Ground report

Should hospitals give patients unbanked blood to save their lives?

Unbanked blood transfusion is illegal. But short of blood, rural hospitals in Chhattisgarh say it is not unethical.

In April, a woman walked into a hospital in Baitalpur in Bilaspur district of Chhattisgarh, bleeding heavily. She was in her thirties, and had ruptured her uterus while delivering a baby at home in a nearby village. She needed urgent medical attention. When a van dropped her off on the highway, she trudged two kilometres to Baitalpur's Evangelical Mission Hospital – only to be turned away.

The hospital had an operation theatre and a gynaecologist, but no blood.

With buses plying only once in two-three hours from Baitalpur to Bilaspur, the district headquarters, getting blood from the blood bank takes at least four to five hours, if not a day. Without a quicker way to access blood, the hospital is not equipped to handle an emergency.

“She had a ruptured uterus and was anaemic," said Dr Kusum Masih, the medical superintendent of the hospital who is also a gynaecologist. "We could not operate without blood."

The doctors sent her to Bilaspur about 35 km away – but she died on her way there.

The woman walked for two hours to the hospital. Credit: Menaka Rao
The woman walked for two hours to the hospital. Credit: Menaka Rao

Eleven districts with no blood banks

There are 16 blood government-run blood banks and 30 private ones across 27 districts of Chhattisgarh.

The deficit of blood in the state is about 48%, said Dr SK Binjhwar, from the State Blood Transfusion Council. According to the World Health Organisation, a country should have a stock of blood equivalent to 1% of its population. By this standard, Chhattisgarh alone needs 25 lakh units of blood at any given point – but it usually collects 16 lakhs units a year.

What's more, 11 out of 27 districts in Chhattisgarh do not have blood banks – the largest deficit in any state in the country. In all, there are 81 districts in the country without blood blanks, according to data from the Union Ministry of Health and Family Welfare. Most of them are concentrated in Chhattisgarh, Jharkhand, Bihar, Uttar Pradesh and the North East.

For Chhattisgarh, a state with very high rates of anaemia, especially among women and children, the shortage of blood throws up multiple challenges.

According to the National Family Health Survey, more than half of the women of the state – about 57% – suffer from anaemia, as do nearly three-quarters, or 71.2% of children aged 0-5. About 2% of both women and children have severe anaemia, with a haemoglobin level below seven grams per decilitre of blood, for which most patients need blood transfusions.

Apart from this, about 60,000 children are estimated to have sickle cell anaemia, a severe form of the condition caused by a genetic blood disorder.

Anaemic women additionally face a higher risk of postpartum haemorrhage, which is a leading cause of maternal mortality in India. The maternal mortality rate of Chhattisgarh is 230 deaths for every 1,00,000 live births, as compared to the national average of 178.

Unbanked blood

For a rural hospital in Chhattisgarh, there is just one option in case of emergencies where blood is required – to refer a patient to a bigger facility. This often means that the person reaches the hospital in a critical condition, or dies on the way, as in the Baitalpur case.

Some hospitals are countering this by opting for an illegal way of giving blood, called unbanked direct blood transfusion. Under this, the blood of a willing donor’s that matches with the recipient’s group is collected, tested for infection with a rapid blood kit and then transfused without roping in a blood bank.

Take the case of a 40-year old woman from Shahdol district in Madhya Pradesh, who had been having extremely painful menstrual bleeding for nearly four months.

Khoon girat rahe [I was bleeding all the time],” she said. “But, I would still have to work in our fields. How can I stop?” She was also not able to eat or walk and had severe chest pain.

On June 28, she somehow made it to a rural hospital in Chhattisgarh, which shares a border with Madhya Pradesh, travelling more than 200 km by train and bus with her husband and son.

When the doctors examined her blood, they saw she had a haemoglobin count of 4.6 – the normal range for women is between 12.1 and 15.1 – which meant she needed immediate transfusion. She also required an abdominal hysterectomy, as she had a large fibroid in her uterus.

In all, she needed three units of blood.

“I do not know how she managed to travel so far,” said a doctor at the hospital. “There is barely any oxygen reaching the organs. We have patients coming in with haemoglobin count of one as well. We can't direct such patients to other hospitals as their condition is already critical.”

The names of the hospitals and the doctors have been withheld because it is illegal to get blood from any other establishment other than a blood bank.

In this case, her son gave one unit of blood through unbanked direct blood transfusion, while two other units were arranged legally.

Doctors have been arrested in the past for using unbanked blood in other states.

Hospitals that practice unbanked blood transfusion usually have a list of donors in the community who can come and give blood when required. These donors are usually not paid – unless they demand payment and the situation is dire.

A woman in a hospital in Chattisgarh. Credit: Anindito Mukherjee/Reuters
A woman in a hospital in Chattisgarh. Credit: Anindito Mukherjee/Reuters

Insufficient blood

In 1996, the Supreme Court outlawed professional blood donation – that is, donating blood for money – and ordered the establishment of National Blood Transfusion Council to oversee and strengthen policies and systems governing blood transfusion in the country. In 1998, unbanked directed blood transfusion was disallowed.

In 2002, the council allowed the setting up of blood storage centres that were allowed to keep blood from licensed blood banks (but were not authorised to collect it). These storage centres could come up in villages and towns, while the mother blood banks would usually be in the district headquarters or cities.

In Chhattisgarh, there are 60 such storage units, mostly in community health centres, many of which do not use the blood at all and direct patients to go to other healthcare facilities. For instance, the community health centre in Gaurella, attached to the Chhattisgarh Institute of Medical Sciences in Bilaspur, has never approached the storage unit for blood. “I am not even sure it [the centre] functions,” said Dr VP Singh, who is in charge of the blood storage centre in the Bilaspur college.

Patients from community health centres often make their way to Jan Swasthya Sahyog, a non-profit in Ganiyari, near Bilaspur city. “Often, we see patients who are bleeding copiously after childbirth and are referred to us in that condition,” said Dr Yogesh Jain, one of the founders of the hospital.

Even hospitals that do use blood storage units, such as Jan Swasthya Sahyog, Shaheed Hospital in Dalli Rajahara in Chhattisgarh's Balod district and the mission hospitals, said they get insufficient units of blood.

“Our storage centre is attached to a mother blood bank in Durg,” said Dr Saibal Jana, chief physician of Shaheed Hospital. “We need about 150 units per month, but have barely about 35 units from the bank. Last month, they gave us only 10.”

Jan Swasthya Sahyog has an understanding with a private blood bank in the city, which gives them blood nearing its expiry date for free. This they use for scheduled surgeries, when the blood requirement is known.

Replacement donation

For every unit of blood taken from the bank, hospitals are supposed to send a replacement donor to the mother blood bank. This unwritten rule holds true even for hospitals that send relatives of patients to collect blood from a blood bank – private or public – for a planned surgery.

This is against the country’s National Blood Policy, which prohibits coercion in enlisting replacement donors and aims to phase replacement donations out.

Dr SK Binjhwar, from the State Blood Transfusion Council in Chhattisgarh, said that the state has 80% voluntary donation. Public health activists, however, said this figure is highly debatable and that more than 99% of the blood is likely collected through replacement donation.

“A hospital that has a blood storage unit organises blood donations camps for mother blood banks,” said Bhinjwar. “This is enough to meet the demands of the districts.”

The demand for a replacement donor for the mother blood bank hangs like a sword over the heads of patients’ family members.

Many donors from the hinterlands are not willing to travel to the nearest blood bank in the city to replace blood. It’s also difficult to find eligible donors in the immediate family – if a patient has anaemia, it’s likely that members of her family would also suffer from the condition.

Many also have an apprehension towards donating blood, fearing it causes weakness.

In such a scenario, touts who can provide ready donors for a price thrive. There are many such businesses in operation near blood banks in the state that provide donors for a sum of money to provide replacement units to the banks.

Rajesh Sharma, who runs the laboratory in Jan Swasthya Sahyog said that touts realise that people are looking for donors for replacement donation when they see an icebox in their hands. To combat this, Jan Swasthya Sahyog sends a patient's relative for replacement donation, they now send a letter (pictured below) that has to be signed by the blood bank.

People who are unaware about the dangers of remunerative blood donation – which has higher chances of infection – are willing to pay for the blood, despite having meagre resources.

In a rural hospital in Chhattisgarh, a 76-year-old was diagnosed with nectrotising fasciitis – a severe bacterial skin infection that spreads to the tissues quickly – on her arm. She had to be operated upon immediately to remove the infected tissues, but her haemoglobin count was just 6.3. During the surgery, the hospital collected blood via unbanked direct blood transfusion. But they were short of one unit.

“I do not know who will donate now...can we buy the blood?,” asked her daughter, who was tending to her.

While admitting that most units of blood are given only after a replacement donation, Dr Singh from the Bilaspur college's blood storage unit said: “We give blood to people who do not have replacements too."

"Usually if someone is an orphan with no family support, or someone comes without attendants, we give the bank without exchange too (referring to replacement donation)," he added.

Dr Singh said he had instituted a rule that no sickle-cell patients should be asked for replacement donors as he found out that the patients' families were bringing in professional donors, especially when the patient needed immediate treatment.

Unbanked blood ethical?

In a scenario where lack of access to blood banks has resulted in deaths that could have been avoided and helped touts flourish, doctors and healthcare activists practicing in rural areas have pushed for unbanked direct blood transfusion to be legalised, even as other activists argue that it shouldn't.

In June, Dr Yogesh Jain and Dr Raman Kataria from Jan Swasthya Sahyog wrote in favour of the practice in Indian Journal of Medical Ethics. They said that unbanked directed blood transfusion, if done by trained and certified healthcare teams, meets ethical standards and helps fulfil emergency blood requirements in rural areas.

In 2014, the Ministry of Health and Family Welfare met a delegation from the Association of Rural Physicians that sought to legalise this practice. Though the Drug Technical Advisory Board considered the proposal, it was eventually rejected.

The delegation argued that there the Drugs and Cosmetics Act allows unbanked directed blood transfusion for Armed Forces in border areas and peripheral hospitals, which should be extended to the same in emergency situations in rural areas too.

The Drug Technical Advisory Board, however, said that testing of safe blood requires a lot of infrastructure and trained manpower, without which the blood is likely to be infected. Besides, they said, it would be difficult to monitor them. They also said that the exemption given to Armed Forces cannot be given to rural hospitals.

“Are soldiers' life more important than a woman giving birth?" asked Dr Jain. "The implication of this policy is that either people go to the cities for treatment, or choose to die wherever they are. People who have to handle emergencies have to be equipped with technology and regulations should look into the ethical requirement of safe blood.”

An ideal solution, said doctors, would be to increase blood availability in the country by having a central blood bank in each district, with well-equipped storage centres.

However, activists working towards ensuring voluntary blood donation said that unbanked direct blood donation should not be allowed.

“All hell will break loose," said Vinay Shetty, from Think Foundation, Mumbai and a member of Voluntary Blood Donation Committee of Maharashtra State Blood Transfusion Council. "There will be no control over the blood in this country and we will go back in time."

The state has to take responsibility for the shortage of blood and has to ensure that no bank is short of blood, he said.

“The only answer to this is blood sufficiency," said Shetty. "Organising blood is not the responsibility of the patient. It is the responsibility of society at large. This is happening because there is no value to human life. Somebody in the state has to take charge."

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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

Play

This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.