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  • The disproportionately low levels of national

    2019-05-14

    The disproportionately low levels of national and international attention paid to NCDs in terms of action plans, funding, and global institutions might be partly attributable to the framing of these conditions. After all, “anything that begins with ‘non’ may be considered a ‘non-issue’ or a ‘non-starter’”. Evidence is mounting that some NCDs are partly or wholly communicable. They can be spread through social networks, viruses such as hepatitis and human papillomavirus, the built environment, cultural and economic conditions, food deserts (ie, areas short on fresh fruit, vegetables, and other healthy foods), and intergenerational transmission (ie, diabetes and obesity). Furthermore, the present misnomer implies that the causes are individual rather than societal. This implication is simply not the case: NCDs have largely sociogenetic antecedents, and efforts focused on individual behaviour have little overall effect if the social and policy environments do not change in parallel.
    Safe and reliable transfusion services remain largely unavailable to the world\'s poorest populations, particularly in sub-Saharan Africa. WHO responded to this azilsartan medoxomil crisis with a strategy focused on centralising blood transfusion services, the exclusive use of volunteer donors, donor blood testing, and transfusion stewardship. On the basis of our experience in Malawi, we think that this policy has unintentionally decreased the availability of blood products for patients with acute haemorrhage. In response to this policy, the Malawi Blood Transfusion Service (MBTS) was established in 2003, replacing an in-hospital model with a government-sponsored centralised service. By 2008, over two-thirds of the country\'s blood donation was centralised and donation became increasingly dependent on unpaid volunteers rather than family member replacement. However, in 2014, data from MBTS showed that blood donation per-capita had decreased compared with 2011, meeting only one-third of blood products requested, largely because of a reliance on secondary and college students who donated 80% of MBTS blood. Prospective data from our study of 293 patients with upper gastrointestinal bleeding in Malawi corroborates that supply has decreased over time, showing that the number of units transfused per patient, adjusted for haemoglobin concentrations, decreased by nearly 50% between 2011 and 2013 (). The fundamental weakness in the WHO blood banking policy is the categorisation of blood donors and emphasis on strict centralisation. WHO recognises three types of donor: volunteer donors, replacement donors (family or friends), and compensated donors. In 2004, over 80% of blood donations in sub-Saharan Africa were from replacement donors, but that number is now closer to 40%. The policy emphasis on volunteer donors focuses on improving safety from infectious diseases, particularly HIV. Collaboration between WHO and the US President\'s Emergency Plan for AIDS Relief has been instrumental in this strategy by setting transfusion policy priorities that focus on HIV transmission prevention or through direct funding for national transfusion services. These policies assume that volunteer donors have a lower risk profile than compensated or replacement donors for key infectious diseases, although available evidence does not support this assumption. Several studies from sub-Saharan Africa have failed to show a safety benefit with respect to HIV transmission when comparing replacement donors and volunteer donors. Instead, evidence shows that red blood cell is repeat donation from volunteer donors that improves safety. Centralised blood banking systems also have considerable financial implications. Bates and colleagues estimated that a centralised, volunteer-based system in sub-Saharan Africa is 4–8 times more expensive per unit of blood than a hospital-based system. Additional costs accumulate from azilsartan medoxomil expansive quality assurance programmes, blood distribution to medical centres, and donor recruitment. Furthermore, the blood donor recruitment strategy developed in most centralised blood-banking systems is dependent on local schools and universities as the primary donor source population, a strategy that is only viable when educational institutions are in session. This problem has been documented in other African countries such as Burkina Faso.