Anyone active in the Lebanese social media bubble will have seen the all too frequent posts, shared on behalf of family or friends, urgently calling for volunteers to donate a specific blood type at a specific hospital. What people may not realize is that the blood they are being desperately asked to donate might not actually go to the patient who is asking for it. Lebanon’s blood transfusion system runs on what is called family/replacement donation—hospitals give the needed blood units, if they have them, to the patient, provided that these are replaced by the patient’s network of family and friends. If a patient needs six units of A+ blood, then they will be responsible for replacing these six units in the hospital’s blood bank.
Replacement donation is not unique to Lebanon; 71 countries are still dependent on replacement or paid donors for over 50 percent of their blood supply, according to the World Health Organization (WHO). Since 2010, the WHO has had a global framework for action to help countries achieve 100 percent voluntary non-remunerated donors (VNRDs) by 2020, with this deadline since extended to 2025 for countries in the Eastern Mediterranean. But even with the extra five years, Lebanon still lags far behind. Replacement donors account for around 80 percent of all blood donations in Lebanon, and without a national impetus to encourage voluntary donation, and a shift in public mentality, this is unlikely to change anytime soon.
Voluntary, not replacement
What reliance on replacement donation means in practice is that while the blood transfusion system in Lebanon is arguably effective, each actor on the supply side (including patients, their relatives, and hospital staff) is placed under pressure to procure blood when needed—rather than being able to rely on a national blood bank. Hospitals, keen to keep an emergency stock of blood, are unwilling to use their own supply unless it is guaranteed to be replaced. And while those who do donate are of course doing so voluntarily and without pay (it is illegal to pay donors in Lebanon), they still fall under the banner of replacement donors because they are making this donation on behalf of a specific patient.
What makes replacement donation problematic is that statistically these kinds of donors are not the safest to work with. Knowing the person involved and being under pressure to donate from friends and family can make it more likely that these donors will not be entirely honest in the screening process—increasing the risk for the blood’s recipient. All blood products in the country are legally obligated to be screened for HIV, Hepatitus B, Hepatitus C, Syphilis, and irregular antibodies, but certain diseases, such as HIV, have a window period in which an affected donor could transmit the disease without any detectable antibodies during the screening process. This is why the national questionnaire—prepared by a committee of experts to check the eligibility of donors and available, along with other information for prospective blood donors, on the Ministry of Public Health (MoPH) website since 2015—is a vital part of the process to ensure the safety of patients.
To add more stress to an already stressful situation, there have been recent reports in local media, as well as personal accounts shared with Executive, of potential donors being turned away for reasons that, when posed to specialists in blood transfusion, do not stand up to scrutiny. These include female donors being rejected on the basis of their gender and potential donors being turned away for having engaged in safe sex. The national questionnaire does ask donors several questions on sexual activity to screen for those at a higher risk of having contracted a sexually transmitted disease, and women are asked specific questions related to pregnancy, and whether they have had sexual contact with a man who has had sexual contact with another man. But to be turned away for having had protected sex in general, or simply for being a woman, has no scientific basis. The only real difference between men and women when it comes to blood donation is that men can donate six times a year compared to four times for women, due to the latter’s slightly lower levels of haemoglobin. Asked why hospitals might turn away potential donors on criteria not addressed in the national questionnaire, the specialists Executive spoke with cited a lack of training as a possible reason.
Procuring the necessary blood units is also complicated by hospitals’ differing standards. Some, for example, will accept donations of blood units, while others require these donations to be made in person at the hospital. Abdo Saad, head of communications at Donner Sang Compter, an NGO set up in 2009 to help connect patients with willing donors, argues that hospitals are the most difficult part of the supply chain. He cites different standards and criteria between hospitals as leading to a lack of trust that makes hospitals insist that people donate in person.
This desire of hospitals to receive donations on site also comes with several drawbacks. In an article titled “Can a decentralized blood supply system reach 100% voluntary non-remunerated donation?” published in the International Journal of Health Planning and Management (IJHPM) earlier this year, the authors noted that most hospital blood banks in Lebanon are clustered in overcrowded urban areas, making them hard to access, given the lack of parking and traffic congestion. Most also stop accepting donors after 5 p.m., except in emergency cases, meaning that potential donors often must take time off work to donate, thus incurring discouraging out-of-pocket expenses.
The pressure to secure donors can also take a heavy toll on patients and their families. Executive spoke with a woman whose father had recently needed regular donations of blood while being treated for leukemia over a seven-month period. The responsibility to find donors was immense. “It’s one of the unforgettable periods in my life. It was super, super exhausting; it really sucks energy and life out of you … and you sometimes feel you really need to beg people [to donate],” the woman, who prefers to remain anonymous, tells Executive.
The Lebanese system
For Saad, blood donation in Lebanon is so fragmented due to a lack of involvement at the governmental level. “Here we have each hospital relying on itself, or on the Lebanese Red Cross (LRC). So [it is a] decentralized system which jeopardizes everything, and there is no one to control it,” he says.
Blood transfusion services in Lebanon are indeed highly decentralized, in line with the healthcare system overall. The IJHPM article says that healthcare facilities carry out 85 percent of national transfusion activities, while the remaining 15 percent is carried out by the LRC. Law 766 (2006) states that authorization to operate a blood transfusion center must come from the MoPH, and the center must be run by a physician who, among other requirements, has a degree specialization in hematology. In reality, however, the situation is more complex. The article estimated that of Lebanon’s healthcare facilities less than half are licensed by the MoPH to practice transfusion services, with the remainder running unlicensed blood bank activities. Dr. Rita Feghali, who coordinates the Lebanese National Committee of Blood Transfusion (LNCBT), an advisory body to the MoPH, says, “All hospitals can transfuse. So if you have a patient needing a blood unit, you will have to transfuse them even if you don’t have a license for a blood transfusion center, which is the case for more than half of the hospitals in Lebanon.”
Since 2010, the MoPH has made efforts to improve the quality and standardization of blood transfusion services, starting with an advisory relationship between the ministry and Établissement Français du Sang (ESF), the national blood bank of France. In 2011, the LNCBT was formed, composed of eight members all working in the field of blood transfusion at Lebanese hospitals. This committee was tasked with advising the ministry on the organization of blood policy, the promotion of VNRD, and the improvement and sharing of blood transfusion practices, among other goals.
In the past seven years, the committee has authored guidelines on good transfusion practice (released in 2012), and developed a hemovigilance program (in 2015) that included the national blood donor questionnaire. They are now in the process of producing an all-encompassing national strategy for blood transfusion in Lebanon. However, enforcement of these guidelines remains an issue. Feghali explains: “It should be mandatory because this is our national questionnaire, and in the new accreditation standards put [in place] by the MoPH there is a grade for using the national questionnaire—because you know in Lebanon we cannot always do these things by force—but there is a grade, so for the hospitals, it is one of the standards the hospitals should be using.”
To improve enforcement, the committee will be recruiting and training auditors to undertake a national audit of all blood transfusion services in the country, part of an accreditation process specific to these services. This process is set to begin in 2019, with all blood banks scheduled to be audited over a two-year period. The ministry has yet to take a decision on what will be the punitive consequences for hospitals found to not be adhering to these standards.
Quality, but also quantity
There is a dual challenge for blood transfusion services: ensuring both the quality and quantity of their supply. While there has been a lot of progress at the ministry-level in terms of standardizing practices to improve quality, ensuring a sufficient supply of voluntary donations is very much a work in progress.
In 2016, the MoPH launched Lebanon’s first national blood donor public awareness campaign to encourage VNRDs with radio ads, leaflets, and a hotline to inform donors of their nearest blood banks. This, while successful, did not have the full impact the ministry was hoping for, according to Feghali. Raising greater awareness of the need to donate blood altruistically and regularly, rather than for a specific person, was raised as one of the most—if not the most—important way to move Lebanon toward the WHO goal of 100 percent VNRDs.
Lack of voluntarily blood donations is not the only roadblock. According to the IJHPM article, other challenges that need to be overcome include: shifting from the mentality of replacement donations, misconceptions within the Lebanese community over the safety of blood donation, the out-of-pocket costs incurred by donors, and a lack of respect toward donors, who often have to contend with long waiting times and poorly trained staff. Even if all these issues can be addressed, the authors of the piece—which include Dr. Antoine Haddad, head of Department of Clinical Pathology and Blood Bank at Sacre Coeur Hospital, and one of the members of the LNCBT—estimate that Lebanon is still a decade away from 100 percent VNRD.
According to Haddad, who spoke in person to Executive, another significant barrier to realizing an all-volunteer blood donor system is the lack of sufficient funds and manpower allocated to blood transfusion services. Haddad, while praising the work the committee has achieved so far, says that the only way to truly move the country toward voluntary donation is to legally designate blood transfusion as a public health issue under the purview of the MoPH. He points to the fact that Lebanon, unlike most countries in the region, does not have a national institute for blood transfusion. This means the country lacks the staff, resources, and funding of a fully empowered national institute, which would be able, among other things, to run a national media campaigns encouraging voluntary donation.
But he also cautions against trying to impose a centralized system that, while perhaps successful in other countries, may not be the best fit for Lebanon. During the 2006 War, for example, the decentralized nature of the system was actually an asset. When roads and infrastructure were bombed, Lebanese people across the country still had access to blood. According to Haddad, Lebanon needs a national solution for blood transfusion that specifically caters to the country’s needs.
In the absence of a national blood bank or institute for blood transfusion, the role played by organizations such as DSC and the LRC remains vital. Following the MoPH’s lead, since 2014 the LRC has been focused on quality control. According to Feghali, who is also head of the LRC’s blood transfusion services, the organization’s 13 centers across Lebanon have been improved and rehabilitated to international standards, with several sites inspected by international auditors. Now, the LRC is shifting its focus to increasing voluntary donations. Currently, the LRC supplies around 15-20 percent of the national demand for blood units, but more than 90-95 percent of this total is still via replacement donors, Feghali says. Next year, the LRC is launching a new communication project for all its services, including social media campaigns and a new website. Raising awareness about voluntary blood donation, along with organizing more blood drives, form integral components of this initiative.
A secondary target for the LRC is to improve the transport of blood units around Lebanon, which currently relies on patients’ families to move blood from their centers to hospitals. “We are trying at the LRC to put in place a transportation system that will assure transportation of blood directly to the hospital, totally monitored: From the time it leaves the Red Cross to the time it reaches the hospital, the temperature and the conditions [will be] completely monitored,” Feghali says.
Donner Sang Compter, meanwhile, helps patients directly through its call center database, which has grown to include the details of around 20,000 potential donors. Saad estimates that they link patients to around 50-60 donors per day—and while there are no official figures, research estimates that Lebanon needs around 150,000 blood units per year, or just over 400 units per day.
DSC is also making efforts to raise awareness around and increase voluntary blood donation in Lebanon. The organization indirectly helps patients by organizing around 160 blood drives per year, in partnership with hospital blood banks, to increase their stocks—through these, Saad estimates that around 6,000 blood units are collected annually. DSC’s greatest success in terms of encouraging VNRDs, he says, is through their affiliated clubs at Lebanese universities, which organize blood drives and awareness sessions on campus. “This has been the most efficient way to raise awareness because we get to meet people one-on-one and correct some misconceptions about blood donation, and we have been targeting the most enthusiastic target audience, university students, which helps build awareness for the future generations,” Saad explains.
The success of blood drives organized by DSC and the LRC, as well as people’s response after mass casualty events, shows that the Lebanese are willing to donate blood. What is required is a cultural shift, from seeing blood donation as an obligation in a specific time of need to something that is always necessary to save people’s lives. As it stands, the blood transfusion system in Lebanon, despite the stress it causes for all the actors involved, does work, and efforts are being made to improve it. But blood transfusion services follow a familiar pattern in Lebanon—one where an imperfect system lingers and gaps are, by necessity, plugged by non-governmental actors.