tag:theconversation.com,2011:/us/topics/blood-supply-34684/articlesBlood supply – The Conversation2022-10-23T12:30:32Ztag:theconversation.com,2011:article/1927462022-10-23T12:30:32Z2022-10-23T12:30:32ZPaying for plasma is the new normal: Why policy has changed decades after Canada’s tainted blood scandal<figure><img src="https://images.theconversation.com/files/491135/original/file-20221021-20-u4i9xy.JPG?ixlib=rb-1.1.0&rect=102%2C54%2C4449%2C2756&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Blood plasma and products made from it are used to treat conditions ranging from blood clotting disorders to immunodeficiencies to Rh-negative pregnancies.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/AP-Arnulfo Franco</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/paying-for-plasma-is-the-new-normal--why-policy-has-changed-decades-after-canada-s-tainted-blood-scandal" width="100%" height="400"></iframe>
<p>There has been a monumental policy shift in paying plasma donors in Canada.</p>
<p>In September, <a href="https://www.blood.ca/en/about-us/publications-and-reports/annual-reports">Canadian Blood Services</a> (CBS) made a <a href="https://www.grifols.com/en/view-news/-/news/grifols-enters-into-agreement-with-canadian-blood-services-to-accelerate-self-sufficiency-in-immunoglobulins-for-canada">15-year deal</a> with Spanish health-care giant Grifols for blood plasma collection and products. The deal upends the 1997 recommendations from the <a href="https://publications.gc.ca/site/eng/9.698032/publication.html?wbdisable=true">commission of inquiry into the tainted blood scandal</a> that urged no paid donations of blood or blood products.</p>
<p>More than 30,000 Canadians were infected with hepatitis C and another 2,000 contracted HIV from tainted blood and blood products during the ‘70s and ‘80s, resulting in more than <a href="https://www.thecanadianencyclopedia.ca/en/article/krever-inquiry">8,000 deaths</a>. </p>
<p>“The hemophilia community was decimated by HIV and hepatitis C through tainted blood,” David Page, national director of health policy at the <a href="https://www.chscontact.ca/">Canadian Hemophilia Society</a>, said at a <a href="https://sencanada.ca/en/Content/Sen/Committee/421/SOCI/53ev-54542-e">2019 Senate hearing</a>. </p>
<p>The <a href="https://publications.gc.ca/site/eng/9.698032/publication.html?wbdisable=true">Commission of Inquiry on the Blood System in Canada</a> released its final report in 1997. The recommendations were clear: do not pay blood donors, including those who donate plasma, “except in rare circumstances.” </p>
<h2>Policy shift</h2>
<p>Fast forward almost three decades and paying plasma donors is standard practice for <a href="https://giveplasma.ca/donors/compensation/">private plasma collection sites</a>. It’s supported by CBS (although it does not pay donors directly at its own sites), Health Canada and many of the groups most adversely affected by the tainted blood scandal, including <a href="https://chscontact.ca/chs-strongly-supports-cbs-plasma-initiative/">hemophiliacs</a> and those with <a href="http://www.cipo.ca/2022/08/15/update-on-canadian-blood-services-news/">primary immunodeficiency disorders</a> whose lives rely on plasma products.</p>
<figure class="align-center ">
<img alt="A window with the logo of Canadian Blood Services" src="https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In September, Canadian Blood Services made a deal with Spanish-based health-care giant Grifols for blood plasma collection and products.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jeff McIntosh</span></span>
</figcaption>
</figure>
<p>Paid plasma donors can donate up to twice per week and can earn in excess of $500 per month by donating at the maximum frequency and volume of plasma collected, according to <a href="https://giveplasma.ca/donors/compensation/">Canadian Plasma Resources</a>, a company with plasma collection centres in the <a href="https://giveplasma.ca">Prairie provinces as well as New Brunswick</a>. </p>
<p>What caused this policy shift? Essentially: enhanced donor screening, rigorous regulation by both <a href="https://www.canada.ca/en/health-canada/services/drugs-health-products/biologics-radiopharmaceuticals-genetic-therapies/activities/fact-sheets/plasma-donation-canada.html">Health Canada</a> and the U.S. Food and Drug Administration, viral inactivation by heat or solvent processes and synthetic methods to produce some plasma products, namely clotting factors. </p>
<p>Page’s opinion has changed. In an interview, he said he feels that sufficient measures have been put in place to make plasma products safe, and supports using plasma from paid donors as a necessity to meet the health-care needs of Canadians. </p>
<p>In the quarter of a century since the tainted blood scandal there has not been a single case of disease transmission via a blood product in Canada, Page pointed out. He attributed this to enhanced regulatory and safety measures. </p>
<h2>Canada’s plasma supply</h2>
<p>The change in policy reflects a little-recognized truth about Canada’s blood system: It doesn’t come close to meeting the nation’s need.</p>
<p>In 2017 Health Canada established an expert <a href="https://www.canada.ca/en/health-canada/programs/expert-panel-immune-globulin-product-supply-related-impacts-canada/protecting-access-immune-globulins-canadians.html">panel on Immune Globulin Product Supply and Related Impacts</a>. It reported that more than 80 per cent of fractionated plasma products, namely immunoglobulins, comes from imported product, almost all from paid donors in the United States. It has cost CBS more than <a href="https://www.blood.ca/en/about-us/publications-and-reports/annual-reports">$700 million</a> a year. </p>
<p>CBS has set an objective of reducing dependence on imports of plasma-derived immunoglobulins to at least 50 per cent, and must do so “with a degree of urgency” <a href="https://drive.google.com/file/d/1_H5PI2JZFqmD_VP7z1ESDrO5AZmAa0sO/view">says Graham Sher</a>, CEO of CBS. </p>
<p>The new <a href="https://www.grifols.com/en/view-news/-/news/grifols-enters-into-agreement-with-canadian-blood-services-to-accelerate-self-sufficiency-in-immunoglobulins-for-canada">deal with Grifols</a> will provide 2.4 million grams of plasma-derived immunoglobulins, collected from Canadian donors, helping CBS reach its targets. </p>
<p>The company entered the Canadian market in 2011 and has a plasma fractionation plant in Montréal and a plasma collection site in Winnipeg. In addition, Grifols plans to expand paid plasma donor sites in Ontario and British Columbia as agents of CBS. </p>
<p>Neither side will reveal the contract details.</p>
<p>The deal with Grifols, by itself, will not meet CBS’s 50-per-cent target. To make up the difference <a href="https://www.blood.ca/en/about-us/media/newsroom/securing-canadas-plasma-supply">CBS plans</a> to increase its own dedicated plasma collection sites from five to 11 by 2024. CBS’s own plasma donation sites will remain uncompensated. </p>
<h2>Plasma and plasma products</h2>
<figure class="align-center ">
<img alt="Gloved hands holding up an IV bag filled with yellow fluid" src="https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&rect=154%2C32%2C5280%2C3837&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Plasma donation can take up to two hours, significantly longer than donating whole blood.</span>
<span class="attribution"><span class="source">(AP Photo/Juan Karita)</span></span>
</figcaption>
</figure>
<p>Plasma differs from the whole blood that is collected for transfusion at donor clinics across the country. </p>
<p>During plasma collection, red and white blood cells and platelets are returned to the donor, leaving a straw-coloured liquid called plasma. This process is called <a href="https://www.canada.ca/en/health-canada/services/drugs-health-products/biologics-radiopharmaceuticals-genetic-therapies/activities/fact-sheets/plasma-donation-canada.html">plasmapheresis</a>. </p>
<p>Essential proteins, such as albumin, clotting factors and immunoglobulins, are recovered from the plasma through <a href="https://www.blood.ca/en/about-us/media/newsroom/plasma-and-blood-system-supply-chain">fractionation</a>.</p>
<p>Such plasma is called “source plasma” and is used only after it has been treated to remove or inactivate viruses and other pathogens. CBS cannot supply sufficient source plasma products, namely immunoglobulins, from unpaid donors, to meet the needs of Canadians and has been buying fractionated plasma products since its inception in 1998. It spent more than $200 million on plasma in 2000 and within the last five years has spent more than <a href="https://annual2019.blood.ca/?_ga=2.139020853.760828163.1666374799-375334784.1662912652&_gl=1*1ba3sb6*_ga*Mzc1MzM0Nzg0LjE2NjI5MTI2NTI.*_ga_YHMRKTXXVD*MTY2NjM3NDc5OS44LjEuMTY2NjM3NTEzNy4wLjAuMA">$700 million per year</a>. </p>
<p>For patients with <a href="https://www.canada.ca/en/health-canada/programs/expert-panel-immune-globulin-product-supply-related-impacts-canada/protecting-access-immune-globulins-canadians.html">immunodeficiencies, those requiring protection from diseases such as rabies or tetanus or Rh-negative pregnant patients</a>, there are no other treatment options. </p>
<h2>Opposition</h2>
<p>Meanwhile, there is still opposition to paying plasma donors. <a href="https://bloodwatch.org/">BloodWatch</a>, a not-for-profit organization, opposes paying donors for plasma or other human tissues. It is a strong proponent of a fully public blood collection system, as is the <a href="https://www.healthcoalition.ca/">Canadian Health Coalition</a>. </p>
<p>BloodWatch cites safety, profit making and potential exploitation of plasma donors as reasons to reject the Grifols deal. A hybrid system of paid and unpaid donors competes with, and compromises, Canada’s ability to become self-sufficient, it argues.</p>
<p>The Canadian Hemophilia Society’s Page disagrees.</p>
<p>“We generally do not make drugs with our public health-care system,” he says, likening fractionated plasma products to drugs. Not least, he adds, plasma collection takes up to two hours, more than twice as long as conventional blood donation. </p>
<p><em>Dr. Sandor Demeter is Fellow of the Dalla Lana Fellowship in Global Journalism</em></p><img src="https://counter.theconversation.com/content/192746/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sandor Demeter does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There has been a monumental policy shift in paying blood plasma donors in Canada.Sandor Demeter, Associate Professor, Community Health Sciences, Rady Faculty of Health Sciences, University of ManitobaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1334242020-03-12T12:05:11Z2020-03-12T12:05:11ZHow coronavirus is upsetting the blood supply chain<figure><img src="https://images.theconversation.com/files/319991/original/file-20200311-116261-humyx0.jpg?ixlib=rb-1.1.0&rect=0%2C10%2C6800%2C4122&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The coronavirus could cause shortages in the nation's blood supply. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/coronaviruses-research-conceptual-royalty-free-illustration/1205741280?adppopup=true">Getty Images / KTS Design / Science Photo Library</a></span></figcaption></figure><p>The coronavirus, which causes the disease COVID-19, has created enormous anxiety, uncertainty, and disruption to our lives. Much has already been written about potential shortages of <a href="https://www.businessinsider.com/drugs-at-risk-of-shortages-because-of-the-coronavirus-outbreak-2020-3">medicines</a> and <a href="https://www.npr.org/sections/health-shots/2020/03/05/811387424/face-masks-not-enough-are-made-in-america-to-deal-with-coronavirus">face masks</a>, but little has been said about something only you and I can provide – lifesaving blood.</p>
<p>Our nation’s blood supply is essential to our health care security. Blood transfusions are integral parts of major surgeries. Blood is used in the treatment of diseases, particularly sickle cell anemia and some cancers. Blood is needed for victims who have injuries caused by accidents or natural disasters. <a href="https://www.redcrossblood.org/donate-blood/how-to-donate/how-blood-donations-help/blood-needs-blood-supply.html">Every day</a>, the U.S. needs 36,000 units of red blood cells, 7,000 units of platelets, and 10,000 units of plasma.</p>
<p><a href="https://people.umass.edu/nagurney/">I am a professor</a> and director of the Virtual Center for Supernetworks at the <a href="https://scholar.google.com/citations?user=ecFsBp0AAAAJ&hl=en">University of Massachusetts Amherst</a>. Because of the <a href="https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6">escalating coronavirus health care crisis</a>, I am deeply concerned the U.S. blood supply chain is under stress. The timing could hardly be worse; the COVID-19 outbreak coincides with our seasonal flus and colds. </p>
<h2>Patients need blood in many states</h2>
<p>Many states, including <a href="https://q13fox.com/2020/03/05/blood-donation-shortage-reported-during-coronavirus-outbreak/">Washington</a>, <a href="https://www.latimes.com/california/story/2020-03-07/amid-coronavirus-concerns-officials-call-on-public-to-donate-blood">California</a>, <a href="https://www.kansascity.com/news/business/health-care/article240891221.html">Kansas</a>, <a href="https://www.citizensvoice.com/news/coronavirus-threatens-blood-supply-as-donations-fall-1.2605604">Pennsylvania</a>, <a href="https://www.newsobserver.com/news/local/article241024616.html">the Carolinas</a>, <a href="https://www.boston.com/news/health/2020/03/10/red-cross-blood-coronavirus">Massachusetts</a> and <a href="https://turnto10.com/news/local/ri-blood-center-in-need-of-donors-as-coronavirus-fears-continue-to-heighten">Rhode Island</a>, are now calling for blood donations. At the same time, some states are closing schools and other sites that typically host mobile blood drives; even prior to the coronavirus, some events had been canceled. <a href="https://www.wwlp.com/news/local-news/hampden-county/red-cross-plans-to-end-mobile-blood-drives-in-western-massachusetts/">In Massachusetts</a>, the Red Cross announced <a href="https://www.masslive.com/news/2019/09/american-red-cross-announces-layoffs-ends-bloodmobile-in-central-and-western-massachusetts.html">last September</a> it would no longer be hosting blood drives in the central and western parts of the state. Obviously, this makes it even harder for people to donate.</p>
<p>Even in the best of times, <a href="https://supernet.isenberg.umass.edu/articles/CompetitionforBloodDonations.pdf">less than 10%</a> of the U.S. population donates blood in a given year, although 38% are eligible. And these are not the best of times. Other than donations, there is no way to maintain a sufficient supply of blood. It cannot be manufactured, and no substitute for it has yet been invented. What’s more, it’s <a href="https://supernet.isenberg.umass.edu/articles/BloodSupplyChains.pdf">perishable</a>. Red blood cells last 42 days, and platelets only five. Regular replenishment of the supply is imperative. On top of that, the blood banking industry was already facing major challenges before COVID-19; the U.S. supply chain is now undergoing <a href="https://supernet.isenberg.umass.edu/articles/MultitieredBSCcompetition.pdf">major economic transformations</a>. This includes increased competition among blood service organizations. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/320014/original/file-20200311-116232-1aclod5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/320014/original/file-20200311-116232-1aclod5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/320014/original/file-20200311-116232-1aclod5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/320014/original/file-20200311-116232-1aclod5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/320014/original/file-20200311-116232-1aclod5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/320014/original/file-20200311-116232-1aclod5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/320014/original/file-20200311-116232-1aclod5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Even with coronavirus, solutions exist for the potential blood supply problem.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/donating-blood-royalty-free-image/1093904838?adppopup=true">Getty Images / Petri Oeschger</a></span>
</figcaption>
</figure>
<p><a href="https://supernet.isenberg.umass.edu/articles/BloodSupplyChains.pdf">Our blood supply chain</a> is stunningly complex. It requires altruistic donations, collection, testing, processing and distribution to hospitals and medical centers. All along the way, the coronavirus can disrupt any of these essential steps. If donors are ill, they cannot donate; if the staff is ill, they cannot collect, test and process. If our health care workers are compromised, they cannot transfuse. </p>
<p>Our <a href="https://supernet.isenberg.umass.edu/articles/BloodSupplyChainCompetition_Nagurney_Dutta.pdf">recent study</a> on the blood supply chain offers some possible solutions. We developed a multi-tiered, competitive supply chain network model for the industry, focused on the United States. The model addressed the very relevant scenario of a major disease outbreak accompanied by significant donor drops and decreased capacity due to limited testing, processing and storage. Our computer-based tool reveals that blood service organizations may gain by cooperating rather than competing. <a href="https://supernet.isenberg.umass.edu/articles/Blood_Supply_Chain_Merger.pdf">Another study</a> of ours also supports this conclusion. </p>
<p>To avoid shortages, the American Red Cross is encouraging healthy, eligible individuals to schedule a blood or platelet donation at <a href="https://www.redcross.org/about-us/news-and-events/press-release/2020/red-cross-media-statement-on-2019-novel-coronavirus.html">Redcrossblood.org</a>. Donating blood is safe, and <a href="https://www.redcross.org/about-us/news-and-events/press-release/2020/red-cross-media-statement-on-2019-novel-coronavirus.html">there is no evidence</a> that COVID-19 can be transmitted by blood transfusion. This was also the case for other major coronaviruses, SARS and MERS-CoV.</p>
<p>That said, blood service organizations may <a href="http://www.aabb.org/advocacy/regulatorygovernment/Pages/Statement-on-Coronavirus-and-Blood-Donation.aspx">implement donation deferrals</a> for those who have traveled to certain countries or been in contact with someone with the coronavirus. <a href="https://www.boston.com/news/health/2020/03/10/red-cross-blood-coronavirus">These extra efforts</a> ensure the environment is safe for donors.</p>
<p><a href="https://www.reuters.com/article/us-china-health-blood/chinas-blood-donations-dry-up-as-coronavirus-outbreak-quells-giving-idUSKCN20K1DS">In China</a>, where the coronavirus originated, blood donations have dried up. Its medical professionals, already under major stress, are trying to take up the slack themselves by donating their own blood. Let’s make certain that doesn’t happen in the United States. Instead, as blood service organizations recognize the need to cooperate, let’s make an appointment to donate. Do that, and we can battle this outbreak together.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/133424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Nagurney does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The US blood supply chain is often fragile, but the coronavirus could make it more so. An expert explains.Anna Nagurney, John F. Smith Memorial Professor of Operations Management, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1157502019-04-19T10:45:49Z2019-04-19T10:45:49ZWhen is dead really dead? Study on pig brains reinforces that death is a vast gray area<figure><img src="https://images.theconversation.com/files/270045/original/file-20190418-28097-1qmsb2d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A recent study of the brains of decapitated pigs showed activity in their brains four hours later. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baby-pig-posing-farm-141750778?src=4Ach7rg5QeRED6FtHaA3PA-1-6">Ivan Loran/Shutterstock.com</a></span></figcaption></figure><p>For the longest time, “death” used to be when the heart stopped beating and breathing stopped. Then, machines were invented in the 1930s that enabled people to receive air even if they could not take in the air themselves. In the 1950s, machines were developed to help sustain heartbeat. </p>
<p>But no machine could bring back an irreversibly brain-damaged patient to have a functioning brain. As a result, <a href="https://www.worldcat.org/title/definition-of-irreversible-coma-report-of-the-ad-hoc-committee-of-the-harvard-medical-school-to-examine-the-definition-of-brain-death/oclc/41768230">the concept of “brain death”</a> was introduced as an additional definition of death to complement death by heart-lung failure.</p>
<p>The concept of brain death, while legally adopted in the U.S. and in large parts of the world, has remained an area of <a href="https://www.newyorker.com/magazine/2018/02/05/what-does-it-mean-to-die">ongoing discussion</a>. It often centers on how someone can be dead when the heart is beating and the body is warm, even if this function is entirely reached through artificial support. Brain death also is more difficult to conceptualize, as it is a less visible form of death. And isn’t it so much easier to believe what we can see?</p>
<p>On April 17, 2019, a <a href="https://www.nature.com/articles/s41586-019-1099-1">study published in Nature</a> that showed signs of activity in pig brains after they were killed added more fuel to the discussion. I am a neurologist specializing in neurocritical care, with both clinical and research interests in acute brain damage, and broad exposure to catastrophic brain injury and brain death. My analysis of the study is that it reinforces much of what we already know, that death is a continuum.</p>
<h2>When pigs die, can their brains be revived?</h2>
<p>In the study, scientists took brains from pigs that had been slaughtered at USDA-regulated facilities, connected them to a machine that pumped an artificial blood-like nutritional fluid through the brains four hours after their “death,” and measured activity of brain cells. They found that even hours after death, blood circulation – or circulation of the artificial blood – and certain brain cell functions could be restored in this experimental setting. </p>
<p>The conclusion was that demise in the brain after the heart stops beating follows an extended process rather than occurring at a defined moment in time, and that perhaps our brains have a better capacity to heal than is currently known.</p>
<p>Is this news? Yes, on a scientific level – that is, under the microscope, because an experiment like this has not been done before. But, have we not known for a long time that death does not occur within the blink of an eye? </p>
<p>Historic accounts of <a href="https://www.theguardian.com/notesandqueries/query/0,5753,-8010,00.html">decapitated bodies vividly describe</a> decapitated bodies taking a few steps or even running. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=771&fit=crop&dpr=1 600w, https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=771&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=771&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=969&fit=crop&dpr=1 754w, https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=969&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=969&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A painting by Sir Peter Paul Rubens illustrates the story of the 9-year-old martyr Justus, who is said to have held his head in his hands after being decapitated.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Het_Mirakel_van_Sanctus_JUSTUS-Sir_Peter_Paul_Rubens.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>That means that such a body was not immediately dead. And, conceivably, if one hooked up such a body to blood supply and healed the wounds, most people could likely imagine that it could continue to be maintained with living body parts or cells. </p>
<h2>Can a head still be alive after decapitation?</h2>
<p>Even worse to imagine: Could the decapitated head still be conscious for a bit? Perhaps yes.</p>
<p>After the heart stops beating, we consider that someone has died. But, after the heartbeat stops, we also know that sometimes, the heartbeat can come back by itself. This is called <a href="https://www.ncbi.nlm.nih.gov/pubmed/29286944">autoresuscitation</a>. In this case, someone that appeared dead for a few minutes may not have actually died. </p>
<p>But the situation is different for the brain than for the heart. When there is a lack of blood flow in the absence of a heart that pumps it, or when there is intrinsic brain injury and blood cannot get in, the situation is tricky. Brains are very sensitive to being deprived of oxygen and energy supply, and <a href="https://content.iospress.com/articles/neurorehabilitation/nre00531">various degrees of brain injury</a> occur. Depending on how long the energy fuel to the brain is absent, brain function can remain alive to various degrees and be rekindled to a degree we neuroscientists do not yet fully know. We know that brain function is seriously disturbed, with variable permanence of function loss depending on how long the brain has not had energy.</p>
<p>The end result of how functional such a damaged brain will come out is one of the biggest challenges we have to learn more about.</p>
<p>After an injury, a whole sequence of consecutive processes occurs that is called <a href="https://www.ncbi.nlm.nih.gov/pubmed/9707338">secondary brain injury</a> and is triggered by the insult to the brain in the first place. And these processes often cause tremendous damage, and sometimes more than the actual first injury. </p>
<p>For example, a hard blow to the head can result in a bruise or bleeding in the brain, which can be removed by surgery in certain cases. Despite the bleeding being stopped or removed, however, the surrounding brain will sometimes start swelling and bruising even more over the subsequent days, like a big bruise on the thigh goes through stages and color changes. There is not yet a preventive therapy for this, but we know that some factors can make this process worse, such as blood pressure that is too low or lack of oxygen to the brain during the healing phase.</p>
<p>Imagine a broken bone: The cast is just the first step, and there is swelling, pain and weakness for weeks to come. In the brain, the process is more granular. And in neuroscience, we are just now beginning to understand this cascade of events.</p>
<h2>What to learn from the pig study</h2>
<p>The study of revived pig brain cells does not even come close to touching on this much bigger picture. It is limited to showing that the time span and spectrum of nerve cell function that can persist and at least partially be restored is longer than had been shown so far. Hence, it supports the idea that dying is a process, and puts an additional piece of data on the length of this process. </p>
<p>But it does not show that these brain cells were able to function as a nerve cell network leading to higher brain function such as consciousness or awareness – the features that set us apart as humans. It also just looks at the immediate restoring of cell function, and not at how these brains do days out, when the continuing processes of secondary brain damage set in.</p>
<p>To summarize, in the absence of blood flow, the brain, including all its individual cells will die – eventually. And this study has perhaps expanded the understanding of “eventually.” </p>
<p>Death is a process, and not a moment in time. It is the human desire to put things in categories of black and white, and to have definitions that let us operate in daily life. Death – this is becoming more and more clear – is a large gray zone, and we will have to expect that this gray zone grows as science progresses.</p><img src="https://counter.theconversation.com/content/115750/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katharina M. Busl does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A recent study on the brains of pigs suggested that some activity could be restored even after the porkers had been dead for four hours. A neuroscientist who specializes in brain death explains.Katharina M. Busl, Associate Professor of Neurology; Chief of the Division of Neurocritical Care, Department of Neurology, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/909092018-02-09T12:41:43Z2018-02-09T12:41:43ZHow game theory could help ensure you will get blood when you need it<figure><img src="https://images.theconversation.com/files/205550/original/file-20180208-180829-hpq3os.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A person, pictured here, donating blood. Blood shortages occur often in the U.S.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Blood-Shortage/62ce5ec50fcf426c944c0c34a6757413/20/0">AP Photo/Mel Evans</a></span></figcaption></figure><p>Blood shortages in the United States <a href="http://time.com/5096917/winter-weather-blood-donation-shortage-east/">are now at the critical level because of severe weather nationally, coupled with widespread flu</a>. Hundreds of blood drives have <a href="http://www.redcross.org/videos/Snow-and-Ice-Cancel-More-Blood-Drives-Red-Cross-Blood-Shortage-Continues">been canceled this winter</a>, and the donor base has decreased because of illnesses as well as difficulties encountered in reaching collection sites due to bad weather. The Red Cross is reporting that <a href="https://www.redcrossblood.org/news/alabama/red-cross-winter-blood-shortage-reaches-critical-level">blood donations</a> are being distributed to hospitals “faster than they are coming in.”</p>
<p>As in all industries, there are networks, known as supply chains, consisting of suppliers, processors and distributors, that get a product – in this case blood – to the health care providers for the patients in need. But the blood supply chain is not your typical supply chain. </p>
<p>Blood service organizations, usually nonprofits, compete for donations, since blood (unlike most other products) cannot be manufactured but must be voluntarily donated. The blood then undergoes testing at sites, which can be far removed from the collection locations. Then it is processed and stored, before ultimately being distributed to hospitals and other medical facilities. </p>
<p>Blood is a perishable, time-sensitive product. Red blood cells (RBCs) have a shelf life of only 42 days, and blood must be kept within the correct temperature range and conditions <a href="http://www.who.int/bloodsafety/processing/cold_chain/en/">from the time it is collected from blood donors to the point of transfusion to patients</a>. Moreover, even under ideal circumstances, although 38 percent of the U.S. population is eligible to donate blood at any given time, <a href="https://www.redcrossblood.org/learn-about-blood/blood-facts-and-statistics">fewer than 10 percent actually donates blood</a> in a given year.</p>
<p><a href="https://supernet.isenberg.umass.edu/">My research team and I at the Isenberg School of Management at UMass Amherst</a> have been studying supply chains for nearly two decades. Our work has yielded insights into <a href="https://supernet.isenberg.umass.edu/bookser/scnebook.html">commercial supply chains of profit-maximizing firms</a> and <a href="https://supernet.isenberg.umass.edu/bookser/fnetbook.html">supply chain disruptions</a>. Currently, we are investigating the volatile health care landscape, including the growing competition among nonprofits, <a href="https://www.sciencedirect.com/science/article/pii/S221169231730053X">from hospitals</a> to <a href="https://supernet.isenberg.umass.edu/articles/BloodSupplyChainCompetition_Nagurney_Dutta.pdf">blood service organizations</a>.</p>
<h2>What makes blood supply chains unique</h2>
<p>Blood service organizations compete for blood from donors on the supply side and with one another on the demand side in providing the blood to hospitals and medical facilities. About 36,000 units of RBCs alone are needed every day in the U.S., with the Red Cross supplying about 40 percent of the nation’s blood. America’s Blood Centers, with 600 blood donor centers, <a href="https://www.redcrossblood.org/learn-about-blood/blood-facts-and-statistics">provide about 50 percent</a> of the blood in the U.S. and about one-quarter of the blood in Canada.</p>
<p>Major hospitals often have their own blood collection and testing facilities, but they still may have contracts with blood service organizations to maintain an adequate supply and to be able to respond in the case of a major disaster. <a href="http://www.redcross.org/news/article/All-Forms-of-Transportation-Get-Blood-to-Needed-Destinations">Blood is transported using different modes of transportation</a>, usually by courier, and using the most efficient route. If the demand is thousands of miles away, then an air courier, <a href="http://www.newsweek.com/massive-winter-storm-caused-severe-blood-shortages-red-cross-says-775413">including UPS and FedEx</a>, does the transport.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/204464/original/file-20180201-123837-gqq709.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/204464/original/file-20180201-123837-gqq709.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/204464/original/file-20180201-123837-gqq709.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/204464/original/file-20180201-123837-gqq709.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/204464/original/file-20180201-123837-gqq709.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/204464/original/file-20180201-123837-gqq709.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/204464/original/file-20180201-123837-gqq709.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">About 36,000 units of red blood cells are needed in the U.S. each day.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/133125962?src=mmiK6WHdsfeKt2j45AbTNw-1-5&size=small_jpg">Praisaneg/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The changing dynamics in the blood industry, which have included <a href="https://www.sciencedirect.com/science/article/pii/S0925527317302475">an increase in the number of mergers and acquisitions and the closure of testing facilities</a>, is forcing blood service organizations to be more innovative in conducting their business. Blood service organizations must price their products competitively based on the supplied quantity in order to recover costs of their operations and to generate revenue for activities such as the research and development required for providing a steady supply of safe blood. </p>
<p>Taking all these factors into account, coupled with critical shortages due to illnesses and weather, and other seasonality issues, there is a need for a change in blood supply chain management. The new supply chain management model should take into account not only the well-defined problems of <a href="https://link.springer.com/article/10.1007/s10287-011-0133-z">perishability, outdating, shortage and wastage</a>, but also the limits on supply capacity, as in the case of the critical shortages this winter and competition among blood banks. My colleagues and I who study game theory believe that game theory can be a powerful tool in assisting decision-makers in assessing and addressing critical blood shortages. </p>
<h2>Game theory analytics</h2>
<p>Game theory is a powerful methodology with major contributions made by <a href="https://www.nytimes.com/2015/05/25/science/john-nash-a-beautiful-mind-subject-and-nobel-winner-dies-at-86.html">John Nash, a Nobel laureate in economics</a>. It allows for the math modeling of interactions among competing or cooperating decision-makers, who are faced with their own objectives and also constraints on resources. Game theory has been used in numerous disciplines but its applications to health care have been only limited and fairly recent; see for example, <a href="https://www.sciencedirect.com/science/article/pii/S221169231730053X">an application to a hospital competition.</a> We have also shown <a href="https://theconversation.com/how-disaster-relief-efforts-could-be-improved-with-game-theory-72923">that game theory can provide more effective disaster relief</a>.</p>
<p>Our new blood supply chain game theory model captures competition for blood donations on the supply side as well as <a href="https://supernet.isenberg.umass.edu/articles/BloodSupplyChainCompetition_Nagurney_Dutta.pdf">competition for business on the demand side</a>. The computer-based model includes capacities on supply chain activities such as testing, storage and distribution, which can be adjusted based on various scenarios. It also includes the capacities associated with the number of available donors in different regions. </p>
<p>In order to minimize wastage at demand sites, we allowed for lower bounds as well as upper bounds on the volume of RBCs needed at each hospital demand point. Perishability is handled using multipliers to capture how much blood may be lost due to, for example, results from testing, as it moves down different pathways from origin nodes to destination nodes. </p>
<p>The algorithmic solution of the game theory supply chain network model yields optimal blood flows plus the prices that should be charged for cost recovery. Since the blood service organizations are nonprofits and interested in doing good, we also included an altruism component in their objectives, while satisfying, as best as possible, the demand. The flexibility of the game theory model allows the decision-makers to evaluate the impacts of a reduction (or increase) in the donor availability and to determine the impacts on blood flows and the prices charged, as well as revenues incurred by the competing blood service organizations. </p>
<p><a href="https://supernet.isenberg.umass.edu/articles/BloodSupplyChainCompetition_Nagurney_Dutta.pdf">In our study</a>, we found which blood service organization is affected the most in the presence of various supply chain disruptions. That includes a disruption in terms of the donor base due to a disease and disruptions to testing and storage facilities as may happen in a natural disaster. The evaluation of different possible scenarios enables the blood service organizations to be more prepared and resilient.</p>
<p>Furthermore, as the results in <a href="https://www.sciencedirect.com/science/article/pii/S0925527317302475">another study of ours have shown</a>, new partnerships over geographical distances – which would correspond to cooperative behavior – can provide significant benefits to blood service organizations, hospitals, as well as patients in the case of a disaster and an accompanying demand surge, <a href="http://wfla.com/2017/09/27/oneblood-sending-blood-to-puerto-rico-following-hurricane-maria/">as occurred post-Hurricane Maria</a>, which devastated Puerto Rico. </p>
<p><a href="https://www.sciencedirect.com/science/article/pii/S0925527317302475">The same study provides quantifiable measures</a> for the identification of possible synergies for blood service organizations through alliances. Alliances can result in cost reduction in operations, the reduction of costs associated with possible blood shortages, and even supply surpluses, which result in waste. They can enable the most cost-effective sharing of resources and making the most of the available blood.</p><img src="https://counter.theconversation.com/content/90909/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Nagurney does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The US is once again experiencing a shortage of blood, a difficult commodity to ship because it is perishable and time-sensitive. Here’s how game theory could help solve the problem.Anna Nagurney, John F. Smith Memorial Professor of Operations Management, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/703162017-01-09T01:34:42Z2017-01-09T01:34:42ZUncertainty in blood supply chains creating challenges for industry<figure><img src="https://images.theconversation.com/files/152109/original/image-20170109-32456-ordgh8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A blood drive in Florida in 2009. </span> <span class="attribution"><span class="source">AP Photo/Chris O'Meara</span></span></figcaption></figure><p>When we talk about supply chains, we may conjure up images of manufacturing plants, warehouses, trucks and shipping docks. There is another, truly unique supply chain for a product vitally important to health care and life, and it is very volatile at the moment: the blood supply chain.</p>
<p>Human blood, unlike computers, smartphones and cars, cannot be manufactured, and no substitute for it has yet been invented. At the same time, blood, like fresh produce, is a perishable product, with platelets lasting five days and red blood cells 42. </p>
<p>This blood industry is now at a crossroads, due to fluctuating demand over the past decade. Hospitals are now requiring less blood as compared to a few years ago because of changes in medical practices, leading, at times, to a surplus in overall supply. In 2011,<a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwil-9aalKnRAhVDPCYKHVS7C1AQFggaMAA&url=https%3A%2F%2Fwww.aabb.org%2Fresearch%2Fhemovigilance%2Fbloodsurvey%2FDocuments%2F11-nbcus-report.pdf&usg=AFQjCNEyX-tU0LIppgOBoWSy1tt2FKkBGg&bvm=bv.142059868,d.eWE"> a total of 1.2 million fewer units of blood</a> were used in hospitals as compared to 2009, bringing them a US$274 million savings in terms of costs. This has resulted in a relatively strong supply and a weak demand for blood at the blood banks, which gives hospitals the upper hand while negotiating with the suppliers. </p>
<p>In fact, hospitals are now demanding lower prices from the suppliers, and many are even considering switching to alternative blood banks. An example of this was at the Indiana Blood Center in 2014, where three of their major under-contract hospitals <a href="https://www.nytimes.com/2014/08/23/business/blood-industry-hurt-by-surplus.html">opted for a cheaper price offered by the Red Cross</a>. This led to a one-third shrinkage in Indiana Blood Center’s revenue, forcing the company to revise its business model by cutting the costs as much as possible.</p>
<p>The excess supply, along with increased competition, force the blood suppliers to lower their prices. The hospital cost of a unit of red blood cells in the U.S <a href="https://www.advisory.com/daily-briefing/2014/08/27/why-lood-banks-are-shrinking">suffered an almost 10 percent drop from 2011 to 2014</a>.</p>
<p>A simultaneous drop in the demand and the price of blood products has tremendously affected the players involved in the blood supply chain, with the blood banking industry revenue <a href="https://www.advisory.com/daily-briefing/2014/08/27/why-lood-banks-are-shrinking">dropping to US$1.5 billion per year in 2014</a>, down from US$5 billion in 2008. Being hit by such a severe revenue loss over a short period, one of the first actions taken by blood providers was to lower their costs by <a href="http://www.thenonprofittimes.com/news-articles/red-cross-layoffs-expects-1-million-few-blood-donations/">cutting jobs</a>. It is expected that, over the next few years, the blood banking industry in the<a href="https://www.nytimes.com/2014/08/23/business/blood-industry-hurt-by-surplus.html"> U.S. will lose 12,000 jobs, roughly a quarter of its workforce, due to the financial stress</a>.</p>
<p>My area of research in business supply chains holds some clues as to how the blood industry can address some of its supply chain challenges.</p>
<h2>A lifesaving commodity that can’t be manufactured</h2>
<p>We probably can all understand that a blood shortage can have devastating consequences in the face of disaster. What may be less recognized is that a continued budget deficit for blood services leads to a reduced budget for research on blood banking and related fields. Such an impact may not only threaten the effectiveness and safety of various activities in the blood supply chain but may also negatively affect the responsiveness at times of crises and disasters. </p>
<p>Blood is a hard commodity to manage for many reasons. First, regular replenishment of the blood supply is necessary. Also, supply is completely dependent on donations by individuals to the blood banks and blood service organizations collecting blood, which, for the most part, are nonprofits.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/149921/original/image-20161213-1615-iw3706.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/149921/original/image-20161213-1615-iw3706.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=901&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149921/original/image-20161213-1615-iw3706.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=901&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149921/original/image-20161213-1615-iw3706.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=901&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149921/original/image-20161213-1615-iw3706.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1132&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149921/original/image-20161213-1615-iw3706.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1132&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149921/original/image-20161213-1615-iw3706.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1132&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Joan Malchow and husband Doug Malchow hold up their arms after giving blood for the Red Cross, Friday, Dec. 21, 2007, in Princeton, New Jersey.</span>
<span class="attribution"><span class="source">AP Photos/Mel Evans</span></span>
</figcaption>
</figure>
<p>Still, a multi-billion dollar industry has evolved out of the demand for and supply of blood, with the global market for blood products projected to reach <a href="http://www.strategyr.com/MarketResearch/Blood_Banking_and_Blood_Products_Market_Trends.asp">$41.9 billion by 2020</a>. The United States constitutes the largest market for blood products in the world. Donors in the U.S. and some others countries are typically not paid.</p>
<p>In the U.S., the American Red Cross supplies about 40 percent of the blood, with America’s Blood Centers, with 600 blood donor centers, providing about 50 percent (and about one-quarter of the blood in Canada). The remainder is collected by hospitals and medical centers themselves or, lately, <a href="http://www.forbes.com/sites/erincarlyle/2012/06/27/blood-money-the-guys-who-trade-your-blood-for-profit/#757b6f956884">by profit-maximizing blood suppliers.</a></p>
<h2>A drop in demand brings uncertainty</h2>
<p>Prior to 2008, <a href="https://supernet.isenberg.umass.edu/articles/bloodsupplychains.pdf">hospitals and other surgical centers consistently reported blood shortages every year</a>. This resulted in the cancellation and postponement of elective surgeries. </p>
<p>Things changed. In part because of medical advances, some procedures do not require as many <a href="https://www.nytimes.com/2014/08/23/business/blood-industry-hurt-by-surplus.html?_r=2">pints for transfusion</a>. This decrease in demand for blood is posing great challenges for the industry, resulting in consolidations and mergers of testing labs and processing facilities. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/149922/original/image-20161213-1613-l09e7f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/149922/original/image-20161213-1613-l09e7f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149922/original/image-20161213-1613-l09e7f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149922/original/image-20161213-1613-l09e7f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149922/original/image-20161213-1613-l09e7f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149922/original/image-20161213-1613-l09e7f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149922/original/image-20161213-1613-l09e7f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A partially empty tray of units of AB-type red blood cells is seen in a refrigerated shortage unit in the American Red Cross Blood Services building in Philadelphia Oct. 28, 2003. The Red Cross has had officials traveling the country since May trying to step up donations to overcome a worse-than-usual blood shortage.</span>
<span class="attribution"><span class="source">AP Photo/Jacqueline Larma</span></span>
</figcaption>
</figure>
<p>In response to the drop in demand, suppliers formed partnerships. Mergers have taken place to counteract rising costs of blood banking operations and even to work for enhanced safety, availability and affordability of blood for hospital partners and patients. At times, the reconfigurations<a href="https://supernet.isenberg.umass.edu/articles/bloodsupplychaindesign.pdf"> have included the closing of testing facilities as done by the Red Cross</a>.</p>
<p>According to the America’s Blood Centers, the largest network of nonprofit community blood centers in North America, 19 partnerships and mergers were formed in the five years from 2010-2015 among their member blood banks, reducing the size of the network <a href="http://www.americasblood.org/about-us/what-we-do.aspx">from 87 to 68 members</a>. That represents a doubling from the 1990s, when 19 mergers took place during 10 years rather than five. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/149923/original/image-20161213-1615-10wzylb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/149923/original/image-20161213-1615-10wzylb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149923/original/image-20161213-1615-10wzylb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149923/original/image-20161213-1615-10wzylb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149923/original/image-20161213-1615-10wzylb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149923/original/image-20161213-1615-10wzylb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149923/original/image-20161213-1615-10wzylb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Blood bank transfusion bags.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/wellcomeimages/12655114045/in/photolist-khhGtF-khi6zP-khhLvt-khhviV-icRgu2-khjuJJ-khij1k-khhYip-HdBJn8-khkk6U-ehX3z3-khi11K-dxxC9h-khiaPx-HduhP9-HdBJjT-HdBJkK-HHWQNQ-HHWQWA-J6sKm7">Wellcome Images via Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<h2>Supply chain analytics tools can assist</h2>
<p>My colleagues and I have been researching blood supply chains, from enhancing their operations with collection, testing and distribution to hospitals and medical centers. The goal is to minimize costs as well as risk and waste and to optimize the supply chain network design. </p>
<p>More recently, our research has turned to the assessment of mergers and acquisitions, since some of its evolving features have taken on the characteristics of corporate supply chains, which we can learn from and take advantage of. </p>
<p>Identifying potential synergies prior to a merger or acquisition (M&A) can provide quantitative measures; indeed, real numbers, as to whether or not such an M&A should take place. In addition, there may be synergies associated with cooperation, rather than a complete merger or acquisition. For example, different blood service organizations may benefit from utilizing shared testing facilities, common facilities for procurement and even vehicles for the delivery of their blood products to hospitals and medical centers.</p>
<p>In addition, donors must be nurtured. Donors, who are the raw material suppliers of blood products, typically can donate no more than three times per year. <a href="http://www.redcrossblood.org/learn-about-blood/blood-facts-and-statistics">An estimated 38 percent</a> of the U.S. population is eligible to donate blood at any given time, but less than 10 percent of that eligible population actually donates blood each year.</p>
<h2>A demand surge could prove challenging</h2>
<p>The future for blood supply chains is fraught with uncertainty. </p>
<p>There could be another rise in demand in coming years due to population increases. Second, changing demographics, such as baby boomers’ aging, will be a new influence. The unpredictability of natural and man-made disasters mandates that all blood banks stay alert and be responsive to fluctuating demand and supply.</p>
<p>It is imperative to apply supply chain analytics tools derived from industry to assist in both supply side and demand management to make for the best utilization of a lifesaving product that cannot be manufactured – that of human blood.</p><img src="https://counter.theconversation.com/content/70316/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Nagurney does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Lower demand for blood may sound like good news, yet it is causing problems in the blood supply chain. Hospitals want to pay less for blood, which leads to disruption of previous business models.Anna Nagurney, John F. Smith Memorial Professor of Operations Management, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.