The History of Transfusion AIDS:
Practice and Policy Alternatives
Harvey M. Sapolsky
Stephen L. Boswell
The relatively small threat of contracting AIDS through blood transfusions in the United States has led to significant improvements in the overall quality of American blood services, nearly all of which could have been achieved without the existence of this new health menace. Nonautologous exposures to blood are always hazardous. Transfusions save lives, but they can also transmit life-threatening diseases. Transfusion recipients are not alone in being endangered. Health care personnel are placed at risk through accidental blood spills and needlesticks. However, as blood-banking service expanded in the 1960s and 1970s, the handling and use of blood became incautious. Convenience rather than safety often guided behavior. But fear of AIDS is now so great that attention has focused on efforts to reduce risk, forcing long-needed changes in medical practice.
The number of transfusions, previously increasing in the United States, has leveled off in recent years as greater care is being taken in prescribing blood. New tests for rare as well as common hazards are being applied to blood. Autologous donations, the safest kind, are up sharply. Research on blood substitutes has expanded. The handling of blood is more carefully audited. Appropriately, health care personnel worry about their exposures to blood. Witness the increased use of gloves and masks whenever contact with blood is possible.[1]
The precautions needed to limit exposures go beyond gloves and masks and are described in Centers for Disease Control, "Recommendations for Prevention of HIV Transmission in Health-Care Settings," Morbidity and Mortality Weekly Report 36, Suppl. 2S (August 21, 1987).
These and other precautions have reduced the risk of disease transmission, including the transmission of AIDS, but they have not eliminated it. The tests are not perfect; medical mistakes and accidents still
An earlier version of this essay, with the title "AIDS, Blood Banking and the Bonds of Community" by Harvey M. Sapolsky, appeared in Daedalus 118 (Spring 1989) and in Stephen R. Graubard, Living with AIDS (Cambridge: MIT Press, 1990), 297–308, and is reprinted with permission.
happen. The risk of contracting AIDS through transfusion may grow if the disease spreads, as some still predict, from the current high-risk groups to the general population, further contaminating the pool of available blood donors.
Irrespective of the actual risk, the search for increased safety caused by the fear of AIDS alone may be sufficient to alter drastically the structure of blood banking. In the United States, and nearly everywhere else, the provision of blood for transfusions is largely a community responsibility. Voluntary donors give blood for those in need without personal knowledge of the recipient and without direct monetary reward. But several of the remaining ways in which the safety of transfusions can be enhanced would require the breaking of these bonds of community, improving chances for some recipients while perhaps harming those for others. Individual gain at the potential expense of the community is not uncommon in society. In this instance, however, the gains and losses are measured in lives.
Aids In The Blood Supply: Differing Perceptions Of Risk
The first case of immune deficiency linked to blood products was reported in a Florida hemophiliac in January 1982.[2]
Randy Shilts, And the Band Played On: Politics, People, and the AIDS Epidemic (New York: St. Martin's Press, 1987).
Although the man's death precluded the elimination of other possible causes of his immune deficiency, and made his exclusion from known risk groups problematic, it nonetheless generated great concern, especially among the epidemiologists at the Centers for Disease Control (CDC). By July two more cases had been documented: the first in a Denver hemophiliac; the second in a hemophiliac living in Ohio.[3]Ibid.
That same month the Morbidity and Mortality Weekly Report , a weekly publication of the CDC, reported the case histories of these three hemophiliacs.[4]Morbidity and Mortality Weekly Report 31 (December 10, 1982): 644-46.
What until that time had been viewed as a problem of sexually active gay and bisexual men, intravenous drug users, and Haitians had suddenly also become an important problem for those who received blood products.It was not long thereafter that the first transfusion-related AIDS case was reported in an infant. The infant was transfused at the University of California at San Francisco for Rh incompatibility at two weeks of age and had died of profound immune suppression at twenty months. One of the units of blood that the child received was from a donor who at the time of his donation was well but who died of AIDS eighteen months later. A second transfusion case was discovered three days after
the announcement of the first.[5]
Shilts, And the Band Played On.
The donor, a man with a history of intravenous drug use, had given blood during a blood drive conducted by the New York Blood Center.What was becoming clear by the end of 1982 was that AIDS was caused by a transmissible agent that behaved very similarly to hepatitis B. It could be sexually transmitted, and it was endemic in many of the same groups as was the hepatitis virus, especially gay men and intravenous drug users. As with hepatitis B, the agent appeared to have a carrier state in which individuals were unaware of their infection or the potential danger their donation represented to others. Individuals so infected appeared well, and thus were able to donate blood and plasma without remonstration. In fact, because bacteria and protozoa can be easily separated from blood products during their preparation, it seemed increasingly likely that the cause of AIDS was a virus, the only organism small enough to pass through the filters used in preparing many blood products, as hepatitis viruses had already clearly demonstrated.
Weighing this evidence, the CDC epidemiologists began warning representatives of the several blood-banking organizations that the blood supply was possibly being contaminated with AIDS. These discussions culminated in a meeting in Atlanta in early January 1983, at which proposals were presented to screen out from the blood donor pool members of high-risk groups. Since the AIDS antibody test was then not available, members of high-risk groups would have to self-identify through questionnaires and/or interviews.[6]
William A. Clark, "Preventing AIDS Transmission: Should Blood Donors Be Screened?" Journal of the American Medical Association 249, no. 5 (February 4, 1983): 567-70; Andrea Rock, "Inside the Billion-Dollar Business of Blood," Money, March 1986, pp. 140-51; Shilts, And the Band Played On; Ross D. Eckert, "AIDS and the Blood Bankers," Regulation, September-October 1986, pp. 15-24, 54.
Blood banking in the United States is divided into two distinct sectors, and so too was the response to the screening proposals. The plasma sector, which is controlled by a handful of large pharmaceutical firms and which pays its blood donors, indicated its intention to adopt screening protocols that included direct questioning of potential donors about sexual preferences, AIDS symptoms, and contact with individuals diagnosed with AIDS.[7]
Clark, "Preventing AIDS Transmission," p. 569; "ABRA Releases Recommendation on AIDS and Plasma Donors," CCBC Newsletter, February 4, 1983, p. 1.
In fact, Alpha Therapeutics Corporation, a major plasma collector, had already stopped procuring plasma in Los Angeles, New York, and San Francisco—major epicenters of the AIDS epidemic—in late 1982; and two weeks before the meeting, it had begun interrogating donors at all other collection sites about their membership in high-risk groups.[8]Alpha Therapeutics Corporation, "Press Information: Alpha Therapeutics Acts to Protect Hemophiliacs from AIDS Epidemic," January 12, 1983; D. J. Gury, "AIDS and the Paid Donor," Lancet 2 (1983): 575.
One of the main uses of plasma is for the production of fractions, which are vital in the treatment of hemophilia. The American Hemophilia Association, which was also represented at the meeting, had already declared its desire that protective measures be implemented immediately. Well that it did, because hemophiliacs weresoon devastated by the AIDS virus. Clotting factors for hemophiliacs are made from pooled plasma lots composed of as many as 5,000 donations and can be contaminated by a single AIDS virus carrier. Nearly half of the 15,000 hemophiliacs in the United States are now infected. Among those with the most severe form of hemophilia, who necessarily have the greatest exposure to the clotting factor, the infection rate is estimated to be 70 to 90 percent.[9]
Gina Kolata, "Hemophilia and AIDS: Silent Suffering," New York Times, May 16, 1988, p. 1.
The effects of the contamination are worldwide, because the United States has been the major international supplier of plasma products.[10]The international plasma business is discussed in Piet J. Hagen, ed., Blood: Gift or Merchandise (New York: Alan R. Liss, 1982).
With the recognition that AIDS is caused by a virus, it has been possible to protect the hemophiliac population from further risk by the use of a heat treatment to kill the virus in the processing of plasma fractions.[11]Centers for Disease Control, "Safety of Therapeutic Products Used for Hemophilia Patients," Morbidity and Mortality Weekly Report 37 (July 29, 1988): 441-44; Margaret W. Hlgartner, "AIDS and Hemophilia," New England Journal of Medicine 317, no. 18 (October 29, 1987): 1153-54.
The other blood-banking sector collects and processes whole-blood donations for transfusions and is almost entirely composed of nonprofit regional blood centers and local hospital blood banks that do not pay donors. Nationally, this sector is represented by three organizations with somewhat overlapping memberships: the American Red Cross (ARC), the American Association of Blood Banks (AABB), and the Council of Community Blood Centers (CCBC).[12]
Alvin Drake, Stan Finkelstein, and Harvey M. Sapolsky, The American Blood Supply (Cambridge, Mass.: MIT Press, 1982), especially chap. 4.
Their representatives opposed the screening proposal at the January 1983 meeting, arguing that evidence was not sufficient to exclude gay men from the donor lists or to implement the use of surrogate tests such as the test for hepatitis B core antibody, which had also been proposed. The words one representative used are often cited to show the concern expressed about disrupting established routines: "We are contemplating all these wide-ranging measures because one baby got AIDS after a transfusion from a person who later came down with AIDS and there may be a few other cases."[13]Clark, "Preventing AIDS Transmission," p. 568.
The whole-blood collectors feared that a linkage between AIDS and the blood supply would significantly reduce both blood donations and blood transfusions. Moreover, they were annoyed by the intrusion of risk-averse epidemiologists into their professional domain. The opposition of the whole-blood collectors delayed governmental action intended to reduce the risks of AIDS transmission through transfusions. It was not until March 1983 that the Centers for Disease Control made public the recommendations for widespread screening.[14]Office of Biologics, U.S. Food and Drug Administration, Recommendations to Decrease the Risk of Transmitting Acquired Immune Deficiency Syndrome (AIDS) from Blood Donors (Washington, D.C.: FDA, March 24, 1983); Centers for Disease Control, "Prevention of Acquired Immune Deficiency Syndrome (AIDS) Report of Inter-Agency Recommendations," Morbidity and Mortality Weekly Report 32 (March 4, 1983): 101-3.
This public announcement forced the banks to begin excluding high-risk donors.Structural differences help explain the inconsistent responses to AIDS within blood banking. The whole-blood sector relies on voluntary donors. Women and minorities give less frequently than do young white males. In several cities the gay community provided a readily accessible,
often organized population of young white males to solicit for donations. Through repeated campaigns the blood banks had built good relations with the gay community and found it to be a convenient source of donations. Many gays regarded the call for screening as scapegoating and saw in it a threat to their recently won civil liberty gains.[15]
Clark, "Preventing AIDS Transmission," p. 569. See also Shilts, And the Band Played On.
Sensitive to the concerns of the gay community, some influential blood bankers were reluctant to force the exclusion of gays and doubted the effectiveness of direct questioning of donors to achieve that exclusion. In contrast, plasma collectors pay their donors. If one group of donors were excluded, another would be found quickly to maintain the supply. Their relationship with donors was simply a financial one, with no attempt to build long-term trust or mutual support.The plasma sector is also highly competitive; its products are interchangeable among manufacturers and are marketed internationally. The buyers of these products are knowledgeable about quality differences, some being government medical agencies and other individuals who must be in constant contact with medical specialists because of their illness. The firm with a demonstrably safer product would rapidly gain business.[16]
Reuben A. Kessel, "Transfused Blood, Serum Hepatitis, and the Coase Theorem," Journal of Law and Economics 17, no. 2 (October 1974): 265-89.
Once donor screening was suggested as a possibility for reducing the risk of transmitting AIDS, plasma collectors had no choice but to adopt it on the fear that one of them would.The whole-blood sector lacks many of these characteristics. It is dominated by nonprofit blood-collecting agencies that are local monopolists, supplying all or nearly all of the blood transfused within a given region. Blood quality in transfusions is more the responsibility of the supplier than it is of the purchasing hospitals. Nationally, the Red Cross, the AABB, and the CCBC coordinate policies, effectively cartelizing the whole-blood sector by refraining from competing with one another. A hospital seeking an alternative to its local blood center would have difficulty obtaining services from an extraregional supplier. Although hospitals can be licensed to draw their own supply, there have been economic and professional obstacles that limit this option for most hospitals.
The structure of blood banking in the United States was altered in the early 1970s, when—at the urging of the nonprofit collectors—the federal government adopted policies favoring voluntary blood donations in collections for transfusions.[17]
For a more detailed analysis of the structure and performance of blood banking in the United States, see Drake et al., American Blood Supply.
Richard Titmuss, the English sociologist, had just published a widely praised comparative analysis of the American and British blood-banking systems, which helped focus public attention on the risks of transfusion-related hepatitis.[18]Richard M. Titmuss, The Gift Relationship: From Human Blood to Social Policy (New York: Pantheon Books, 1971).
In a devastating critique of the American system, Titmuss argued that paymentfor donations significantly increased the hepatitis hazard for transfusion recipients. In Britain, where the most a donor could get for his donation was a cup of tea or a glass of stout, hepatitis was not a problem; but in the United States, where payment was permitted, the gift of life was often something else, he claimed. The nonprofit collectors, under pressure to improve the safety of transfusions, promoted this view, inaccurate though it was; they sought the elimination of commercial collectors, as well as the elimination of payment for donors from the whole-blood sector.
The critique was quite misleading, because transfusion hepatitis rates do not correlate well with donor payment. Sweden pays all its donors but has a low hepatitis rate. Japan switched in the 1960s from a largely paid donor system to an exclusively voluntary one without greatly altering its high hepatitis rate. The low rate that Titmuss observed in Britain probably had more to do with the fact that British blood is transfused there than the fact that British donors are unpaid. Incredibly, Titmuss failed to mention the extra precautions that the British transfusion service took to keep the hepatitis rates down. It has avoided collections in areas with large concentrations of immigrants from Third World countries, where hepatitis is endemic. It also has labeled blood donations by race and did not transfuse the blood donated by Pakistani, African, and other immigrants. In addition, Titmuss ignored the fact that some of the leading medical institutions in the United States, the Mayo Clinic and the Massachusetts General Hospital among them, paid donors but had low hepatitis transfusion rates as a result of careful donor-screening practices.[19]
Harvey M. Sapolsky and Stan Finkelstein, "Blood Policy Revisited," Public Interest 46 (Winter 1977): 15-27; Comptroller General of the United States, Hepatitis from Blood Transfusions: Evaluation of Methods to Reduce the Problem (Washington, D.C.: General Accounting Office, February 13, 1976).
Ironically, paid donations were not a major factor in American blood collections by the early 1970s because the commercial collectors, which did most of the paying, had already shifted their attention to the plasma market, which was rapidly growing due to the discovery of important plasma products. Plasma donations are more demanding in terms of donor time, and usually require compensation. Federal policies encouraging voluntary donations for transfusion merely assured the nonprofits that competition from commercial collectors would remain limited. The nonprofits attempted to consolidate their position further through a co-operative program of regionalization that certified dominant collectors as monopoly suppliers in designated areas.[20]
"As GAO Investigates, Blood Commission Seeks Regionalization," American Medical News, April 14, 1978, p. 1.
Not surprisingly, these actions had little effect on the national hepatitis rate. Like AIDS, hepatitis is a complex scientific problem that has eluded a quick solution.[21]
Harold M. Schmeck, Jr., "Scientists Seek Ways to Limit Lasting Harm of Hepatitis Infection," New York Times, May 19, 1988, p. B15; Janice Hopkins Tanne, "The Other Plague," New York Magazine, July 11, 1988; pp. 34-40.
Research on control techniques continuedduring the 1970s, but the nonprofits devoted much energy to reducing their responsibility for the continuing presence of hepatitis in the blood supply. They persuaded the federal government and some state governments to require the labeling of blood by donor source, either paid or volunteer, with the implication that the transfusion of paid donor blood held a special legal liability for the transfusing agent. At the same time, they obtained legislation in nearly all states designating blood a service rather than a product, thus exempting themselves from liability other than for negligence when hepatitis or any other disease is transmitted via transfusion. Because they set their own practice standards, through professional organizations with relatively little governmental supervision, negligence itself becomes difficult to prove.[22]
Gilbert M. Clark, ed., Legal Issues in Transfusion Medicine (Arlington, Va.: American Association of Blood Banks, 1986); Lynn Shodahl, "Liability for Transfusion-Transmitted Disease," William Mitchell Law Review 14 (1988): 141-67; David A. Roling, "Transfusion-Associated Acquired Immunodeficiency Syndrome (AIDS): Blood Bank Liability?" Baltimore Law Review 16 (1986): 81-116; Stan N. Finkelstein and Harvey M. Sapolsky, "Controlling Post-Transfusion Hepatitis: A Proposal to Publicize Hepatitis Rates of Transfusion Facilities," American Journal of Law and Medicine 5, no. 1 (Spring 1979): 1-9; "Blood Bank Is Cleared in Colorado AIDS Case," New York Times, June 5, 1988, p. 29; Beth Rabkin and Michael Scott Rabkin, "Individual and Institutional Liability for Transfusion-Acquired Diseases," Journal of the American Medical Association 256, no. 16 (October 24, 1986): 2242-43; Patti J. Miller et al., "Potential Liability for Transfusion-Associated AIDS," Journal of the American Medical Association 253, no. 23 (June 21, 1985): 3419-24. On recent developments see Stuart Wasserman, "Nation's Blood Supply on Trial," Boston Globe, January 3, 1989, p. 1.
The nonprofit blood banks hold a unique position in American medicine. They are protected from commercial competition, exempt from most consumer suits, and free to divide geographical markets among themselves. As economists often remind us, monopolists prefer the quiet life free from public scrutiny. When the AIDS crisis appeared, the blood bankers' inclination was essentially to deny that it was a major threat to blood safety. A week after the Atlanta meeting, the ARC, the AABB, and the CCBC issued a joint statement arguing that the evidence regarding the transmissibility of AIDS via transfusions was "inconclusive" and "incomplete."[23]
American Association of Blood Banks, American Red Cross, and Council of Community Blood Centers, Joint Statement on Acquired Immune Deficiency Syndrome (AIDS) Related to Transfusion, January 13, 1983.
The only screening they advocated was much less intense than that employed by the plasma sector. Specifically, potential donors would be given brochures describing AIDS symptoms and would be asked to sign forms indicating that people with AIDS or in contact with AIDS victims should not donate, but they would not be directly questioned about their sexual preferences. And when the AIDS antibody test was developed in 1985, the associations jointly proclaimed it to be entirely sufficient to protect the blood supply. There was no longer a need to worry about getting AIDS through transfusions, they implied. Unlike many in the society who have sought to exploit public fears about AIDS, the nonprofit blood bankers have continually offered reassurance that all was safe despite AIDS.[24]Harvey M. Sapolsky, "AIDS and the Blood Supply: Is Honesty the Best Policy?" in AIDS: Public Policy Dimensions (New York: United Hospital Fund, 1987), pp. 107-14.
The Search For Safer Transfusions
Despite the reassurance offered by the national associations, some professionals recognized that the blood supply would be increasingly contaminated unless immediate action was taken. The screening of donors alone would not protect transfusion recipients. A screening test for
blood was needed. Until a direct test for the AIDS virus was developed, a surrogate test was required. Dr. E. Engleman, medical director of the Staford University Blood Bank, was the first to try such a test. A research hematologist whose interest focused on a type of blood cell known as a lymphocyte, Engleman stood apart from the pathologists-turned-administrators who were usually in charge of blood banks in the United States. He noted that people with AIDS and many individuals in high-risk groups who appeared well had abnormalities in their T cells, a subset of lymphocytes. Aware of the growing evidence of a long incubation for AIDS, Engleman proposed using a T-cell test to screen donations for AIDS-infected units. His attempts to gain support for the T-cell test among fellow blood bankers were frustrated, the argument being that the benefits of costly surrogate testing could not be proven—as indeed they could not be until an actual test for the virus was developed.
Engleman nevertheless instituted the test at Stanford. In one dramatic incident the Stanford bank discarded a unit from a person who had donated thirteen times in the San Francisco Bay area before being diagnosed as having AIDS. The T-cell test had rejected the unit given at Stanford, but the other dozen units were transfused elsewhere. When the AIDS antibody test finally became available, it was learned that 5 percent of blood discarded at Stanford was HIV positive, whereas only 0.01 percent of blood donated by individuals with normal T cells was positive. Thus, HIV-positive donors were 500 times more frequent in the group with T-cell abnormalities than in those with no abnormalities.[25]
E. Engleman, "AIDS and the Blood Supply: A Report to the Presidential Commission on the Human Immunoceficiency Virus Epidemic," May 9, 1988.
Admittedly, the T-cell test was difficult to administer and relatively expensive. Other surrogate tests were also suggested for use in screening the blood supply to prevent transfusion-related AIDS. Unlike the T-cell test, which discriminated among units of blood on the basis of abnormalities closely associated with AIDS or the preclinical stages of the disease, these tests sought evidence of past infections, which occurred frequently in those at risk for AIDS. Chief among them was the hepatitis B core antibody test, which utilized equipment already available at most blood banks and was not especially costly.
The Food and Drug Administration's Blood Products Advisory Committee studied the issues pertaining to screening the blood supply in early 1984, concluding that surrogate testing, and most specifically the hepatitis B core antibody test, was not appropriate as a means of identifying those at high risk for developing AIDS because it screened out too much of the blood supply. The incidence of hepatitis in the United
States was much higher than the perceived incidence of HIV infection (AIDS) in 1984. To exclude large numbers of individuals because these individuals are at higher risk of transmitting AIDS, it was argued, would add significantly to the cost of blood and blood products. The blood banks not only would incur the cost of this testing but also would be faced with the added cost of recruiting more donors and processing additional blood to replace the discarded units. Irwin Memorial Blood Bank in San Francisco estimated that the use of the test for antibodies to the hepatitis B core antigen would result in a 5 to 7 percent increase in deferrals.[26]
E. J. Power, AIDS and the San Francisco Blood Supply, contract No. 433-4520.0 (Washington, D.C.: U.S. Congress, Office of Technology Assessment, April 1984).
The committee did recommend that small-scale experiments be conducted with another test, beta-2 microglobulin, a cell surface glycoprotein present on certain human immune cells and found in elevated concentration among patients with AIDS. This test, it concluded, seemed to be more specific for blood that might transmit AIDS. Very much aware of costs, the committee sought a test that would incorrectly exclude as few units of blood as possible. Less attention was given to the issue of test sensitivity—the ability to identify as many of the infectious units as possible.
The flaw in this thinking is that high-risk, asymptomatic individuals who would later develop AIDS could still donate blood. It was known at the time that beta-2 microglobulin seemed to be elevated with increased frequency in those with AIDS. However, little was known about the test's behavior in those who were asymptomatic but at high risk. If, as many suspected, there is a long latent period before the onset of symptoms, and if beta-2 microglobulin is elevated only in the later stages of AIDS, then large numbers of potentially infectious individuals might be missed. The committee seemed to be arguing that in the tradeoff between sensitivity and specificity, which always occurs when screening tests are employed, test specificity is of greater importance. Put another way, if surrogate tests were going to be employed, the committee desired that the added costs of those tests be borne by those who receive the blood rather than those who process it. These added costs would be measured in lives lost rather than in dollars spent.
In spite of the committee's recommendations, some nonprofit blood banks and several plasma companies began to employ surrogate tests for AIDS. In large part these decisions were made because of growing public pressure on the blood industry to take aggressive steps to protect the blood supply, but other factors also played a role in these decisions. The concern over the growing threat of lawsuits arising from transfusion-associated
AIDS contributed greatly to the increase in surrogate testing. As was pointed out earlier, competition among the various companies in the plasma sector also added to the use of surrogate tests. In fact, in at least one case, competition among nonprofit blood banks may have contributed to the wider adoption of surrogate testing. San Francisco's Irwin Memorial Blood Bank adopted the hepatitis B core antibody test, in part, because of perceived differences in quality between the blood in its possession and blood from nearby Stanford University Blood Bank, where the T-cell test was being used.[27]
Ibid.
The pressure to employ surrogate testing was largely mitigated when the Department of Health and Human Services announced on April 23, 1984, that the cause of AIDS had been identified. With the identification of the offending agent, a virus, came a promise that a blood test would be "widely available within about six months," which should "identify AIDS victims with essentially 100 percent certainty."[28]
M. Heckler, Secretary, U.S. Department of Health and Human Services, Statement announcing the discovery of the possible etiological agent for AIDS, Washington, D.C., April 23, 1984.
One year later, in March 1985, the Food and Drug Administration licensed antibody kits that were able to identify those exposed to the AIDS virus with 93 to 99 percent certainty.Surrogate testing was not the only issue around which controversy centered. Early in the epidemic calls for directed donation were often heard. The calls emanated from patients and their families, and in some locations led to the development of "blood clubs."[29]
"As AIDS Scare Hits Nation's Blood Supply," U.S. News and World Report, July 25, 1983, p. 72.
"Directed donation" means that the potential recipient of blood designates those who will be allowed to donate on his or her behalf. By its very nature, directed donation cannot be employed in every situation where a transfusion is necessary. For example, virtually all situations where the need for blood cannot be anticipated are not amenable to this kind of donation. However, with proper planning many transfusions could be accomplished within the framework of directed donations.Many nonprofit blood bankers opposed the widespread use of directed donations. In opposing it, they cited four points. First, they argued that there was no reason to expect that directed donation was any safer than the traditional anonymous system. But this contention was incorrect, and the blood bankers knew it. Many obvious criteria could be used to decrease one's risk of being transfused with HIV-positive blood. One obvious criterion, for example, might be to select women as donors, since women were far less likely to have been exposed to HIV than were men. Further, at the time the argument that directed donations were no safer than regular donations was being made, a prominent East Coast blood banker had on the wall of his office a map
displaying the relative risk of various blood-transmitted diseases by zip code of the donor's residence. There were wide and predictable variations based on this criterion. Clearly, there were ways to affect one's risk of receiving HIV-tainted blood, and most of them were readily available to those who wished to utilize a directed donor program.
Second, those who opposed directed donations argued that patients would place great pressure on those they selected to donate on their behalf, and that this pressure would cause donors to be untruthful about their ability to meet donor requirements. What the blood bankers did not acknowledge was that this problem already existed in the anonymous system. Many of the techniques developed by blood bankers a decade earlier to increase the supply of blood facilitated this kind of pressure. Blood drives at schools, work, and other social gatherings were far more successful because of the peer pressure created within these social contexts. In fact, many blood bankers had already recognized the adverse effect such peer pressure might have on donor behavior and in early 1984 began to establish twenty-four-hour telephone lines so that donors who deemed themselves at higher risk of HIV infection and later regretted having donated could confidentially ask that their blood not be used for transfusion.[30]
"Blood Bank Opens AIDS-Risk Hotline," Santa Ana Register, January 10, 1984.
Further, most blood banks that employed directed donation did not allow the recipient of the donation to know whose blood was actually used. Thus, the patient would never know that a high-risk individual whom he had solicited as a directed donor had excluded his blood from human use.Third, the blood bankers argued that directed donation would be more costly than the anonymous system already in place. Costs, however, depend on one's perspective. The costs of concern to the blood banker are not the costs perceived by society as a whole or by the individual who receives a unit of HIV-positive blood. Even when viewed from the perspective of the blood banker, however, a system of directed donation would not necessarily be more costly. In 1984 an article published in the New England Journal of Medicine cast doubt on the blood bankers' assertion when Thomas Jefferson University's blood bank analyzed its nascent directed donor program—a program initiated largely at the insistence of cardiac surgeons who feared the migration of patients if directed donation were not available. Contrary to the arguments put forth in the communiqué from the AABB, the ARC, and the CCBC, the researchers who analyzed the program found that it "resulted in savings to the institution of $4,142 in four months. The annual figure is $12,426—a substantial reduction in operating expenditures."[31]
S. K. Ballas et al., "Designated Blood Donations," New England Journal of Medicine 310 (1984): 124.
These savings, in part a result of decreased recruitment costs, run counter to the argument put forth by the nonprofit blood bankers and suggest that, in addition to improving the quality of the blood supply, directed donation might decrease its costs as well.
Fourth, the blood bankers contended that directed donation would result in de facto discrimination against those who are socially isolated. In particular, they argued that the poor and the elderly would be adversely affected in a two-tiered blood supply. That is, the use of directed donors would undermine the ability of blood banks to find anonymous donors, and the resulting burdens would fall disproportionately on those who found it difficult to locate directed donors. This contention assumes that directed donation will adversely affect the anonymous donor pool, which is not necessarily the case. Although it is undoubtedly true that some participants in a directed donor program would have previously been anonymous donors, it is incorrect to assume that all directed donors would have previously donated. To the extent that directed donors have not participated in the anonymous pool, the blood they donate represents additional blood that would not have been available without a directed donor program. And to the extent that the blood donated in this fashion is safer than anonymously donated blood, the overall quality of the blood supply improves. There are three possible scenarios.
The first scenario is one in which the individual who donates in a directed donor program has never been an anonymous donor. The overall effect of this individual's donation will be to increase the availability of blood within the anonymous system. In the second, the donor has previously been an anonymous donor and the directed donation withdraws blood from the anonymous pool temporarily. In this situation the donation would have no net impact on the overall supply of blood. However, the additional blood donated by those who were not previously blood donors would increase the available blood within the anonymous pool. In the final scenario the donor has previously been an anonymous donor but, in order to remain eligible to give blood should an emergency arise for a friend or family member, he or she elects to refrain from anonymous donation permanently. The extent to which this is a realistic concern is uncertain. In order for it to have an adverse effect on overall blood availability, however, the loss of blood as a consequence of this phenomenon would have to outweigh the amount of blood gained from those who did not previously participate in the anonymous donor system.
Regardless of the comparative safety of blood obtained by directed donation vis-à-vis blood that is anonymously donated, a strong directed donation program would not a priori result in additional costs to the blood banker, as the Thomas Jefferson University's blood bank was quick to realize. Further, the actual risk of contracting AIDS from a blood transfusion may be only one factor in the patient's well-being. Los Angeles' Cedars-Sinai Hospital concluded that "we function with a philosophy that incorporates a concern for the patient's psychological responses to illness, as well as his need for blood. … [B]y providing these very frightened patients with knowledge that the blood to be received is from their chosen donors … we enhance their general well-being and eventual recovery."[32]
L. Pura et al., "Directed Donor Program: A Three-Fold Benefit," paper presented at the 36th annual meeting of the American Association of Blood Banks, New York, November 1983.
As time has passed, pressure in favor of directed donation has grown. Legislators in several states—Florida and Georgia were two early examples—have introduced bills requiring blood banks to accept the practice. Irwin Memorial Blood Bank, located in San Francisco, one of the metropolitan areas hardest hit by the AIDS epidemic, adopted such a program in June 1984.[33]
"Irwin Initiates Directed Donation Program," AABB News Briefs, July 1984, p. 4.
Its variation reflected the disdain the blood bank harbored for the concept. Irwin advised patients "that blood from directed (family and friend) donors is at best no safer than blood from other volunteer donors [and] there is actually a danger that direct donations may be less safe."[34]Blood Policy and Technology, OTA-H-260 (Washington, D.C.: U.S. Congress, Office of Technology Assessment, January 1985).
Patients desiring directed donation were required to have their physicians place the request for blood at least one week prior to the anticipated transfusion. An additional charge of $15 was assessed against each directed donor. The actual donation had to occur on a second visit, thus making it more inconvenient for the directed donor.In contrast to the controversy surrounding directed donation, one source of blood was recognized as inarguably safer than blood obtained from other individuals—either through directed donation or anonymous donation. A rarity prior to AIDS, autologous transfusions—achieved through either the predeposit of blood or its intraoperative salvage—now account for as much as 2 percent of blood usage and are growing in popularity.[35]
D. M. Surgenor, "The Patient's Blood Is the Safest Blood," New England Journal of Medicine 316, no. 9 (1987): 542-44; Pearl T. C. Y. Toy et al., "Predeposited Autologous Blood for Elective Surgery," New England Journal of Medicine 316, no 9 (1987): 517-20; Johanna Pindyck et al., "Blood Donations by the Elderly," Journal of the American Medical Association 257, no. 9 (1987): 1186-88; Lawrence K. Altman, "The Safest Blood: One's Own," New York Times, December 2, 1986, p. C1; B. U. Anderson and P. A. Tomasulo, "Current Autologous Transfusion Practices: Implications for the Future," Transfusion 28, no. 4 (1988): 394-96; "Autologous Blood Transfusions: Principles, Policies and Practices," Forum Focus (Spring 1988): entire issue. Note also "Contact Lasers Reduce Pain, Blood Loss in Mastectomies," Modern Healthcare, November 1988, p. 90.
Blood banks had not encouraged the practice, despite the safety advantages offered patients who can anticipate their need for blood and who are healthy enough to provide the donation. Autologous collections cause inventory complications for blood banks and contradict their donor recruitment message that blood is a community responsibility. But the fear of AIDS among patients and surgeonshas left the banks with little choice other than to advocate the maximum possible use of autologous donations.
Risks Remain
About 3 percent of the AIDS cases recorded in the United States are attributed to the therapeutic exchange of blood. The AIDS toll is certain to grow, but not likely the transfusion-related share of that toll. The AIDS antibody test provides an important, although imperfect, defense against the spread of the disease through blood services. So, too, do improvements in medical practice.
The number of units of whole blood and red cells transfused annually in the United States, which peaked at approximately 12 million units in 1986 after years of steady growth, is now declining.[36]
D. M. Surgenor et al., "Collection and Transfusion of Blood in the United States, 1982-1988," New England Journal of Medicine 322 (1990): 1646-51.
In the absence of a national blood data system, precise figures are not available; but estimates are that in 1987, the most recent year for which there are complete data, the rate of red cell transfusion was 15 percent lower than could have been expected if the historic growth in transfusion rates had been sustained.[37]The figure for the Massachusetts General Hospital is a 25 percent reduction. See "AIDS: Out of Tragedy Comes Good," MGH News 46, no. 8 (November 1987): 2.
The growing tendency in many medical centers is to avoid transfusion unless defined need criteria are met. It is becoming less common for a physician to order a unit of blood to put the blush back into the cheeks of a patient about to be discharged from a hospital. And physicians and patients think harder than they once did about the risks of transfusions when considering surgery.Ultimately, it is the AIDS test that guards transfusions. Not all uses of blood can be avoided, nor can all recipients provide for themselves. When someone else's blood is to be transfused, safety depends on the effectiveness of the screen. In AIDS testing, as in testing for many other diseases, the screen is less than perfect. Some infected units will get through.[38]
Don Dagani, "The Problem of Diagnostic Tests," Chemical and Engineering News, November 23, 1987, pp. 35-40; Deborah M. Barnes, "Keeping the AIDS Virus Out of the Blood Supply," Science 233 (August 1, 1986): 514-15; Philip P. Mortimer, "Serological Tests," in Blood, Blood Products and AIDS, ed. R. Madhok, D. D. Forbes, and B. L. Evatt (Baltimore: Johns Hopkins University Press, 1987), pp. 125-42.
The most commonly used screening test for AIDS is the enzyme-linked immunosorbent assay (ELISA). Blood bank procedures require each donated unit to be screened by the ELISA test immediately after collection. Positive units are often rescreened. If the rescreening test is also positive, the unit is usually considered unusable and not transfused. (Many, but not all, blood centers discard initially reactive units, even though this status is not predictive of the disease.) A confirming test, usually the Western blot, is performed before the donor is notified of a positive status. Most ELISA positives turn out to be false positives.[39]
Thomas F. Zuck, "Human T-Cell Lymphotropic Virus, Type III, Antibody Testing in the United States: Experience of the First Year," in AIDS: The Safety of Blood and Blood Products, ed. J. C. Petricciani et al. (New York: Wiley, 1987), p. 221.
The ELISAscreen is purposely set low so as to eliminate as many dangerous units as possible. The intent of this process, however, is that some blood pass the screen in order that there will be blood for transfusions. A perfect screen for a low-incidence population, such as blood donors under current conditions, would mean substantially reduced blood availability. As it is, nearly 1 percent of donated blood is discarded on the chance that it might be HIV infected.[40]
Personal communication with Michael Barry, 1989.
For the potential recipient the issue is not how many units are discarded but how many infected units are passed into inventory and transfused. As a result of technican error, faulty test batches, or mishandled units, some HIV-infected units will get through. More significantly, the AIDS screen as an antibody test has inherent limitations. One problem is that infected individuals do not immediately produce antibodies to HIV. Several weeks will pass before antibodies begin appearing in the blood of a virus carrier. Those in the terminal stage of the disease may also be antibody free. There are also reports of a few victims who do not produce detectable antibodies in the middle stages of the disease.[41]
H. A. Kessler et al., "Diagnosis of Human Immunodeficient Virus Infection in Seronegative Homosexuals Presenting with an Acute Viral Syndrome," Journal of the American Medical Association 258 (September 4, 1987): 1196-99.
Absent the use of a test for the HIV viral antigen, which is under consideration, there will always be some false negatives as long as infected individuals donate blood. And some potentially infected individuals will continue to donate, if only because blood banks unintentionally provide a convenient and confidential way to discover one's antibody status. The question then becomes: How many infected units pass into the blood supply and cause AIDS?Several factors complicate the calculation of the blood-related AIDS transmission rate. Not all collected blood is transfused; upward of 10 percent of the units are discarded because they are outdated. Transfusion recipients are often severely ill; as many as half die immediately or shortly after the transfusion because of their underlying condition. Not every infection necessarily will produce a defined AIDS case; AIDS-related complex, milder infirmity, or no disease may result. And the incubation period for AIDS may be longer than ten years; consequently, not all cases contracted since the antibody screen was implemented have yet been identified.
Blood bankers, concerned about the impact that fear of AIDS was having on public confidence in the safety of the blood supply, were over-enthusiastic about the effectiveness of the antibody test and proclaimed its arrival as ensuring the total elimination of HIV infection risk from blood use.[42]
Lawrence K. Altman, "Blood Supply Called Free of AIDS," New York Times, August 1, 1985, p. 1.
Since then they have had to acknowledge the test's inherent limitations and to revise their estimates of the continuing AIDS risk intransfusions. At first the rate was cited as 1 in a million. Then it was 1 in 300,000. Still later it was 1 in 100,000.[43]
Gerald H. Friedland and Robert S. Klein, "Transmission of the Human Immunodeficiency Virus," New England Journal of Medicine 317, no. 18 (October 29, 1987): 1126.
Currently it is listed as between 1 in 10,000 and 1 in 100,000, although some researchers claim it is as high as 1 in 5,000.[44]"AIDS Risk Cited in Donated Blood," Boston Globe, August 25, 1988, p. 8; J. R. Bove, "Transfusion-Associated Hepatitis and AIDS: What Is the Risk?" New England Journal of Medicine 317 (1987): 242-45; Philip M. Boffey, "Federal Panel Calls for Improved AIDS Test," New York Times, July 16, 1986, p. A20; Gina Kolata, "New Blood Test Raises Thorny Issues," Science 233 (July 11, 1986): 149-50.
Given approximately three and a half million transfusions, that means there are between 35 and 700 new cases each year still being transmitted through the blood supply.AIDS, of course, is not the only hazard of transfusions. Several thousand transfusion hepatitis cases, most of the elusive type C, are transmitted each year, with a significant fatality rate. HIV-2, a virus related to the AIDS agent, has been detected in blood, although not yet in great frequency. The human T-cell leukemia/lymphoma virus, HTLV-1, has also been found in the United States blood supply, with a transmission rate that is much greater than that of HIV-2. A screening test for HTLV-1 was instituted in early 1989. A test for hepatitis C became available in 1990. Other screening tests are in development, but their efficaciousness has not been determined.[45]
"Testing for HTLV-1 Infection Should Begin among Blood Donors, Yale Researcher Tells NHLBI Panel," The Blue Sheet 30, no. 44 (November 4, 1987): 2; "Red Cross Plans Blood Test for Cancer Virus in Donors," New York Times, April 29, 1988, p. A1.
Not surprisingly, there is still much public fear about the safety of the blood supply, a fear that affects potential donors even though they are not at all threatened directly by these transfusion dangers.[46]"AABB Public Opinion Poll Reveals Surprising Views," AABB News Briefs 11, no. 6 (July 1988): 1; see also "AIDS: A Multicountry Assessment," Public Opinion 11 (May-June 1988): 36-39.
Donations are down by about 6 percent, and in some regions a supply crisis has been averted only because usage has also declined.Science can make transfusions safer. Better tests and the development of vaccines will help, but the significant gains will be in the introduction of blood substitutes, artificially produced substances that can duplicate the life-sustaining traits of blood components. Helpful, too, will be the use of recombinant human growth factors to stimulate the endogenous production of various blood cell lines.[47]
J. E. Groopman, J. M. Molina, and D. T. Scaddem, "Hematopoietic Growth Factors: Biology and Clinical Applications," New England Journal of Medicine 321 (November 23, 1989): 1449.
Chief among these new hormones is erythropoietin, which can stimulate the production of red blood cells in certain individuals.[48]J. W. Ischbach et al., "Recombinant Human Erythropoietin in Anemic Patients with End-Stage Renal Disease: Results of a Phase III Multicenter Clinical Trial," Annals of Internal Medicine 111 (1989): 992-1000.
Much work along these lines is under way, enhanced by the accumulating progress being recorded in biotechnology. When they occur, the advances may alter the structure of blood banking and eliminate the need for recruiting and screening blood donors. Given its emphasis on research, Genentech or some other biotechnology firm is more likely to be the supplier of the substitutes than are the American Red Cross and the other traditional blood collectors.Seeking Greater Safety
Even without a breakthrough in synthetic blood research, the structure of blood banking seems certain to change. The fear of AIDS, disproportional
though it may be to the actual risk, is sufficient among transfusion recipients and medical staffs to force a continuing search for alternatives to the random draw from the community blood donor pool. Provision of autologous donations, however, is likely to satisfy no more than 10 percent of the demand for blood, because of the unpredictability of individual need and because of the frailty of many recipients. The search then will be for safer homologous sources. At least three exist, each of which threatens blood banking as it is currently structured.
One is directed donations, in which donors provide blood to designated recipients, usually friends or relatives, who actively solicit their contributions. As was mentioned, blood bankers have generally opposed this form of donation because it undermines the basic ideology of the blood system: that blood banks serve the community rather than individuals, operating like a community charity rather than a bank with individual accounts. But—as demonstrated in insurance, schools, and other social systems—individuals and groups often have much to gain by withdrawing from community pools. This should be especially true for achieving isolation from a disease focused in defined groups that are separated from most of the rest of the population.[49]
The insurance analogy is discussed in two articles by Harvey M. Sapolsky: "Prospective Payment in Perspective," in Health Policy in Transition, ed. Laurence Brown (Durham, N.C.: Duke University Press, 1987); and "An Evaluation of the New Jersey DRG Hospital Payment System," New Jersey Medicine 85 (January 1988): 32-37.
A second alternative is to obtain blood for transfusions from locations that have a very low AIDS incidence. This already occurs to some extent in the United States, because high-donating rural areas subsidize low-donating urban areas in most regions. It is also the unintended by-product of a little-publicized program that imports red cells from Switzerland and Germany to New York City, where a chronic blood shortage exists because of inadequate donor recruitment. The Swiss and German Red Crosses overbleed their populations to obtain sufficient supplies of plasma for domestic processing. As a result, they produce a surplus of several hundred thousand red cell units, which they ship to the New York Blood Center in exchange for blood-processing equipment, deftly avoiding the embarrassment that a transfer of cash would involve.[50]
See Drake et al., American Blood Supply, chap. 7, for a discussion of the "Euroblood" program. There is currently discussion of extending the program to Atlanta, which is said also to experience chronic supply problems. According to the American Blood Commission, overall blood imports are up, accounting for perhaps as much as 5 percent of the 12 million units used in the United States each year.
Further extension of such programs would increase the safety of the blood supply in many American cities but would require recognition that the concept of community responsibility for blood is inadequate or at least requires substantial expansion.A third alternative is to expand donor exclusion so that other high-risk groups will be prevented from contributing to the blood supply. Such an expansion of donor exclusion criteria was recently proposed by the Food and Drug Administration when it suggested that Haitians
be banned from donating blood. The reasons for the FDA's proposal were straightforward. First, the Haitian community has a much higher prevalence of HIV infection than the United States population as a whole.[51]
"FDA Defends Plan as Based on HIV Data but Might Re-examine," American Medical News, June 15, 1990, p. 3.
The FDA argues that, since the blood test for HIV is not 100 percent accurate, a disproportionate fraction of HIV-infected Haitian blood will enter the blood supply. Second, the FDA argues that adequate screening of Haitian donors is not possible, because heterosexual intercourse is believed to be the primary mode of transmission among Haitians.[52]Collaborative Study Group of AIDS in Haitian-Americans, "Risk Factors for AIDS Among Haitians Residing in the United States: Evidence of Heterosexual Transmission," Journal of the American Medical Association 257 (February 6, 1987): 635-39.
Fearing the loss of large numbers of potentially safe donors, blood banks do not currently screen people who have multiple heterosexual partners.The proposal to eliminate Haitian blood donors created great controversy and led to numerous protests around the country, including a march by more than 100,000 people in New York City. Although the Haitian donor ban may decrease the risk of transfusion AIDS in the United States, the decrease comes with a price. The price of such a plan is borne disproportionately by the communities affected. There is, of course, a precedent. The gay community, one of the first groups recognized to be at increased risk of HIV infection, is largely excluded as well. The net effect of expanding the donor exclusion criteria is to further diminish the notion of community responsibility for blood.
Paying donors is yet another option that is likely to be considered in order to reduce the risk of AIDS transmission in transfusions. The use of direct financial incentives, of course, would reverse federal policies favoring voluntary—that is, noncash—donations established in the 1970s and strongly supported by the nonprofit collectors. But, as was previously mentioned, several of the nation's leading medical institutions once used cash payments to create panels of frequently tested and monitored blood donors to protect against transfusion hepatitis. Today the same procedures could be used to recruit more women, middle-aged donors, or other donors who are less likely to harbor HIV or to engage in high-risk behavior.
Paying blood donors is an anathema to nonprofit collectors, who argue that money is a corrupting force in blood banking, tempting both the collector and the donor to conceal the truth about the quality of the blood they supply. Ignored is the fact that some voluntary donors currently receive substantial cash-equivalent rewards in the form of extra vacation days and time off from work and that blood banks sell blood and other products to hospitals for cash. Confusing blood bankers' arguments against payments, directed donations, and increased imports
are their concerns about the future of blood banking. Each of the reform proposals holds potential for increased competition from hospitals and commercial blood collectors, which are likely to be responsive to the real or imagined fears of transfusion recipients and medical staffs about the safety of blood. But there is a more compelling public policy question: How will attempts to reduce the risks of transfusions affect those who may not be able to take advantage of the additional protections made possible by implementing the proposals and who therefore must rely on the community supply of blood?
Titmuss claimed that blood-banking systems are symbolic of the relationships favored within a society. Voluntary systems, he believed, encourage altruism and strengthen the bonds of community, because these systems are based on the giving by one stranger to save another. Payment systems, he thought, destroy community by creating a market in the gift of life. Timuss did not discuss directed donations, but he would undoubtedly view them as divisive and dangerous, replacing trust among strangers with tribal and family-defined selfishness.
However, the problem we face today is that disease can spread by either altruistic or selfish acts. Not every carrier is aware of his or her exposure to the virus. Tests provide no guarantee that the uncompensated gift from a stranger is safer than the compensated gift from a stranger. The random draw from the community blood pool can be quite hazardous, depending on the pool's composition. Titmuss was mistaken in believing that voluntary donations would eliminate the hepatitis problem. We have no assurance that voluntary blood donations will protect absolutely against AIDS.
Frightened people will seek to protect themselves. Better public understanding of AIDS will surely reduce fears, but it will not eliminate them. Small risks as well as large risks encourage avoidance. Physicians, entrepreneurs, and policy analysts are certain to inform us how that avoidance can be achieved. The reality is that neither the fear nor the risk of transfusion-transmitted AIDS will disappear.
Some cannot fend for themselves when fending is required. The elderly, the poor, and the friendless are most vulnerable in systems that permit payment and directed donations. But donor payments may actually decrease blood collection costs by reducing recruitment expenditures and blood wastage. Much, although not all, blood use is financed through insurance and public benefit programs. Increased costs, if there are any, can be absorbed by adjusting reimbursement levels or through charity drives. More difficult, if this blood collection method becomes common, is the identification of directed donors for those in society
who are alone or in high-risk groups. Here churches, fraternal orders, clubs, and other voluntary organizations may be willing to provide donors for those in need. It is not clear that altruism disappears when alternative donation systems exist. Those who donate for friends and relatives may be quite ready to step forward for others as well.
The more people withdraw from the community pool by making private arrangements to protect themselves, the more likely it is that the shrinking pool will become increasingly disadvantageous for those who must continue to use it. This is the result in too many institutions, urban public schools being but the most dramatic example. A cartel of nonprofit organizations is not sufficient to manage this problem, because they tend to deny the risks and fears that drive people from the community-based arrangement. Blood banking needs to be made more responsive to the public's concerns if it is to retain broad support.
One possibility would be to remove the exemption from strict liability standards that blood banks have obtained in most jurisdictions. The purveyors of nearly all other products in the United States are held strictly liable for faults that cause illness or death independent of any negligent acts in product preparation or distribution. With the burden of liability shifted back to the blood banks, they would soon adopt one or more of the methods previously described that would reduce the hazards of transfusions. Protections that are certain to be available for some could be made available for all.
Another possibility would be for the federal government to encourage interregional and international transfers of blood. In a focused epidemic some areas suffer more than others. The task then is to even the risks of transfusion transmissions among locations. Surgical candidates in New York, Newark, or San Francisco need not suffer greater risks of contracting AIDS simply because New York, Newark, and San Francisco are especially burdened by AIDS. Like other disaster victims, they should expect government-directed assistance from those who are spared or at least less threatened.
The measure of community is not the sharing of risks but the effective management of hazards that may or may not be evenly distributed within a population. There are opportunities to reduce anxiety and risk for all, but we cannot realize these opportunities by denying the existence of dangers or ignoring the possibility of risk avoidance. Instead, to seize these opportunities we must acknowledge and use the many motivations that guide behavior in society, altruism being only one of them.
The justification in the United States for favoring community responsibility for blood has been that it was safer. But that is not the case in
at least some locations. What is necessary is to make blood use safer for all, for the friend as well as for the stranger. Protecting organizations that hold small empires and convenient ideologies does not reduce the risks of transfusions or build community. Finding ways to give reassurance to those who must be transfused is the more responsive and more responsible course to serve the community.