This is why several experts in transfusion medicine like Dr Zarine Bharucha, a member of the National Blood Transfusion Council, had expressed the view that the amounts fixed by the Union Government are too low. But no further review was done since then, though it is long overdue. With budgetary cuts affecting the public hospitals as well as private institutions, managements find it extremely difficult to bear the additional burden of subsidizing the blood transfusion services.

Therefore, on the face of it, the recent directive is a praiseworthy effort to control the costs of healthcare that ordinary people have to bear. If however, the hospitals find that it does not meet their expenses, they may respond either by not following the safety guidelines properly or by charging under the table. In extreme cases, hospital managements may even decide to close their transfusion department entirely. The last would undoubtedly be a disaster.

Those who have followed the healthcare scene at least in the major cities know what can happen when blood bank managements begin to cut corners on safety aspects. Barely five years ago, the Mumbai chapter of Indian Red Cross Society hit the headlines after it had allegedly supplied HIV infected blood to as many as 12 hospitals in the metropolis. Till today, efforts to trace all the infected units of blood have not succeeded.

The Red Cross blood bank has since reopened after a two year gap, by using the simple expedient of obtaining a license from the FDA under a different name. Around the same time, there were media reports that the Red Cross blood bank in New Delhi is in an equally deplorable state. We have very little reason to believe that things have improved. The latest order is bound to make matters worse, not better.

Similarly, in 1997 as many as 29 out of 100 private and government blood banks in West Bengal were ordered shut, creating a major crisis all over the state. The reasons: failure to comply with Supreme Court guidelines issued in a January 1996 judgment. Some of the blood banks in Bengal have since reopened but quite a few have preferred to remain closed. But one shudders to think what must be happening in Bihar, Uttar Pradesh and Rajasthan, which are facetiously referred to as the "Bimaru" states. In those places, neither the blood transfusion services are well organized and monitored nor is the surveillance for HIV cases carried out properly.

On a smaller scale, there are periodic reports of young people being infected after blood transfusion during surgery or after an accident. Several years ago, the Tata Blood Bank which used to function as part of the J J group of Hospitals, had to shut down after an incident like this. Instances of less deadly diseases like serum hepatitis acquired through blood transfusion are unfortunately not recorded as accurately as those of HIV, but that does not mean it is not happening.

This also brings us to the question of quality control in blood transfusion services. Though the country now has a National Blood Transfusion Council, with counterparts in several (but not all) states, it is hardly equipped to conduct FDA-style policing of the hundreds of legal blood banks functioning all over India. The onus for that still rests on the drug control departments in various states, which are overburdened with the gargantuan tasks of controlling the quality of 60,000 drugs in the market as well as the entire food industry. Where do they have the time or financial resources to take up yet another responsibility?

The only way out is to ensure that the available blood is used more efficiently and thus reduce the demand for transfusable blood. There are two ways to do this. One is to order a blood transfusion only when nothing else will do. But products of technology such as high molecular weight proteins can look after a severe volume loss, as in an accident case. Or packed cells could be administered instead of whole blood, while the serum can be used for some other patient. Similarly, leading professors of surgery used to say that if somebody has ordered just one unit of blood to be kept ready, that unit could very probably be avoided. The idea is that even if there is a crisis, blood substitutes are available. This age-old dictum can be propagated as widely as possible.
To make blood products available, however, we will now have to set up what may be called a "blood industry", on the lines of the pharmaceutical industry, where Good Manufacturing Practices are clearly defined and closely. This has to start with the procurement of blood from reliable donors, who must be screened before hand, not only from the point of view of infectious diseases but also conditions like anemia. Extensive databases of such blood donors have to be prepared so that a continuing supply can be assured.

Thereafter comes the need for setting up fractionation units in different locations in the country, so that the donated blood can be broken up into its components. By testing the huge quantities of blood for HIV and other illnesses, instead of screening each unit at a time, would also help to reduce the costs of the procedures. To some extent, the well known principle of economies of scale would operate here.

This technique, described loosely as "pooling of blood" was once discouraged by AIDS activists including Indian Health Organization secretary Ishwarprasad Gilada, because of the relatively high proportion of false negative and false positive results from the earlier generations of ELISA test kits. Today, however, with the latest generation of ELISA kits, this problem has become almost non-existent. Hence Gilada himself is much more flexible today than he used to be even five years ago.

The last but not the least is the system of autologous transfusion, that is, giving one's own blood to be kept ready transfusion during surgery at a later date. In the West, this concept is slowly but steadily gaining acceptance. It is surely worth examining in the Indian context.