The solution is for the culture of blood donation in the community to be changed

The solution is for more funding and greater resources and better systems and services

It’s one of the most all-consuming realities that I have experienced and have been forced to eventually embrace (kicking and screaming) while working in the developing world.

The frustration of discovering that poverty and disadvantage is complicated. And systemic. And cultural. And contextual. And economic. And political. And relational.

It’s just plain hard.

Blood is a beautifully tragic example of this.

If anyone tells me about an ‘easy’ or ‘simple’ solution to poverty and disadvantage these days, in any context, I smile. I listen. Then I politely disagree.

One response to “Blood: It’s complicated

  1. on the other side of the coin, we in Australia over-transfuse!

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