Blood deserts in a universal health system: Addressing structural inequities in northern Canada

Abbreviation

OCAP

Ownership, Control, Access, and Possession

1. COMMENTARY

Canada's healthcare system prides itself on its universality, yet critical gaps persist in remote Indigenous communities. While emergency transfusions save lives elsewhere, in these regions, life‐threatening hemorrhages can be a death sentence due to delayed access to blood transfusions. Despite Canada's wealth and infrastructure, the structural health inequities that result from geographic isolation, colonial history, and underinvestment leave many Indigenous communities without timely access to blood products.

2. A BRIEF OVERVIEW: CLINICAL CONTEXT IN REMOTE CANADA

Over 6 million people, approximately 17% of Canada's population, live in rural communities, spanning small towns, fly‐in communities, and isolated villages. ¹ These areas face challenging and intersecting hurdles related to geography, infrastructure, and access to clinical care. Many communities, particularly northern regions, do not have access to basic health necessities such as food security and water security. A 2018 report indicated household food insecurity rates as high as 57% in Nunavut, 21.6% in Northwest Territories, and 16.9% in Yukon compared to the national average of 12.7%. ² As of November 2020, 60 long‐term water advisories were in place, of which 47% had been for at least a decade. ³ Furthermore, health services are scarce, with only 3% of specialists and 13.6% of general practitioners residing rurally or remotely, leading to individuals having to displace themselves large distances to access care. ⁴ Rural populations have also been shown to have higher rates of chronic disease. ⁵ Compounding these issues is the lack of health infrastructure. For example, only 20% of rural emergency departments have computed tomography (CT) scanners and 28% have ultrasounds. ⁶ , ⁷ In urgent, life‐threatening situations, patients often rely on air ambulance to transfer to distant and better‐equipped hospitals. However, medevac and road transport are susceptible to the extreme weather conditions observed in Canada's north. These delays can be fatal in time‐sensitive medical emergencies. For example, in one study, mortality following traumatic injury was 3× higher in rural emergency departments compared to urban emergency rooms. ⁸ Other studies point to similar findings with higher rates of mortality in rural settings despite similar severity of injury. ⁹

These challenges affect many rural Canadians; however, indigenous communities face additional risks due to the persistent impact of colonialism and underinvestment. The jurisdictional divide for funding on Indigenous healthcare between provincial and federal authorities causes much uncertainty, leading to fragmentation of the healthcare network for these individuals. ¹⁰ This fragmentation has been so pronounced in the past that it has caused the death of an Indigenous patient, ultimately leading to the creation of Jordan's principle. ¹¹ These factors result in a healthcare system in which both geography and ethnicity can determine survivability. Without long‐term planning, investment, coordination, and leadership, individuals living in rural and northern Canada will continue to face structurally imposed health disparities compared to their urban counterparts.

3. STRUCTURAL INEQUITIES AND “BLOOD DESERTS” IN REMOTE CANADA

Vast distances mean many rural and northern Indigenous Canadian communities effectively live in “blood deserts”, where reliable access to blood is largely absent. ¹² Access to blood products is so limited that the first units of blood available to critically ill patients often arrive only with emergency air ambulance. ¹³ Furthermore, weather delays and sparse infrastructure impede emergency medical evacuations, putting patients at risk. A 2019 transfusion medicine conference highlighted challenges in northern Canada, including extreme weather, language barriers, and colonial legacies in healthcare delivery. ¹⁴ Together, these factors have created major inequities for Indigenous peoples, where limited access to services like on‐site transfusions places patients at heightened risk during medical emergencies. ¹⁵

4. EVIDENCE OF NEED: MISSED TRANSFUSIONS AND DELAYED CARE

Despite having a universal health system, Canadians in northern and remote regions face critical gaps in transfusion access. A recent study based in northern Ontario found that 80% of patients requiring blood transfusion who were transported by medical air ambulance did not receive transfusion, underscoring the need for more robust emergency blood availability in northern communities. ¹⁶ Similarly, another study found that 42.4% of patients requiring blood transfusion on emergent medical air transport in Ontario did not receive it either. ¹⁷ Massive hemorrhage protocols, which are proven to reduce mortality in trauma, remain inconsistently implemented in rural Canadian hospitals, likely due to their perceived irrelevance due to inadequate transfusion networks. ¹⁸ Despite representing only 15% of the population in British Columbia, rural patients account for 28% of hospital admissions for severe injury and 58% of deaths prior to arriving at hospitals, further highlighting the need for blood availability. ¹⁹ Canada has 30 critical care transport bases, but only 11 currently operate with blood products on their airplanes, often the only lifeline in regions lacking local supply. ¹³ Delays are deadly; for every minute delay in a patient requiring blood transfusion, there is a 5% increase in mortality. ²⁰ Together, these findings suggest that current gaps in transfusion in remote locations may be contributing to preventable morbidity and mortality in the Canadian context.

5. GLOBAL INNOVATIONS: LESSONS FROM RWANDA AND GHANA

In contrast, lower‐income countries like Rwanda and Ghana have pioneered drone delivery to overcome geographic barriers in blood distribution. Rwanda partnered with a drone startup to launch the world's first national drone blood delivery service in 2016. ²¹ Between 2017 and 2019, drones delivered 12,733 blood orders to remote Rwandan hospitals, averaging ~50 min per trip—at least 79 min faster than by road. ²² This reduced blood wastage by 67% and enabled rural clinics to receive emergency blood in under an hour. ²² Today, ~75% of blood outside Rwanda's capital is delivered by drone, cutting transit times from 4 hours by road to as little as 15 min by air. ²³ Ghana followed in 2019, operating 519,000+ flights and transporting 16,000+ units of blood to rural facilities. ²¹ These examples underscore how drone delivery can bypass infrastructural barriers, improving timeliness and reducing wastage. They offer key lessons ²² : First, reliable blood access is possible even in resource‐limited settings with structural solutions, a clear contrast to wealthy Canada, where remote Indigenous communities still lack access. Second, success depended on strong government commitment and partnerships with tech firms and global agencies, ²¹ showing that leadership drives equitable blood access.

6. POLICY IMPLICATIONS FOR CANADA

Canada has explicit obligations to address these disparities. The Truth and Reconciliation Commission's Call to Action #19 urges closing health gaps and ensuring equitable access for Indigenous communities. ¹⁵ Fulfilling this requires bold, evidence‐based strategies. Drawing from global models, Canada should pilot and scale innovations like drone delivery in remote regions. Regulatory changes must permit beyond‐visual‐line‐of‐sight medical drone flights in rural areas with appropriate safety controls. Early trials during COVID‐19 (e.g., delivering medical supplies via drones in northern Canada) suggest feasibility, but a concerted national initiative is needed to deploy drones for emergency blood delivery. ²⁴ Partnerships with Canadian Blood Services and Transport Canada will be essential to integrate drones into existing supply chains and aviation rules.

Complementary strategies should also be explored. Walking blood banks, which are pre‐arranged local donor networks mobilized in emergencies, have proven effective in military and disaster settings. ²⁵ “Buddy transfusion” protocols and community donor mobilization, with proper training and screening, could serve as stopgaps while awaiting blood delivery. Autologous transfusions, or freeze‐dried plasma, may also help. ²⁵ , ²⁶ While each has challenges, combining low‐ and high‐tech approaches can strengthen blood supply resilience in isolated areas (Figure 1).

FIGURE 1.

Barriers and pathways to addressing blood delivery inequities in remote indigenous Canadian communities. [Color figure can be viewed at wileyonlinelibrary.com]

Critically, innovations must respect Indigenous self‐determination and be co‐designed with communities. Historically, top‐down approaches have bred mistrust. Future efforts should follow ethical frameworks centered on Indigenous leadership. Training local drone operators or establishing Indigenous‐run donor registries aligns with the principles of Ownership, Control, Access, and Possession (OCAP) and decolonized health services. ²⁴ Indigenous‐led drone models emphasize that communities must guide technology and ensure cultural safety. ²⁴ This collaborative approach will increase buy‐in, cultural appropriateness, and sustainability.

7. CONCLUSION

In 2025, preventable deaths due to hemorrhage in Canada's Indigenous communities are an unacceptable failure of policy and leadership. Geographic remoteness should not justify second‐class healthcare. Rwanda and Ghana's drone delivery systems prove that it is not technological limitations but political will and structural investments that can surmount logistical challenges. Canada must act. By investing in drone delivery, supporting community‐driven blood donation strategies, and reforming policy to prioritize rural and Indigenous access, no Indigenous patient should die from lack of a transfusion. Life‐saving care is a right for all, not a privilege of geography.

During the preparation of this work, the author(s) used ChatGPT to edit, improve grammar, and rephrase parts of this text to ensure the quality and standard of the English used. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.

AUTHOR CONTRIBUTIONS

Boaz Laor and Shreenik Kundu conceptualized the article. Boaz Laor and Shreenik Kundu wrote and revised the article. Boaz Laor and Shreenik Kundu made critical revisions to the manuscript.

CONFLICT OF INTEREST STATEMENT

The authors have disclosed no conflicts of interest.

Laor B, Kundu S. Blood deserts in a universal health system: Addressing structural inequities in northern Canada. Transfusion. 2025;65(9):1746–1750. 10.1111/trf.18347