inequality and expectations.

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Sometimes reading two things together brings certain details to the front. The other day I was reading two blogs about obstetrics in other countries. One of them is by a doctor who went with Doctors Without Borders (MSF) to work in Sierra Leone. The other blog is by a doctor who lives and works in India.

The doctor in Sierra Leone mentions recruiting blood donors from among a patients relatives and from hospital staff. He also describes autotransfusion where they scoop blood from the abdomen of a woman with a ruptured tubal pregnancy:

She didn’t have any blood donors available so we auto-transfused her with her own blood. This was a first for me and it was pretty basic, nothing fancy. We used a ladle to scoop blood out of her abdomen and pour it into a container then ran it through something like a cheesecloth to remove the clots and then poured it into some blood transfusion bags and starting running it right back into her veins. Her hemoglobin was 3.2 when we started the case, very low. When we checked it afterwards it was almost 6, still low but double what it was before. I was pretty impressed with the whole process. It’s not an option if the mother has a fever because you don’t want to be putting infected blood straight into her veins but in cases like this one it can literally mean the difference between life and death. Barring any complications she should do well and walk out of here in pretty good shape, anemic still but with iron tablets she’ll build her blood back up to normal levels within a few weeks.

The doctor in India writes that they used to be able to do direct blood transfusions from one person to another but they cannot anymore because of rule changes. The consent form says:

. . . there is no blood bank in NJH . . . if we have to operate with a low hemoglobin, we give authorization to do the surgery without blood . . . the responsibility of getting blood is with us and not with the hospital . . .

If a patient at the hospital requires blood the family has to go and buy blood at a blood bank and bring it to the hospital. He describes the price:

In our nearest blood bank, the usual practice is to allot a pint of blood for 350 INR if the relatives are able to donate blood. However, when one cannot arrange a donor, there are processes quite unknown to most of us by which you can buy the blood from elsewhere at rates ranging from 2400 to 4000 INR.

In India unbanked blood transfusions have been banned so they can’t hook a relative up and transfer blood directly, like the doctor in Sierra Leone does. The Indian doctor has to refer people off to other hospitals too, even when they know that for financial reasons the person will not go to the other place but simply home to die, whereas it sounds from the blog like in Sierra Leone there is no where else to go so they do whatever they could. Is a half measure better than no measure? Or would half measure prevent a person from seeking the full measure they need?

It is weird thinking about the different rules and expectations, and how rules meant to keep people safe can at times cause people harm. Yet I’m not a believer that we need to deregulate everything. Some things yes, but not everything. Thoughtful changes to regulations, in response to situations.

It sounds bad to admit that there have to be different standards for poor areas. It comes close to sounding like lower standards as though the poor don’t deserve the same regulation. Except that to hold people to standards that they lack the resources to meet can be just as problematic.

I remember years ago in college while mad cow disease was a big deal in the news and a classmate suggested that instead of killing potentially contaminated herds and destroying the meat that the meat should be shipped to starving people overseas, because the horror of dying at some later time of mad cow might be less than starving in the meantime. People were horrified at the suggestion because it seems wrong to give to others what we would deem unsafe for ourselves. We want to believe that we value their lives as much as we value our own, accepting their poverty as beyond our capability to control.

Of course critics of the ban on unbanked blood transfusions are not all saying that the poor aren’t as deserving as those better off. The articles advocating for India to change its laws say that the unbanked blood is still tested and safe. They’re advocating for what is possible for rural clinics right now. And that makes sense. But still, it raises all sorts of questions of the perfect standing in the way of the good, and of what risks different people have to take.

The inequality in the world horrifies me. I’m writing this while my oldest son listens to the audio book of Catching Fire by Suzanne Collins and part of me feels like I’m part of the capital, thinking about the medical care available to me that is not available to so many others. And in the news are question of when a teenager declared brain-dead will be removed from a ventilator. As sorrowful as that whole situation is, what luxury to have that possibility of waiting, taking time to come to terms with what has happened, when viewed in comparison to a Sierra Leone hospital with a single operating room

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