In Defence of the National Blood Service
Posted Under: Gay Rights,Health Care,Minorities,Public Sector,Society
Image: makelessnoise
As you may or may not have noticed, there’s recently been a series of ads in various places urging us all to give blood. This is because the National Blood Service (NBS) wants us all to donate now so it can boost its stocks before the winter when we’re all going to have swine flu so we won’t be able to donate. However, the well-informed among you will know that my use of “all” in that last sentence was an exaggeration. Among other restrictions, they don’t want you to give blood if you weigh less than 50kg, if you’ve recently travelled to a malarial zone…or if you’re male and you’ve ever had sex with another man. Perhaps unsurprisingly, this last restriction has proved somewhat controversial, and a number of commentators have at various times attacked it as homophobic, most recently this guy on the Guardian website today.
It’s probably best to leave aside the thorny metaphysical issue of precisely which entity Charlie Critchley and his fellow critics are accusing of homophobia (the Chief Executive of the NBS? The organisation itself? Some of its employees?), so let’s focus on two questions. First, is the NBS right to have this ban? Second, is the ban evidence of homophobia? On the first question, I’m prepared to remain agnostic. The NBS has a pretty detailed and, as far as I can tell, sensible explanation of the reasons for its ban, and some of the criticisms of the policy are simply misguided – witness Peter Tatchell’s completely erroneous claim (albeit not repeated in any of his subsequent writings on the subject) that the ban covers “[m]en whose homosexual experience is limited to a few mutual wanks behind the school bike sheds”, when it quite explicitly only applies to oral or anal sex. Equally, though, there seems little reason (for example) to exclude from donating men who haven’t had sex with other men since before the AIDS epidemic, and plenty of other countries have lifted their own blanket bans in the past few years.
But even if the NBS is wrong to have the blanket ban in place, it doesn’t follow that we should conclude that the ban is the product of homophobia. Bear in mind here that the NBS is in constant, urgent need of blood supplies. If you visit their homepage, one of the first things that catches your eye is a gif reading, “WE ARE RUNNING LOW OF BLOOD GROUP O NEG, B NEG AND AB NEG. WE NEED NEW DONORS NOW”. The accusation of homophobia, if correct, would mean that the NBS (or its employees or whoever) is unnecessarily putting the lives of those who need blood at risk simply because of a prejudice against gay men. This could indeed be the case. But how plausible is it? Inferring that the very existence of a ban is evidence of homophobia seems uncharitable to say the least. The NBS also bans from donating anyone who has themselves had a blood transfusion in the past 30 years, on the basis of a single case where vCJD (aka Mad Cow Disease) might have been transmitted via blood transfusion. Given this, it seems far more likely that all the NBS’s restrictions on donation are the result of extreme caution (as suggested by the assertion, from the PDF linked to above, that “any transmission as a result of a change in policy would be one too many”), rather than homophobia.
I can understand that the donation ban might feel unpleasant and stigmatising for gay and bisexual men who want to donate blood. And it’s quite possible that the ban is misguided and should be repealed. But deciding who should and shouldn’t be allowed to give blood requires the very careful weighing up of different risk factors, including the disproportionately high incidence of HIV among men who have sex with men. Angry accusations of homophobia aren’t going to make that decision any simpler.
Reader Comments
“The accusation of homophobia, if correct, would mean that the NBS … is unnecessarily putting the lives of those who need blood at risk simply because of a prejudice against gay men.”
Ah but one aspect of their homophobia could be the belief that all gay men are at high risk of having HIV. In which case their ban would make sense given what they believe, but would still be homophobic.
Imagine if they barred black people from giving blood on the grounds that Africa has a high HIV rate.
Personally I agree with you, but the idea of institutional homophobia in the blood service is not unthinkable.
To go ultra-utilitarian, there is also the question of how many cases of aids transmition is acceptable given the number of lives saved by increased blood supply. I don’t know how the numbers worked out, so it may not be relevant, but if both numbers were significantly different from zero, with the latter greater than the former, then it would be an interesting case of incompatability between overall desirability and public acceptability.
Also, I believe the current system does not allow for actively gay men who have been tested for HIV and are clear. Which seems a bit odd.
I’m not saying the NBS is necessarily right to have the ban in place – I state quite explicitly that I’m keeping an open mind on that. And I’m not denying that it’s possible the NBS is institutionally homophobic. What I’m saying is that even if the ban is misguided, it doesn’t necessarily follow that it’s the result of institutional homophobia. I find the homophobia interpretation implausible because the NBS has other restrictions on who can give blood which on the face of it look unnecessarily restrictive – specifically on those who’ve received blood in the past, as mentioned in the article. In the light of that, extreme caution seems a more likely explanation than homophobia – in the finest traditions of philosophy of science, it’s a better explanation because it has greater explanatory power, accounting for all the NBS’s restrictions rather than just one.
It’s an indisputable fact that there is a higher prevalence of HIV among men who have sex with men than among the rest of the population. Of course correlation doesn’t imply causation – there’s nothing about being a sexually active gay man per se that means you’re at higher risk of HIV – but from an epidemiological point of view that’s completely irrelevant. It’s pretty analogous to car insurance companies demanding higher premiums from young men, except for the minor assymmetry that the NBS is trying to save lives rather than just maximise profits.
“there’s nothing about being a sexually active gay man per se that means you’re at higher risk of HIV ”
In a certain sense there is. It’s all to do with sexual biology and transmission rates. If I was to have sex with an HIV+ woman I would stand a 0.1 per cent chance of contracting the disease. If a woman had penetrative sex with an HIV+ man she would stand a higher risk since semen carries a great viral load than VF. Meanwhile a man who is annally penetrated by an HIV+ man stands the highest risk due to the biology of anal sex.
Anyway the NBS position is completely reasonable, but they haven’t been completely explicity in their reasoning – perhaps for fear of causing public alarm. It’s all to do with probability trees:
The hint is in their statement ‘Blood safety starts with the selection of donors before they give blood.’ Now as they say this is partly because of the window period. But it is perhaps also because of the inevitable possibility of screening error – human or otherwise. There is, almost by definition, always a possibility of error even if it is only human error.
Now say for the sake of argument they make a screening error 1 in 10,000 times. Does this mean that there is a 1 in 10k chance of an officialy clean blood donation being hiv positive. Nope. Because for that to be the case, two things would have had to occur in tandem. An HIV+ person would have give a blood donation AND that blood donation would have to be misscreened. Now to get the possibility of both those things occuring together you multiply one by the other. So HIV prevelance in the general population is 0.1%, and the probability of misscreening is 1/10000 so that gives a total probability of one in ten million.*
Now say the process was repeated but they took the blood from a sexually active gay man in london. Here the prevelance has been reported to be as high as 1 in 10. Multiply that by the probability of a false screening, and you have a 1 in 100,000 chance of HIV+ blood getting in.
But what about gay men who have always used a condom? Well the point is that people tell white lies and condoms split. Imagine a certain small proporiton of people (gay and straight) who say they have always had safe are discounting 1 or 2 odd occurences of split condoms/unsafe sex from back in the day. Those who had anal sex would have raised thier risk by far more because a) anal sex has a higher transmission rate, b) the person they were having sex with is more likely to be a carrier on account of being gay.
While i’m on the subject, the vast majority of the population need not be nearly as scared of HIV as is often suggested – as explained in a 2007 book http://tinyurl.com/no2642. Just over 1 in a 1000 people in the uk have HIV. And even if they are HIV positive, the chances of a man getting HIV from having sex once with an HIV+ woman are again around 1 in a thousand – giving a basic probability of 1 in a million per sex act. But the chances are actually far lower. Because of the roughly 0.1 per cent of the UK that has HIV vast proportion are either gay men or intraveneous drug users (IDUs). So if you can be sure that the woman you are shagging is neither a gay man or an IDU, her chances of carrying the disease are far less than 1in 1k and your chances of getting it are far less than 1 in a million per sex act. As far as STDs go, you should be far more worried about pregnancy.
*Please do note that the chances of a false negative screening are probably far less than 1 in 10,000. This stat i made up for the purposes of illustrating the statistical mechanism but my point still stands. Meanwhile for the population that actually do give blood – i.e. minus sex workers, IDUs etc – the prevelance of HIV will be far less than the 1 in 1k which is for the whole population. Meaning the chances of infected blood getting in are far far less than 1 in 10m. Don’t panic people.
Considering my last point, all of this brings into question the ethics of a decade and a half long campaign to deliver the message that everybody is at high risk from HIV. A typical example of such cooked statistics is offered by the sexual health clinic at adenbrookes (who i must say were very nice on the one occassion i visited them) who tell us – as is often repeated – that ‘there are more new infections in straight, heterosexual, people in the UK than in gay, homosexual, men’. Of course, this may be true but is so because straights outnumber homosexuals by about 9-1. What would be worthwhile when evaluating the risks of different kinds of sexual behaviour is to look at proportions not absolute numbers.
Bt i don’t want to get bogged down in the minutiae here. As Dr Chin suggests, the “everyone is at equal risk” message has probably been pushed to avoid stigmatising already stigmatised groups. A laudable aim but not very helpful for those they are trying to protect. Campaigns need to be properly focused towards those whose potential risks are far greater. More important though is this. I have heard numerous gay friends repeat some variation of the stats described above. Surely people should no when they are NOT at the same risk as everybody else and when it is a hundred times more important to use a condom.
“I was to have sex with an HIV+ woman I would stand a 0.1 per cent chance of contracting the disease.”
I’d say the chance of you having sex with any woman ever is about 0.1 per cent.
“Considering my last point, all of this brings into question the ethics of a decade and a half long campaign to deliver the message that everybody is at high risk from HIV…”
If it prevented one case of HIV it’s ethically justified. And I hardly think gay men need reminding that they are at higher risk than other people.
Neuroskeptic writes “Imagine if they barred black people from giving blood on the grounds that Africa has a high HIV rate.” But this is not a fair comparison. Your hypothetical would clearly be a racist policy as not all blacks are African nor are all Africans black.
However, if we found that those who have visited or lived in a particular African country have an unacceptably high rate of HIV/Aids then it would not be racist to ban that particular group from donating blood. If such a policy meant that a much larger number black people were banned compared to whites then that would be a by-product of the policy decision rather than a racist policy.
Greg – I chose my example carefully. As you say, it would be clearly racist – not to mention stupid – to assume all black people were at the same risk as Africans, because many black people have never even been near Africa.
however many gay people would say that this is effectively what the NBS is doing, on the grounds that not all gay men are at high risk, only promiscuous ones who don’t take proper precautions.
I’m not endorsing that but you have to admit they have a point.
Neuroskeptic’s example would clearly strictly speaking be a case of discrimination on racial grounds, but again, it wouldn’t follow that said discrimination was the result of prejudice. Just as with the actual ban I discuss, prejudice is certainly one possible explanation, but equally it’s possible to imagine circumstances where the rate of HIV among the black population of the UK (or indeed any other among any other group of people in the UK you care to name) was so high that a ban might be justified. Whether the risk of infection via transfusion is high enough that a ban is needed is an empirical question of degree – it would indeed be stupid to have a ban on black people donating blood, in most circumstances. But it wouldn’t be in all possible circumstances.