The Malaysian blood bank’s policy is endangering lives
Today was going to be another one of those days when I asked myself, “what do I blog?” However, that changed after a flurry of emails arrived in my inbox this morning.
About ten years ago, I chanced upon a blood donation drive and decided I had a moral and social obligation to donate to the blood bank. Unfortunately, I never fully acted out on my decision. As I approached the registration counter, I was confronted with a large signage explicitly stating that the Malaysian blood bank (for which you could also read, Malaysian Health Ministry/Government) did not welcome donations from prostitues, drug users, or homosexuals. I was naturally aghast at the policy and vowed then never to donate blood as long as such misguided and morally reprehensible discriminatory policies are in place.
[Note: the Malaysian blood bank also does not accept donations from a few other groups of individuals, however, this is guided by health considerations, e.g. pregnant women.]
Today, I discovered that ten years hence, this misguided policy is still in force.
While I agree that certain segments of society are at more risk at contracting (fatal) diseases and illnesses which can be transmitted via blood, it is an inefficient, misleading, and morally reprehensible, manner of screening quality of blood by excluding donations from these segments of society.
If the fundamental issue is risk, the blood bank should view all donations with equal scepticism. In this day and age, everyone is suspect - though admittedly, some more than others. However, given that in the matter of life and death, risk, however, small must be taken seriously, the blood bank has a moral (and in some countries, even legal) obligation to screen all blood thoroughly - this includes those individuals who are perceived to be at less risk of transmitting diseases and illnesses.
Thus, if the issue is fundamentally about risk, there should be no need for the Malaysian blood bank to exclude segments of society provided they undertake proper and thorough screening of all donations, regardless the source of the blood.
One has to bear in mind that in a state of scarcity and of life and death, we cannot afford such luxury as rejecting certain sources of blood even when it’s “clean”. By not accepting the donation in the first place, and not allowing the opportunity for the blood to be properly screened in order to validate its scientific acceptability for donation, the Malaysian blood bank is making a moral and discriminatory judgement, however inadvertent (if that be the case).
I therefore reassert that the use of social groupings as a proxy for screening blood is inefficient, misleading, and morally reprehensible. Furthermore, this policy can have two very real, and very unacceptable, consequences.
First, it may lull lab technicians from conducting thorough screening under the false assumption that since donors are not from these high-risk social groups, the chances of blood being tainted is lower - this is far from true for many reasons, but that is the subject of another debate. [I'd hate to think of the consequences if the Malaysian blood bank is adopting this proxy-method of screening in order to avoid a thorough scientific screening...]
Secondly, in a situation of general scarcity, by not accepting blood from these social groups, the blood bank is effectively depriving people who need blood from a life-giving resource. In the event of a run on the bank and of a near-death situation, the blood bank can be morally (and in some countries, legally) faulted for not having done all possible, and that includes taking “clean” blood from a socially-tainted individual, to ensure that sufficient blood supply is available to save lives.
I am saddened that an organisation that should be driven by scientific knowledge and truth should continue to adopt such a method of risk management when better techniques are (now) available - that again, is assuming that risk management was the sole reason for the adoption of such a method in the first place. I have raised enough arguments to fear that this is not entirely the case.
However, that brings me to the following. If moral judgement underlies the discriminatory practice, a national, governmental organisation such as a blood bank should not be making these moral decisions on our behalf. These personal moral decisions should be left to the individuals themselves.
Yes, some people might object to having the blood of a homosexual injected into his/her body, but others, who might be lying on their death beds, might have other priorities and moral judgements to make - life or death? When you push the argument further, homosexuality, prostitution and drug-use are not the only possible moral judgements an individual can make. What about vegetarians who might have a moral stand against taking blood that has been tainted by the carnivorous habits of its donor? What if I, a non-smoker, object to being infused by blood carrying carcinogenic deposits from cigarettes? What of women versus polygamist donors? I could go on.
If the blood bank was indeed concerned about the moral values of its recipients, then they should ask all donors to submit a full declaration - are you a smoker? homosexual? prostitute? alchoholic? carnivore? polygamist? misogynist? etc. - and provide this information to the recipient who, I again state, should be the rightful person making such moral decisions and not the blood bank. [Whether the recipient would, at the point of needing blood, be mentally capable of making such decisions, is fodder for another discussion.]
In short, the Malaysian blood bank has a policy of official “exclusion” and “discrimination”. And it is endangering lives in the process.
Posted on July 8th, 2003 by jl
Filed under: My Malaysia, Other Notable Stuff
Jikon…sigh…we live in a country whose paranoia borders on the absurd…i did not know of this form of proxy screening and its ethically and morally wrong..wut message are we sending to our children?
Its blatant discrimination and its indeed a very prevalent force in Malaysia.
Humans fear what we do not understand. And unfortunately, we don’t try to understand, either. I bet noone even remembers who thought of it or why the rule was made in the first place.
BTW, love your blog. Keep on writing!
The policy is solid and based upon epidemiological data. If this was implemented earlier in Japan, USA and France at the initial outbreak of the disease, there wont be so much transmission in those countries due to blood transfusion.
Read up about “window period” then you’ll understand why the high risk segment of the population must be excluded from donating blood. That policy only came into force in 1995 and the rate of donated blood found to be positive for the HIV antibodies, dropped drastically. I’ll post the link to that illustration once I have acces to my notebook.
Read up first before writing up about such topics, else you’ll display your own ignorance.
I’ll be interested to read the medical underpinnings of the policy and I would stand partially corrected. However, I would still argue that the Malaysian blood bank’s policy is discriminatory. It should exclude donors on the basis of practice and behaviour, and not social groups.
For instance, screen out only homosexuals who practice anal sex - that is what is mainly at issue where exposure to risk is concerned. However, screening through high-risk behaviour would also lead the blood bank to excluding individuals who have recently (up to 12 months ago?) had ear-piercing, body piercing, tattoos or any other such practices that would have exposed them to greater risk of being at least carriers of transmittable diseases. In fact, individuals who have been “treated” with acupuncture, and there would be many in Malaysia, should also be excluded. This would all be consistent with the “window period” argument.
Risk management is important, I agree. But where an agency such as the blood bank is concerned, such policies should be guided by scientific medical findings and not shoot-in-the-dark proxies. I might agree that donors might need to be screened through practices and behaviour - and perhaps that would be an efficient way of managing risk. However, to discriminate potential donors only through social segmentation is discriminatory, and as I have argued, morally reprehensible.
It is not just homosexuals who practice anal sex - straight people do it too. It is not just prostitutes who have multiple sexuals partners - many other individuals have active sexual lives too. It is not just drug users who inject themselves with substances through potentially “dirty” syringes - so do atheletes these days and many others for medical reasons.
Blanket exclusion of potential donors on the basis of social groupings is just not on. While the rationale might hold water in an earlier period, it seems in some ways rather myopic to continue with it when better tests are now available to filter out tainted blood.
?better test?????
The public may be fooled with such statements by companies intending to make a fast buck. We look at the sensitivity and specifity of the test available before making any decision.
Highly sensitive test are used to screen for diseases while highly specific tests are used to confirm it.
We also have to be pragmatic.If we are to use highly complicated test at high cost which takes a long time to conduct for screening blood from donors, by the time the test results come back the blood has already passed its expiry date, therefore can’t be used for transfusion.
BTW do pick up one of the questionnaire that a blood donor has to fill up from your nearest blood bank. You’ll realise they do not discrimate. All high risk donors are excluded, not only IVDUs, homosexuals. Even those on certain types of medications, HIV+, HBV+, HCV+, highly promiscous people etc.
HIV+ is a fate worse than death. Therefore the attempt by Blood Bank to ensure the safety of its blood supply should be applauded, not contested by ignorant and deluded individuals.
I’ve been publicly admonished! *slap* *slap*
AIDS? - I’ve gotten more out of you than anyone else I’ve come into contact with on this issue. I’m much obliged.
That said, I’ll still retain the minimal argument that the way the policy is presented needs rectification if it is not to attract public criticisms of discrimination. In no public literature, prior to actually filling in the form (the latest of which I have yet to see), have I seen any argument other than “homosexuals, prostitutes and drug-users need not apply here”. As it is presented, it can only result in the view of a systemic discriminatory practice which does not help socially misinformed views of who and what represents risk in our society.
As promised in my previous comment;
The link to the graphic is at http://161.142.92.103/aids/bloodscreening.gif
It clearly illustrates that once high risk individuals are persuaded not to donate blood, starting from year 1993 (my mistake, not 1995), the proportion of donated blood positive for HIV antibodies dropped drastically.
The original chart came from http://dph.gov.my/Division/dcd/AidsStd/aid1.htm#BLOOD but it is no longer available there.
Interesting…
Let’s move this discussion forward - would you be able to clarify/answer the following:
(1) Why did the number of test positives shoot up so much from 1990 to 1991/2?
(2) Why did the numbers after 1993 not fall back to the levels of 1990 (or before)?
I assume the low (zero?) figure in 1986 was because the recognition of HIV was still in its initial stages?? If I remember correctly, it was around this period that HIV/AIDS caught the public imagination.
The graph is for the proportion of DONATED BLOOD positive for HIV antibodies.
The mandatory screening for donated blood were implemented in 3 phases. By May 1987, 24 screening centres has been established throughout the country. That is why few cases were detected before that.
For question 2, the proportion is reflective of the prevalence of HIV among the non high risk population at that point in time, which was about 18/100,000. Which comes to less than 0.02%. The current prevalence rate may be much higher.
As for question 1, it is difficult to answer without hurting the feelings of some people. It may have been due to the explosive rise of HIV infection within our own population. At the same time, I personally (this is based on personal experience, therefore cannot be stated as official statement of any organisation) noted that “some” high risk individual has been using the blood bank as a “free” and “confidential” HIV testing centre. At that point in time, it was difficult to get your blood tested for HIV. The private labs were charging quite a high price for it, therefore it is not surprising “some” of these high risk individuals were resorting to this.
After that, MOH came out with a circular making it easier for members of the public to have their blood tested for HIV at any govt clinics. This may have changed the trend to some extent.
Therefore when the policy on blood donors were implemented more thoroughly in 1993, the proportion of HIV+ donors were much less, although the trend in the general population were increasing at a much higher rate. This you can see in the following slide;
http://161.142.92.103/aids/rate.gif
Referring to the second pic - on first view, it’s very worrying that Malaysia appears to have a higher prevalence of HIV cases among its neighbours. But then on reflection, and after a much needed night’s sleep, I have the following questions before I am able to form a more reasoned opinion:
(1) I gather figures in the graph are absolute figures. What is the proportion of reported cases against the size of the general population
(2) How many of the countries in the graph have an official policy (is it a legal requirement or just administrative?) where all individuals tested positive for HIV have to be reported to the MOH (or its local equivalent)?
(3) Are the results for Cambodia and Vietnam sufficiently reflective of the real situation - how good are the reporting/statistical systems and structure there compared to the other countries?
You do ask some hard questions. I’ll do my best to answer them. All those questions are best illustrated by these two following tables;
1) For question one, this illustrates the rates between these countries quite well;
http://161.142.92.108/images/rateofhiv.gif
You can make your own judgement on how bad the situation is in our own country.
2) Q2 & Q3 is best answered by the following table;
http://161.142.92.108/images/detectionrate.gif
There are a lot more discussion on the quality of data available but I think the above will suffice. Just imagine if the 1st table is based on only the 2nd table detection rate. Therefore the real problem is much more immense.
Corrections;
The URLS are;
http://161.142.92.108/image/rateofhiv.gif
http://161.142.92.108/image/detectionrate.gif
Couldn’t check it out initially. The firewall is pretty weird over here.
Difficult questions? - Teach you to engage with me!! *grin*
Looking at the first chart [in (1) of your reply] - my next question is what and/or where is/are the source(s) and basis of these estimates?
I assume the estimates from the first chart forms the basis for the information in the second chart… So let’s assume for the moment that the estimates in the first chart are good and sufficiently reliable, then looking at the second chart, I become very cynical again…
If in the best of countries, we can only safely say that the detection rate for HIV is only more than 50%, as opposed to stating a higher confidence of say, more than 90%, then, we all live in very deplorable circumstances where the fight against HIV is concerend.
I gather when the charts refer to detection rates, we are referring to detection from all sources and not just blood donors, right? If that be the case, and if we are in effect saying that about a third of HIV-infected individuals walk around undetected, then I’m very concerned at the state of affairs in Malaysia, particularly when you compound that with the fact that sex is (still largely) a taboo subject in our society and that a large proportion of the population in Malaysia is still largely uneducated about (general) sexual practices (whether it’s HIV or syphillis etc.).
I could go on.
Which brings me back to my original contention. The blood bank could do more in dispelling misleading notions of who are at risk of such infectious diseases by rephrasing (if not discontinuing) its policy of who should not be donating blood. In public, they should use language that excludes on the basis of sexual practices and not social groupings. By using language of the latter nature, they are merely reinforcing social MIS-perceptions of who may or may not be at risk of such infectious diseases. More importantly, they continue to help stigmatise certain social groups - this contributes to the reluctance among these individuals from going for blood tests, thus the low detection rates, among other consequences.
In the 2001 Durex Global Sex Survey, only 23% of Malaysian’s were concerned about AIDS (see http://www.durex.com/template/global_sex2001_conc.htm). I don’t see this as being very encouraging. Everyone needs to do more to change such apathy against this very destructive disease. Dispelling social myths is a very important part of that effort.
1) Official reports from each country to WHO WPR (Western Pacific Region)
2) The detection rates is based on consensus report from each country. Malaysia is already preparing its 3rd consensus report.
A lot of people are walking around, not realising that they are infected with HIV virus. That is why individuals practising high risk behaviour are discouraged from donating blood. It is difficult to put a label to encompass such a diverse group, therefore each donor is requested to fill up a questionnaire which will enable the staff to exclude these high risk individuals. Medical staff treating the public and patients are asked to practise universal precautions at all times, to protect both the public and themselves.
Such HIV infected individuals may infect their spouse and sexual partners. That is why, if they care about their love ones, they should avoid high risk behaviours and get themselves tested for HIV. Voluntary testing is the way to right now. Although my wife and I were not of the high risk groups, we both underwent voluntary testing for HIV. Of course it turns out negative for both of us. We both avoid high risk behaviours before and after being married to each other.
Other more adventurous individuals more find it hard to follow such examples, therefore “protect yourself”. And if you do practise unsafe practises, don’t donate blood. This is the very least and the very best that you can do.
Hear, hear!