Black People: Please Give Blood (Unless You're African)

When am I going to learn to avoid blood donations during the news hour? I made donation 71 today at Canadian Blood Services (CBS). I scheduled the donation for 5:55pm, and so I overheard the 6pm local "news" broadcast from our local CTV affiliate CKCO. To the program's credit, they aired one story about The Lancet retracting support of a study that linked vaccinations to autism. They also aired some nationalist propaganda of how visiting dignitaries will be fed raw seal meat to demonstrate how much the EU ban on Canadian seal hunting will hurt the North (which is infuriating: this issue is about seal fur, seal skin, and scapegoating seals for human overfishing. It is not about the domestic consumption of "country food" or even exporting seal meat).

I'm pretty sensitive to local TV nonsense; I don't have TV at home or work, so I only get to consume television when I am giving blood. So it was particularly bad luck that I happened to give blood on the same day the "local news" aired a "news story" urging local black people to give blood. The story said that there are very few black blood donors in Canada (the figure was 1% or 0.4% or something ridiculous like that) and that as a result black people who need close genetic matches for things like plasma and blood marrow lose out.

Why don't black people give blood? The newscast suggested that black people did not know the importance of giving blood. Then they interviewed the minister at some local church to echo that sentiment (because, of course, church ministers are appropriate spokespeople for the entire black community).

What a crock. The "news story" failed to mention the real barrier to black people giving blood in Canada: Canadian Blood Services is at best culturally insensitive and at worst racist. They go out of their way to make sure people from white cultures can donate blood easily, and they put up all kinds of barriers to people of other cultural ethnicities who might like to donate. As usual, black people get the worst of it.

Banning Africans

This is a strong claim, and there is a very long entry that could be written to back it up. For now, let's focus on the gaping hole in this "news story": the "journalist" did not mention the final question of the Canadian Blood Services questionnaire. This question (which is in the "high risk" section) asks potential donors three things:

Were you born in or have you lived in Africa since 1977?
Since 1977, did you receive a blood transfusion or blood product in Africa?
Have you had sexual contact with anyone who was born in or lived in Africa since 1977?

Failing these questions earns you an "indefinite deferral" from giving blood in Canada. In other words, you are BANNED FOR LIFE.

This was the wording as of the April 2009 version of the screening form, which is available at http://blood.ca . This link worked for me as of this writing, but new versions of the form come out occasionally.

Before reading further, ask yourself why the above questions are on the screening questionnaire at all. Then ask yourself why these questions are in the high-risk portion of the questionnaire. Can you figure it out? The actual reason might surprise you.

The Official Explanation

I was hoping to avoid a long discussion of the reasoning behind this question, but I don't think I can avoid it without being accused of libel. Previous versions of this form did not use the word "Africa". Instead, the form (and nurses who administered the high-risk portion of the questionnaire) rattled off a specific list of eight African countries: Instead, the nurses rattled off a specific list of African countries: Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger and Nigeria.

According to documentation on the official website, as of this writing the indefinite deferral still applies to those eight countries only. My guess is that if you answer "yes" to any of these questions then you are asked to identify the specific country (or countries) involved. Personally, I think that substituting "Africa" for "Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, and Nigeria" is itself a comment about the possible racism and/or cultural insensitivity of Canadian Blood Services. If CBS is having so much trouble attracting black donors, why would it want to make it appear that more Africans are BANNED FOR LIFE than necessary?

It is also really easy to misinterpret the official explanation for this question and the indefinite deferral. Despite what you (and many many others) might think, the deferral is not because HIV is frighteningly common in Africa. Otherwise, South Africa (which is always interesting given its well known white population) and Botswana would be on that list. The official reason is because HIV is rare -- specifically, there is a variant (HIV-I Type O) of HIV that has been found only in the above eight countries. This variant is special because the usual HIV antibody tests have traditionally not detected it effectively (in part because it is so rare). In the pursuit of "keeping the blood supply safe" Canadian Blood Services has decided to ban anybody who has had contact with those countries.

Of course, people who see this question are often not aware of the official explanation. Many of them jump to different conclusions. Did you? If so, ask yourself why Canadian Blood Services is so invested in the wording of the question when they are already facing perception problems and donor shortages among black people.

Sex Partners and Cognitive Load

As if BANNING FOR LIFE people for the high-risk behavior of living in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger or Nigeria is not sketchy enough, Canadian Blood Services has decided to ban the sexual partners of those people as well. This is where CBS indisputably crosses the line, in my opinion. If you accept the premise that sexual relationships between black people are more prevalent than sexual relationships between black people and people of other races, then it is hard to deny that CBS is discriminatory. Specifically, CBS places a (significantly!) higher cognitive burden on potential black donors than on potential donors of other ethnicities.

First, let's note that screening based upon the behaviour of your sex partners is inherently more of a burden than screening based upon your own behaviour. You probably know whether you have ever used illegal drugs or steroids with a needle. If you are male, you probably know whether you have had sex with a man even once since 1977. Answering such questions truthfully about your past and present sex partners is harder.

Nonetheless, Canadian Blood Services does ask other screening questions based on the activities of sex partners. Here they are:

Have you had sex with anyone who has AIDS or has tested positive for HIV and AIDS?
Female donors: In the last 12 months, have you had sex with a man who has had sex, even one timne since 1977 with another man?
Have you had sex in the last 12 months with anyone who has ever taken illegal drugs or illegal steroids with a needle?
At any time in the last 12 months, have you had sex with anyone who has taken money or drugs for sex?
Have you had sex in the last 6 months with anyone who has taken clotting factor concentrates?
In the past 6 months, have you had sex with someone whose sexual background you don't know?

and then the question under investigation:

Have you had sexual contact with anyone who was born or lived in Africa since 1977?

There's a pattern here. Two of the questions (of sleeping with somebody who is HIV+ or sleeping with somebody who has done drugs with needles) expect you to remember all of the sex partners you have ever had. Both being HIV+ and doing illegal drugs or steroids with a needle are pretty highly correlated with being HIV+. The needle question is tricky because your partners may not have disclosed this information. The HIV question is probably easier.

The African question expects you to remember all of the sexual partners you have had since 1977, for the "high-risk" behaviour of living in Africa (oops -- living in the magical eight countries), where "high-risk" is defined as "possibly having a really rare variant of HIV regardless of their sexual history".

All the other questions are time-limited. You only have to know about your sex partners in the past year. Even the infamous "have you ever had sex with another man" question only has a 12 month window.

It is not hard for you to know whether you have ever had a black sexual partner. It probably is not even hard to tell whether your black sexual partner is from Africa (as opposed to the Caribbean or North America or someplace else). Knowing exactly which African country your partners have lived in? That's tougher. Unlike Canadian Blood Services, I do not assume that Africa is a homogenous lump. But if fifteen years ago you had a one-night stand with a black person, knowing whether that person came from Equatorial Guinea, Guinea, or Guinea-Bissau is a deciding factor whether you are BANNED FOR LIFE from giving blood or not.

Maybe you disapprove of one-night stands. But Canadian Blood Services doesn't -- unless you are sleeping with Africans, interveneous drug users or HIV+ people, you don't even have to remember your one-night stands two years ago, never mind fifteen years ago.

This completely ignores the question of execution. Say that you answer "yes" to the question. My understanding is that the nurse is supposed to clarify your situation. We are assuming that this will always happen, and that the nurses will screen based on the eight countries, not on all of Africa. Despite this variant of HIV-1 being rare, I suspect that if you display any uncertainty about every African sex partner you have had since 1977, you will be BANNED FOR LIFE. Despite the shortage of black donors, I am pretty sure nurses would rather cover their asses rather than get in trouble for letting ineligible donors through. If one of those uncertain donors ends up being HIV+ (regardless of whether they got it from sleeping with somebody from one of the eight countries or a nice middle-class white person who from British Columbia), there will be a big stink. It's better to be safe than sorry, right?

African Tourists vs African Citizens

I would argue that the above already constitutes a systemic chilling effect against black people (including those from the Carribean or North America) giving blood. But it gets better: from what I remember from previous conversations with CBS nurses, "living" in Africa means staying there for six months or more.

If this is true, that means that those young (largely white, largely middle-class) idealists at Engineers Without Borders can go off on their touristy four-month African internships without getting BANNED FOR LIFE. The young idealists do have to put up with long deferrals (as does anybody who travels outside the U.S. or Canada, which is another interesting cultural message) but eventually they can give blood again. But if you were born in Africa and immigrated to Canada when you were two years old, then you are BANNED FOR LIFE.

This also means that all of the other largely white middle-class people those young internists sleep with will also continue being eligible to give blood (especially if they remain ignorant about their partners' previous internships). Convenient, no?

The Message: Africa is Dirty

None of this is explicitly racist, of course. It's just culturally offensive. Whether intentional or not, the message is clear: Africa is dirty, and it is totally acceptable to ban every inhabitant of an entire continent from giving blood on the basis that they are "high-risk". There are a lot of black people (from Africa and other places) who identify with Africa strongly. This policy tells them that their continent is dirty.

This is important. Just as the infamous MSM questions make a lot of people feel uncomfortable with Canadian Blood Services, I can't imagine that having screening questions about all of Africa (especially when they aren't technically about all of Africa) earns CBS a lot of friends among those who care about Africa and its perception as scapegoat of the world.

What about Europe?

Yes, people who have lived in several non-favoured European countries (i.e. not the UK or France) for five or more years are also deferred on the basis that they might have Creutzfeldt-Jacob disease (vCJD, aka "mad cow" disease).

Furthermore, there is a parallel between Europe and Africa in the
screening. The question "Have you spent a total of five or more years
in Europe since January 1, 1980?" actually does not refer to all of
Europe. Just as with Africa, [this deferral is more
limited](http://www.bloodservices.ca/CentreApps/Internet/UW_V502_MainEngine.nsf/page/vCJD%20An%20Introduction): the only countries on the blacklist are Belgium, Luxembourg, Spain, Germany, Italy, Switzerland, Republic of Ireland, Netherlands, Austria, Liechtenstien, Portugal and Denmark.

Does that mean CBS is even-handed? I don't think so.

Firstly, even though that question also results in "indefinite deferral" the question itself is not in the high-risk section of the questionnaire.

Secondly, judging from the huge amount of effort that CBS has done to limit the European ban as much as possible, I do not expect that this indefinite deferral will translate into a lifetime ban -- Canadian Blood Services will lift that ban or restrict it to a specific time period as soon as they can get away with it. In contrast, the stated restrictions against Africans have become broader, not narrower.

Thirdly, there are other sources for genetically European blood that can donate easily -- namely white North Americans. In Canada, the pools for drawing on non-African blood from black people is thinner (although still present, thanks to black immigration in the maritimes and a reasonable Carribean immigrant population). The supply in Kitchener-Waterloo is especially thin: from what I can tell a sizeable fraction of the black population here is composed of first-generation immigrants and refugees from Africa. Given this lack of donors, you would expect that CBS would attempt to make the screening process friendlier to Africans, not less friendly. Their public appeal tells one story; their screening processes another.

Managing Risk

The original restrictions were put in place because there were no officially-reliable tests available. Apparently, these tests are coming if they are not here already. Once the tests are available we will be able to determine just how much Canadian Blood Services cares about the health of black people in Canada. If Canadian Blood Services switches to the new tests that effectively screen for HIV-1 Type O and lifts the BAN FOR LIFE, then my argument gets a lot weaker.

Canadian Blood Services says that the reasoning behind the African ban is to protect the blood supply. However, if you restrict donors too much (say, by banning potential donors from entire countries) then you necessarily reduce the quality of care to those recipients who have specific genetic restrictions in their blood.

It is true that there is more genetic diversity across races than within races. But it is also true that certain genetic characteristics are concentrated within certain genetic (and to some degree racial) communities. That is why Canadian Blood Services is mounting these public outreach campaigns to ethnic minorities in the first place.

This brings up the issue of risk. The most effective way to "keep the blood supply safe" is to screen out EVERYBODY. Then you guarantee that nobody will donate tainted blood that infects somebody with HIV -- but then a lot of people suffer and/or die for lack of blood. There is a tradeoff here. To me it looks like the draconian restrictions Canadian Blood Services puts on African donors specifically and black donors in general has the effect of reducing the supply of blood products (and bone marrow) to sick people of African descent. Maybe you don't have a problem with that, but I do: Canadian Blood Services has put into policies that systemically lower the quality of care for people of certain genetic backgrounds. That sounds awfully close to racism for me, especially when you look at the history of the vCJD restrictions on people from Britain and France.

It might cost more (maybe a lot more) to administer HIV antibody tests that effectively screen for the rare HIV-1 Type O variant. But if Canadian Blood Services continues their current policy of "Indefinite Deferral" even when such tests are available, it will demonstrate that they are more concerned with covering their asses than providing a good supply of blood products to black people. CBS does not even need to use the more expensive tests for every potential donor; it could continue screening for donors from the eight countries, and then administer the tests on the blood of those donors it suspects may have been exposed to infection.

Update

It appears that the U.S. Food and Drug Administration has approved at least one screening test which detects HIV-1 Type O. The name of this product is "Genetic Systems HIV-1/HIV-2 Plus O EIA". This test was approved in 2003. There is at least one other test which has been approved by the FDA; see the complete list for more information. I don't know the exact implications of this (not all of these tests are approved for donor screening) but the evidence is strong that it is possible to test for HIV-1 Type O.

Blaming the Victim

What really gets me upset is that Canadian Blood Services has the audacity to blame the victim. First, they render ineligible a huge swath of the potential black donor pool. Then they subjugate the potential donors who are left to ridiculous overly-broad questions. And then they complain that there aren't enough black donors, and that all those black people are just too ignorant to know they should give blood.

Unlike the "local news" and Canadian Blood Services, I do not believe that black people are ignorant or stupid. I believe that black people (and to a lesser extent other ethnic and cultural minorities) directly or indirectly learn that they are not welcome donating blood and blood products in Canada. I am willing to give CBS credit for their public outreach programs to ethnic minorities, but their approach is decidedly two-faced and therefore likely to be ineffective.

Why am I blaming CBS for this? Wasn't this story produced by our local TV affiliate? Yes, and they are guilty of failing to conduct even the slightest bit of investigative journalism. This really is the official Canadian Blood Services story; I am sure they are exceedingly pleased with the "news" coverage of their appeal.

tl;dr

I think it is pretty apparent that Canadian Blood Services is culturally insensitive. Are they racist? I say yes:

Their appeal is to the black community, which is based on race.
CBS is making this appeal on the grounds that there are not enough black donors.
CBS has chosen to manage the risk of screening donors in ways that make it harder for Africans (and the people who have sex with them) to give blood and make it easier for other (primarily white and favoured minorities in North America) to give blood.
These screening procedures are not officially race-based, but because of local/national demographics they have the effect of screening based on race.
CBS understands these criticisms and steadfastedly refuses to alter their screening because they want to cover their asses. In fact, they have made the screening questions more broad over the years, not less broad.
Therefore black people (or at the very least African people) who need genetically-close blood products suffer.

Then they blame the victims for being ignorant. Awesome.

A Final Note

Do the deplorable practices of Canadian Blood Services mean you should avoid giving blood? I say no. Despite bearing some really strong negative feelings towards the organization, I intend to continue giving blood until at least my 75th donation (or until I am BANNED FOR LIFE, whichever comes first). CBS is the only game in town. I believe that blood transfusions are medically necessary. So I give blood, and if you are eligible I hope you will as well.