Blood Donation Part 3: Blood Tourism

While researching blood donations in Cambodia one of the strangest things I came upon was the amount of advertising advocating blood donations from tourists. Just a quick google search renders the following:

Jayavarman VII Hospital
Angkor Hospital for Children (AHC) in Siem Reap
Kantha Bopha Children's Hospital

These are also recommended by both TripAdvisor and Lonely Planet. 

I have never given blood in Cambodia and now greatly regret it. I remember the last time I was there with my family my brother expressed interest but everyone decided that it was probably a risky decision. I now firmly believe that that trepidation was unwarranted, and is similar to the reason there is a shortage in the country in the first place. Not donating blood in Cambodia, because of fear of lack of sterilization, is much akin to the native aversion due to “lack of energy.” It does much more good than many other forms of volunteerism in the country. Donating blood goes directly to saving an individual's life. Many other tourist volunteer programs, such as visiting orphanages, are somewhat less substantial and can often do more harm than good (recent studies have shown that the turnover of volunteers at orphanages in developing countries is traumatic for the children).

The blood contribution of a single individual does little to fix the widespread problem but certainly has much more impact in Cambodia than it would have in a developed country.

Accounts I have found online of foreigners who donated blood are generally positive. Here are two samples from individual bloggers.

Sample 1:

"When I came to the gate I said I wanted to donate blood and I was walked to the blood bank. There was no one else there and after filling out a form I had a needle in my arm and they were draining blood. Maybe I looked pale or something but there were three of the nurses and doctors standing around asking me if I was feeling fine. But donating blood here was not a problem – I only had to donate 300 ml compared to the 500 ml that is donated in Norway. I guess it is because Cambodians have a smaller body than your average westerner and that is why they drain less blood here. Anyway, I got a Coke while I was donating blood and I even got a t-shirt."

Sample 2:

"In Cambodia donating blood is not very common, as there is a fear that you could get sick. One of the tuk tuk drivers told me it has something to do with the thought that the old and new blood mixing together will cause illness. First we would check the place out to make sure we were all comfortable with the set up. Two of the girls from Belgium actually draw blood back home so they knew what to look for, and I have donated enough times to also know what to look for.The hospital was not even close to anything I've seen in the US. There did not appear to be an official waiting room as there were a lot of people just waiting around outside the various buildings. We headed to the blood bank which was housed in it's own building. It was a bit small so we quickly filled up the place.There were 2 ladies working in the clinic that really only spoke Khmer, but we had one of the Khmer teachers with us to help with the translation. We asked to see the equipment that would be used, with the needles being our main concern. We checked everything out and felt comfortable with the set up, they seemed to have no problems with all our questions.We started with a questionnare which asked many of the same questions that are on the paperwork in the US. Somehow I ended up going first and so they checked my pulse, my blood pressure, and my iron levels (this is normally the point where I fail), and everything was at acceptable levels. Last thing they did was weigh me, which just looking at me it's clear I'm nowhere near being underweight, but they were just following procedures. Then they cleaned my arm, found a good vein and put in the clean disposable sterile needed. My blood is a little slow, but once I was done they put the bag (350ml) next to me so that I could have a photo taken (I'm sure not part of the standard procedure). They had me lay there for a bit and once I sat up they had a nice cold Coke waiting for me (they also had these for us as we filled out the paperwork). They could only do one person at a time so we sat around talking, drinking Cokes and eating the cookies I brought. I'm sure the ladies worked well past their normal time, but never indicated this was an issue. They even gave each of us a t-shirt, and started a blood donation card for the Cambodian blood blank."

If you are still feeling uncomfortable about donation safety. Here are two videos of how the process works for foreigners in Siem Reap.

Foreign donation has two positive effects and I highly encourage it. The first is that it is a reliable source supplying a very small portion of the needed blood. The donations are entirely altruistic and therefore will generally be screened effectively. The second is that sufficient reporting of international participation should both instill confidence and a sense of national guilt/obligation. This second benefit is by far more important and will hopefully lead to an overall increase in blood bank supply.

Blood Donation Part 2: Blood Money

In the simplest terms, the shortage of blood is a result of perceived high risk of donation, very low incentive for donation and increasing demand for blood.

Not only are people afraid of possible serious health ramifications (whether they are real or not) but the cost of travel and time is significant. I know diabetes patients who don’t go to pick up free medication because it is too expensive to get to the hospital. Interestingly enough they are also afraid of getting in accidents and dying on the way but that may just be a result of age and illness.

Cambodia currently does not pay for blood, unlike countries like China. They follow the same model that the US FDA advocates which requires that all blood used in hospitals needs to be obtained purely by donation. There is one overriding reason for this. Studies and common sense have shown that when money is offered for blood people are more willing to lie during screening (one example). While most diseases can easily be screened, some cannot, and many countries are not following correct screening procedures in the first place (source). Additionally, screening blood that ultimately cannot be used is costly. I can certainly see this being a problem in Cambodia and understand completely why they rely on donations.

There are problems however. Many people are also suspicious that doctors and hospitals are profiting off of their charity because blood needs to be paid for by patients. These costs are mostly due to the price of screening but accepting that requires trust in the medical system which does exist (and perhaps isn’t warranted). Furthermore, the shortage is so acute that when blood is not available for a patient, and family members are unwilling to supply blood themselves, the common recourse is to petition, and pay, anyone who is willing to fill the need. Doctors are left with no option but to request that their patients follow these measures. Ultimately all of the problems that you avoid by taking only donations are still in play, if not more so.

A quote from a recent article:

“Older street children...are selling blood sometimes, including drug users...They mostly hang around the hospitals, and if people need blood, they'll buy from them.” - Man Phally

I have heard quite a few suggestions of measures that could be used to incentivize blood donations without increasing the frequency of risky donations. To do this effectively you would have to do two things. First, you would need to create an incentive that is not particularly attractive to at risk populations. I would not know where to begin to profile the type of donor that you want in Cambodia. Certainly you want to exclude drug using homeless children but beyond that many of these diseases are not necessarily demographic specific. Its possible that someone could argue further that more wealthy populations are more educated and therefore understand more clearly the implications of falsifying medical data but I don’t buy it. Not only is wealth not necessarily tied to education its also not particularly tied to morality. Suggestions such as tax exemptions or gym memberships that have been popular solutions in the United States do not seem entirely plausible. I do think that it may be worthwhile to create a partnership with the flurry of exercising groups that have overtaken almost every public park in Phnom Penh. These are health conscious people organized into neat social groups. Is there a more opportune population to target? Another possibility could be providing free physicals to blood donors. It is a clear incentive, but receiving a physical and lying about health information at the same time is somewhat counter productive. Not foolproof, but a possible solution.

Second, you would need to find a way to tie said incentive to the individual giving blood. This would be necessary to avoid creating tertiary markets which would negate any effect of the first requirement. In Cambodia in particular this would be difficult. National IDs could be used but they are not beyond forgery. Fingerprints or palmprints (hospitals in NYC have begun using technology that identifies individual vein patterns in palms) may be effective but the country may not have the infrastructure/man power to handle the data and unless some very complicated measures were put in place it could be a very serious breach of privacy.

Without financial incentive, the only real benefit to blood donation is the warm fuzzy feeling that comes from fulfilling moral or national obligations. This works for quite a few countries, including the US which currently has a surplus. Indeed, the book Freakonomics quotes a study which shows that paying for blood donation decreases the altruistic incentive and decreases blood donations. Unfortunately this hasn’t been working for Cambodia. I am preferential to the idea of only receiving donated blood but am forced to wonder if offering hard cash incentives under a more controlled environment would be a better option than allowing families to pay street children. Soft incentives (T-Shirts, buttons, cups, hats, physicals, subsidizing exercise, etc...)  need to be explored but if they fail to produce results it may be necessary to take the lesser of the two evils.