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Saving lives ... at what cost?

Should doctors in rural areas ignore a law that affects blood transfusion and risk punishment, asks Dr. KAVERY NAMBISAN.

AFP

In the urban areas, the demand for blood can be safely met by authorised blood banks.

FEW medical practitioners address issues that affect society as a whole. Most of my colleagues believe it's not their business. "We are busy doing our jobs. Where do we have the time to think of causes? We will carry on with our work, which is to treat the sick and save lives."

Save lives? Doctors face the threat of being punished for doing that.

The issue of blood banks

Many rural hospitals do excellent surgical and medical work among the poor and middle class, quietly and without fuss. Life-saving major surgeries, treatment of complicated childbirths and other critical interventions are routine. In many such cases, fresh blood transfusion helps to save lives. This recourse may soon be denied to the rural doctors. The law (an amendment of the Drugs and Cosmetics Act) has ordered that smaller peripheral hospitals should cease transfusing blood until they have authorised blood banks.

And what is an authorised blood bank? It is an area of 1,000 square feet with seven rooms of which four should be air-conditioned, with round-the-clock power supply, specially designed refrigerators and other sophisticated equipment (costing Rs. 5 to Rs. 6 lakhs) and managed by a medical officer and full-time, competent technical staff.

Like many laws drafted from urban armchairs, this law will ruin the people in villages and small towns. In most peripheral hospitals, establishing such a blood bank would be the same as purchasing a Mercedes to drive on roads where only a bicycle can go. And this Mercedes must first get its stamp of approval from authorities who are known to delay it endlessly, until they are "properly satisfied".

Rural surgeons around the country are being forced to shut down their blood transfusion centres, which means they must turn away critically ill patients or ask them to purchase blood at great expense and inconvenience from an authorised blood bank far away. Thousands of doctors are faced with this choice: Should they follow the rules and disregard the lives of patients who come to them for treatment? Or should they ignore a blatantly unjust law, help patients in distress and risk punishment?

The importance of transfusion

Every schoolchild knows that blood is essential to life. This red liquid flows through the body, carrying life-giving nutrients and oxygen to every cell. Sudden and rapid loss of blood can lead to death if it is not replaced quickly, as was inevitable until less than 100 years ago. Blood transfusion has been practised since the Second World War, when doctors found that blood can safely be transferred from one person to another, if done with proper precautions and testing. Since then, transfusions save lives every second, all over the world.

Now, illegal

Picture courtesy: KAVERY NAMBISAN

A dilemma that thousands of doctors in the rural areas have to face.

Surgeons in rural areas — where three-quarters of our population live — have long used fresh blood to save lives. This method is called Unbanked Directed (to a specific patient only) Blood Transfusion or UDBT. Until 1999, this was entirely legal and the blood transfusion equipment was freely available to any doctor or hospital who needed it. On April 4, 1999, through an amendment to the Drugs and Cosmetics Act, UDBT was made illegal.

Many eminent doctors and medical associations have since been attempting to present — by representations and petitions — the true picture of rural health care. The major thrust of this campaign has been taking place in Maharashtra, headed by Dr. Ravindranath Tongaonkar, an eminent surgeon based in Dhule district. Scientific papers have been presented in national and international conferences. Health ministries in many States have been briefed. The parameters of safety were submitted to the National AIDS Control Committee. The Union Law Minister was shown a video on the practice of safe blood transfusion in smaller hospitals, and requested to help legalise UDBT.

The official `solution'

This resulted in the Union Government proposing "Blood Storage Centres" in smaller hospitals, where they can store blood "procured" from a blood bank. This is the Mercedes car again, although a slightly cheaper version. The storage of blood requires those specially designed refrigerators, trained staff and air-conditioners, on a smaller scale. There are other difficulties: The blood must be obtained from a blood bank, transported safely and stored. The optimum shelf life of stored blood is 21 days. In rural India where the power supply is notoriously unpredictable, it is unlikely to last longer than a day or two. The hospital I work in has a generator, but diesel is like gold. Who pays the cost of wasted blood, the air-conditioned rooms and the specially designed refrigerators?

In every rural hospital I have worked in — in Uttar Pradesh, Bihar, Tamil Nadu, Kerala and Karnataka — reaching an authorised blood bank involved several hours of difficult travel. Even if a blood bank can be reached in time, how is blood to be brought back while maintaining a constant temperature? If it is needed for an urgent Caesarean, a ruptured early pregnancy, a bleeding ulcer, or a road accident victim, the delay could cost a life.

Last month, we admitted a woman with serious bleeding in early pregnancy and no relatives who would give blood. We sent an urgent request to the blood bank in Mysore, which is the nearest city. They could not help since they did not have enough to meet local demand. In another, similar instance, our anaesthetist donated blood for a severely anaemic man and then we carried on with the surgery. We had one instance of a middle-aged man given a blood transfusion in a city hospital die of AIDS three weeks later. On checking, we found that the donor blood had not been screened for HIV, as required by the law.

Besides, stored blood is more expensive. If you add transportation costs, it means anything from Rs. 1,500 to Rs. 2,500. Safe, fresh blood transfusion costs Rs. 350 to Rs. 600 in rural areas across the country. In cities, the scene is very different. Multi-speciality hospitals offer surgical and medical procedures which often require large quantities of blood.

There is also an ever-increasing number of high-speed road accidents. The demand for blood can be safely met by authorised blood banks which fulfil all the parameters of staffing and equipment. There are problems, though. Travelling in any city is not easy or quick. A surgeon about to embark on a major surgery is likely to ask that one or more bottles of blood be kept ready. The blood thus bought may or may not be used, depending on the course of the surgery. If it is not used, it may ultimately join the effluents which leave the hospital. For the relatives who got it at considerable expense, it is money down the drain.

No storage, no waste

In rural areas where we use fresh blood, we have a suitable donor ready at the time of surgery. In at least half such cases, after the surgery we can tell the donor that we managed without need of transfusion. No storage, no waste. And given the nutrition standards in rural India, a pint of blood may mean a day's work.

Dr. Tongaonkar told me that blood transfusion laws are not equal. According to an exemption in the Act, UDBT (as we practise in rural areas) is permissible and legal if done by Armed Forces Medical Personnel in border areas and smaller hospitals. So. It is ethical to save the life of a jawan or an Army officer, but not that of a police officer or a child with gunshot wounds in Bihar, a farm worker whose arm was pulped in a threshing machine or a tribal woman who had a ruptured pregnancy.

The amendment in question is flawed because the authorities concerned are ignorant of the rural scene. It is possible to have quality without sophistication. The only sophistication required in medical treatment is that of concern.

The Association of Rural Surgeons of India has submitted a petition to the Human Rights Commission complaining of the injustice of the law. It has requested the Commission to study the problems of blood transfusion in villages and make it legal for doctors to practise the giving of blood in a safe manner. There should be no compromise on safety.

The doctors' oath to try and save every life will become an empty promise, if mindless interference in their work takes away the opportunity. Rural practitioners are a hardy lot, working under difficult conditions: The majority of them continue to use fresh blood transfusions and believe that the law will find a practical and humane answer. Till then they continue to save lives, risking punishment and their liberty in the process.

Parameters for safe transfusion