Twenty-year-old Putul, living in a village 70 km from a district headquarters town in Chhattisgarh, had been in labour for two days and a night. It was her first pregnancy. In order to hasten labour, the local quack administered several injections that increased her uterine contractions. Forty hours after the onset of labour, she was brought to a non-profit hospital around 9 p.m. in a jeep hired for a neat sum. She made it there after a 150-minute tedious journey accompanied by her mother and brother.
The young lady was deathly pale and in obvious shock from the loss of blood due to a ruptured uterus. Immediate resuscitation with intravenous fluids was started, while waiting for her blood grouping report. Unfortunately, a match for her group was unavailable at the hospital’s blood storage centre and her brother is asked to go to the blood bank in the district headquarters town to get three units.
What is an hour away during day takes more than three hours at that late hour. In the town, the blood bank staff insists on a replacement donation. Even though her brother offers his own blood, it is rejected as he is anaemic. A helpful bystander (read tout) directs him to a private blood bank where he gets one unit for Rs. 2,400, but without any replacement donation. He rushes back to the hospital, where his sister has already been operated upon to remove her uterus and the dead baby. She continues to remain severely pale and in shock. A single unit of blood is not enough to save her and she dies in the early hours of the next morning. Her mother is inconsolable, while her brother is completely drained of all emotions as he squats with his head on his knees. The doctors and the nursing staff are equally heartbroken and angry.
Why did this happen? Obviously, the socio-economic, gender, caste and class causes are apparent and have been there for several centuries, though more pronounced in the last two decades. What is glaring and ironical in this age of revolutionary cures and high-tech medicine is that the young lady died for want of blood at the right time — a “drug” that has been in use to save human lives for well over a century.
Impact of amendment
There were enough donors at the hospital even among the staff who could have been of help to Putul in this life-threatening situation. Their blood needed to be matched, tested for infections — as would be done in any blood bank — and then given to her immediately, without the need for banking, a procedure known as Unbanked Directed Blood Transfusion (UDBT).
Doctors in rural areas, where 69 per cent of India lives, have long used UDBT in life-saving major surgeries, treatment of complicated childbirths and other critical illnesses. This method of blood transfusion was perfectly legal till 1998. In response to concerns about HIV transmission due to unscrupulous practices by some commercial blood banks, an amendment was made to The Drugs and Cosmetics Rules, 1945 (“Rules”) that mandated that even collection of blood could be done only by a licensed bank. Thus, UDBT became illegal and in a stroke, blood availability in emergencies in rural areas became almost impossible.
While it is difficult to estimate the actual requirement of blood, government statistics that show a huge deficit for the country at 31 per cent (116 lakh units required annually against 80 lakh units available) are still a gross underestimate (Indiastats 2012). For Chhattisgarh, this deficit is an appalling 81 per cent.
There is a yawning gap between laws to establish blood banks and what is practically feasible and safe for rural areas. Setting up a standard bank requires eight rooms — five must have an air-conditioned environment with round-the-clock power supply — specially designed refrigerators and other expensive, sophisticated equipment to be run by a medical officer and full-time technical staff. Though this is possible in urban areas, rural areas and towns are faced with several problems, besides huge infrastructural costs such as a) non-availability of blood in an emergency b) non-availability of blood banks in rural areas c) excess time taken to obtain blood from banks, d) cost to the recipient for blood at between Rs.600 and 1,200 per unit, e) poor availability of transportation, long distance and huge costs in carrying blood from remote banks, and f) need for insulated containers to avoid wastage of blood carried from banks.
In 2001, realising that the new rules were clearly inadequate, the government came up with a partial solution, offering a possibility of storage centres in such places where emergency childbirth care is undertaken, whose needs would ideally be nourished by authorised blood banks but which could store blood and use it in emergencies. They were not allowed to draw blood from potential donors. Twelve years later, only a handful of storage centres are approved in any State. Even these function far below the desired level. “Parent” banks often cite a shortage of blood in their own stocks as a reason for refusal to issue blood to these centres, and insist on replacement donations each time.
Consequently, people like Putul continue to die for want of blood. Many more people would have died had several good doctors in rural hospitals, both government and non-government not been practising UDBT illegally but ethically till now. In mid-2013, even this possibility disappeared since the National AIDS Control Organisation (NACO) has smothered the sale of blood bags in the open market, making it impossible to draw blood from any potential voluntary donor outside authorised banks. A doctor was arrested for practising UDBT and another hospital had its blood bags seized. The deaths will increase now.
What is the way out? There is no way other than legalising UDBT for use in emergency situations after proper testing in certified institutions for physicians who have had some initial training. Ways to prevent unscrupulous elements misusing this are eminently possible.
Second, replacement of blood by a relative of the patient should not be made mandatory to get blood issued from a bank or storage centre, especially in a life-threatening emergency. Even NACO guidelines insist that one should aim for only voluntary, non-remunerated safe blood donors and gradually phase out replacement donors.
As of now, licensed banks have no responsibility for maintaining a minimum stock of units of each group and to ensure adequate replenishment of stocks. There should be a minimum number of camps, and a minimum number of blood units should be ensured. Keeping a good stock and having regular camps will ensure that blood is available.
There is need to ease infrastructure norms for establishing new banks in smaller towns, especially in the public sector. We need to have several more storage units. All community health centres must have these. Finally, there is a great need to license several institutions in remote areas for UDBT after proper training of staff.
Being an essential drug, blood must be brought under the price control order with a reasonable fixed price, but which could be waived in emergency situations.
Until we take these steps, many more Putuls will die in our villages. The government must immediately address this concern.
(Raman Kataria and Yogesh Jain are doctors working at Jan Swasthya Sahyog in rural Bilaspur, Chhattisgarh.)