"Blood Deserts" Face the Burden of Global Blood Deficits

Reliable access to blood is crucial for the provision of safe, affordable, and timely surgical care. However, critical shortages in the availability of blood and its components lead to millions of preventable deaths each year.¹ Hemorrhage is responsible for approximately one-fourth of maternal deaths globally and up to 40% of deaths among trauma patients who reach the hospital.²

Recent modeling studies suggest that almost 2,000 units of blood per 100,000 people are needed to meet current demands. With severe shortages of blood existing in every country in sub-Saharan Africa, south Asia and Oceania, global transfusion needs outcompete the available blood supply.³

In these low- and middle-income countries (LMICs) that face blood shortages, the overall mortality index from hemorrhage is significantly increased compared to high-income nations.¹ Rural communities bear the brunt of global blood shortages, effectively becoming “blood deserts,” where the closest blood bank may be hours away. Without adequate availability of blood products, providers in LMICs are often required to defer lifesaving operations due to the high probability of a patient dying on the table.⁴

What Is a Blood Desert?

A blood desert is a geographic area where there is no timely and affordable access to blood components in more than 75% of cases in which transfusions are necessary.⁵ Blood deserts persist due to myriad factors ranging from geography to blood banking infrastructure and national policies.²

With the majority of blood banks located in urban areas, distribution of rural blood banks tends to be sparse. Access to blood banks in rural settings is further limited by treacherous terrain and unreliable road infrastructure.^1,2 Pervasive mistrust and limited education around blood donation create additional scarcity, evidenced by a six-fold lower rate of blood donations in LMICs.⁶

Moreover, traditional blood banking is both expensive and logistically complex, requiring integration across collection, testing, and delivery of blood products. These requirements are often inconsistent with the reality in LMICs, where a dearth of trained providers is operating under an insufficient budget with limited laboratory resources and storage space.

Why Is Access to Blood a Surgeon’s Problem?

According to surgeons who work in the world’s lowest resource areas, access to blood is one of the most pressing issues facing patients, families, and providers in their communities. Take, for example, a referral hospital located in a blood desert in Kenya, where a patient from a road traffic accident arrives with severe fractures and unstable vital signs. The surgeon calls for blood, but the blood bank has no matching, screened blood available for transfusion.

Now the surgeon faces a dilemma. Does the surgeon operate knowing that the patient is likely to die without blood? Or is the patient referred to another hospital knowing that the individual may not survive the transfer? Should the surgeon wait to see if another unit of blood becomes available?

Despite the physician’s best efforts, the question of transfusion is the one that determines the answer to life or death. The doctor chooses to send the patient to a nearby hospital, hoping that he survives the journey and that the next hospital has blood. Unfortunately, like most hospitals in the region, it does not.

These types of stories emerge repeatedly in conversations with rural surgeons in LMICs. As we look toward ensuring safe, reliable access to transfusion, we must center the needs of communities living in these blood deserts where blood scarcity has life-threatening consequences.

Current Strategies Are Filling the Gaps

Creative solutions in recent years have employed innovative technologies to target resource-specific challenges in the global blood deficit. Damu Sasa, a digital platform in Kenya, enables real-time access to blood product inventory, allowing neighboring hospitals to promptly address regional shortages.⁷

Walking blood banks, a strategy historically used in military settings, offer a solution to delivery and storage challenges through mobilizing a pre-screened pool of donors.⁸ Aerial drones also are being explored to reduce costs and delivery time, particularly in areas with limited infrastructure.⁹ Surgeons also are developing low-cost methods for intraoperative autotransfusion, in which the patient’s own blood is collected and reinfused, which has proven to be a safe and established technique.¹⁰

The successful and sustainable implementation of these innovative solutions requires a community-centered approach. Capacity assessments are critical to understanding each blood desert's unique challenges, discovering community perspectives, and identifying strengths that can help address the blood shortage. Community-implemented research like the BLOODSAFE Program—a National Heart, Lung, and Blood Institute-led blood safety and availability program in sub-Saharan Africa—has demonstrated enhanced access to blood transfusion, emphasizing that community engagement is the cornerstone of successful blood banking.¹¹

While these novel initiatives underscore the urgency and determination to overcome barriers to blood transfusion, they must be accompanied by significant advocacy efforts for increased finances and infrastructure dedicated to improving blood banking systems. The Blood Delivery with Emerging Strategies for Emergency Remote Transfusion (DESERT) Coalition, a group led by clinicians, researchers, policymakers, and industry experts, is one example of a cross-disciplinary movement to implement research and policy initiatives in this area.⁵

Call to Action

Blood products are a required component of lifesaving medical and surgical interventions, yet critical shortages and limited access affect countless communities across the globe. Inadequate distribution of blood banks, insufficient infrastructure, and incohesive policies have facilitated the creation of blood deserts in rural regions across LMICs that face life-threatening lack of access to blood stores.

 Surgeons on the front lines confront these challenges every day. The surgical community must come together to support our colleagues in blood deserts and generate momentum across local communities, healthcare systems, and governments.

Safe, accessible solutions that have been implemented and tested across settings—such as walking blood banks, intraoperative autotransfusion, and drone-based delivery of blood products—already exist. The technology is not only available, but in the case of walking blood banks and intraoperative transfusion, it also is affordable.

Surgeons must take the next step, whether through advocacy in high-resource settings or direct action in blood deserts.

• Examine the current need and resources in your communities.
• Implement available solutions.
• Train personnel and standardize protocols.
• Advocate for local and national governments to devote attention to blood deserts and reduce regulatory barriers to implementation of existing technologies.
• Stay informed about ongoing efforts of the Blood DESERT Coalition.

Community-based, innovative solutions have laid the path forward to transform blood deserts into lifesaving oases.

Surgeons, the safety of these communities now lies in your capable hands. 

Disclaimer

The thoughts and opinions expressed in this viewpoint article are solely those of the authors and do not necessarily reflect those of the ACS.

Isita Tripathi and Vanitha Raguveer are medical students working with the Systems for Trauma and Blood (STAB) Lab at the Program in Global Surgery and Social Change at Harvard Medical School in Boston, MA. The STAB Lab, led by Dr. Nakul Raykar, associate trauma surgeon at Brigham and Women’s Hospital in Boston, focuses on applying innovative solutions to the global blood crisis and strengthening surgical systems in low-resource settings.

References

1. World Health Organization. (2021). Global Status Report on Blood Safety and Availability 2021. Available at: https://www.who.int/publications-detail-redirect/9789240051683. Accessed December 14, 2023.
2. Raykar NP, Makin J, Khajanchi M, Olayo B, et al. Assessing the global burden of hemorrhage: The global blood supply, deficits, and potential solutions. SAGE Open Medicine. November 2021. Available at: https://journals.sagepub.com/doi/10.1177/20503121211054995. Accessed December 14, 2023.
3. Roberts N, James S, Delaney M, Fitzmaurice C. (2019). The global need and availability of blood products: A modelling study. Lancet Haematol. 2019;6(12):e606-e615.
4. Sood R, Yorlets RR, Raykar NP, Menon R, et al. The global surgery blood drought: Frontline provider data on barriers and solutions in Bihar, India. Glob Health Action. 2019;12(1):1599541.
5. Raykar N, Raguveer V, Abdella Y, et al. Innovative blood transfusion strategies to address global blood deserts: A consensus statement from the Blood Delivery via Emerging Strategies for Emergency Remote Transfusion (Blood DESERT) Coalition. The Lancet Global Health. 2024;S2214-109X(23).
6. Tagny CT, Diarra A, Yahaya R, Hakizimana M, et al. Characteristics of blood donors and donated blood in sub-saharan francophone Africa. Transfusion. 49(8):1592-1599.
7. Damu Sasa. Available at: https://damu-sasa.co.ke/. Accessed December 14, 2023.
8. Sood R, Raykar N, Till B, Shah H, et al. Walking blood banks: An immediate solution to rural India’s blood drought. Indian J Med Ethics. 2018; 3(2):134-137.
9. Ling G, Draghic N. Aerial drones for blood delivery. Transfusion. 59(S2):1608-1611.
10. Sjöholm A, Älgå A, von Schreeb J. A last resort when there is no blood: Experiences and perceptions of intraoperative autotransfusion among medical doctors deployed to resource-limited settings. World J Surg. 2020;44(12):4052-4059.
11. Delaney M, Telke S, Zou S, Williams MJ, et al. The BLOODSAFE program: Building the future of access to safe blood in sub‐saharan Africa. Transfusion. 62(11), 2282-2290.