The exception came toward the end of the war in French West Africa. After the Allied landings in North Africa in November 1942, the French set up a transfusion service in Algiers, and in 1944 Gaston Ouary was sent there from Senegal to learn the new techniques. Ouary was a surgeon who had occasionally given transfusions before the war at the so-called Hôpital indigène (later Hôpital Aristide le Dantec) in Dakar.
More will be said later about how this visit changed blood transfusion in Senegal and the rest of French West Africa. Of note here is how much Ouary was immediately impressed by the new techniques he saw in Algiers. In the report he filed with authorities upon his return, in November 1944, Ouary compared what he had just learned in Algiers with prewar transfusions he had done. “Transfusion then,” he explained, “gave the impression of a minor surgical intervention with all the necessities implied.” A syringe was used to withdraw the donor’s blood, which was then immediately given to the patient. The French called this procedure arm-to-arm transfusion, requiring the donor to be next to the patient. Ouary explained the limits imposed by this procedure: “Transfusion is thus a veritable minor surgical intervention, possible only in well-equipped health facilities by a competent doctor, most often by the surgeon on duty. One or both must devote a rather long time for preparation and execution, which would not be a major inconvenience if it was the only urgent task to accomplish.”4 Thanks to new techniques developed for the much larger scale of blood transfusion during the Second World War, Ouary went on to explain what these techniques permitted:
The apparatus today permits transfusions almost as easily as an intravenous injection of artificial serum. It requires a sterilized bottle containing an anticoagulant solution of sodium citrate which is attached to sterilized tubing for the collection and injection of blood. An essential feature is that the injection tubing always includes a filter required to prevent small clots. This filter was not part of earlier apparatus. . . .
In sum, the technical progress today permits numerous transfusions, easily and rapidly in any location, because it has become possible to store blood in one form or another as well as to transport and inject it without complicated equipment.5
Doctors and Decisions about Transfusions
Even with these technical improvements, in the end the decision to do a transfusion was like the decision to use any scarce Western medical resource in places such as mid-twentieth-century Africa. Doctors still faced “urgent tasks” with only limited resources to accomplish them, and there was no obvious answer to the question of whom or what to care for first. For example, when colonial powers decided to build expensive state-of-the-art Western hospitals after the war, they justified it by the need to set standards high if medical care in Africa was to be taken seriously by Western medicine. The common counterargument was that the money would help far more Africans if invested in more facilities that were less expensive.6 Likewise, a doctor in a regional hospital could do hundreds of surgeries, with only basic anesthesia and antisepsis. Adding the ability to do transfusion could save lives, but so, too, could doing even more operations that did not require it.
Given these possibilities, then, perhaps the most crucial change after 1945 was that more European doctors went to Africa who were likely to be trained in the use of transfusion. This followed from a variety of underlying developments, including growth of health infrastructure in the colonies, growing demand from increasing population pressure, and the surprising postwar economic recovery of Europe, including expanding medical training. By the time of independence it is estimated that there were 450 Western-trained medical doctors in Uganda and 750 in Kenya.7 The figures for the Belgian Congo were 731 doctors in 1959 (mostly with the government, but about one-third employed by missionaries and private companies), working in 422 hospitals (1957 report) averaging over 110 beds.8
The result was that even if they had no plans upon arrival to devote the time and resources to transfusion, these doctors could be persuaded to do so by something at the local level as simple as the availability of blood or the visit of a guest doctor who demonstrated new techniques. On the broader level, when colonial health authorities invested in large modern hospitals in the capitals of Africa, they were equipped with the latest facilities, including operating rooms, plus support services for radiology, anesthesia, and transfusion. Once a blood service and accompanying blood banks were established, their use quickly spread as people came from far away to take advantage of them. Even though doctors in the provinces did not set up their own service, they referred their patients to larger hospitals with the resources for transfusion until the smaller hospitals eventually made arrangements to do it themselves.
In the British and Belgian colonies, there was an outside stimulus to the introduction of blood transfusion: branches of the British and Belgian Red Cross. Because of their experience in collecting blood on the home front during the Second World War, national Red Cross societies all over the world became leaders in adapting their expertise in blood collection to peacetime operations: recruiting blood donors and in some places, processing blood for transfusion. This was the case in the United States, many European countries, Canada, and Australia, to mention just a few examples.9 The Red Cross expertise was transferable to the colonies, where even though transfusion remained a hospital operation, Red Cross volunteers certainly made it easier to begin or expand transfusion by helping assure adequate donors and in many cases providing funds for equipment and supplies to store blood. This was less the case in the French colonies, because in France a national transfusion service emerged after 1945 out of collaborative efforts between the hospitals and governments dating back to the interwar years, with little or no participation by the French Red Cross.10
All colonial medical department directors were overwhelmed by the health problems in their districts. Moreover, their budgets were small, and requests for additional funds exceeded the resources and competed against one another to make services available to meet basic medical needs. As a result, viewed from the colonies, an organization like the British Red Cross held out the promise of a significant source of volunteer staff time to recruit donors, not to mention funds for such things as transportation, equipment to draw blood, and refrigerators to store it for transfusions. The Red Cross also enjoyed a formidable reputation for beneficence that bolstered confidence in any new scheme. Thus, in whole colonies such as Uganda, Northern Rhodesia, and the Belgian Congo, the Red Cross was asked to run the transfusion services, at least initially.
Despite these immediate advantages, there was a condition imposed by Red Cross involvement in blood transfusion that prompted an ongoing debate and controversy: insistence that blood donation be voluntary, that is, with no remuneration for the donor. This had become part of the ethos of the transfusion service in Britain from its start, after the First World War, and was especially championed by its founder, Percy Oliver (see chapter 1). It spread to other European Red Cross societies involved with blood collection, as in Belgium, the Netherlands, and Switzerland, where they eventually ran their countries’ blood programs.11
This ethos did not, however, take root automatically in African societies. As will be seen, it was difficult to find adequate numbers of Africans to give blood on an anonymous, voluntary basis. When demand grew for the procedure after the 1950s and 1960s, hospital transfusion services had to adopt other means of securing blood. This was done either by direct remuneration, or by requiring patients to find a family member or friend either to be the donor for the patient or give blood as replacement to the blood bank. In addition, almost all donors were given refreshments, cigarettes, and sometimes cash. As a result, transfusion in most African countries was hospital-based by the 1970s, except in such places as Senegal and Uganda, where the newly independent countries continued and expanded the centralized blood services created during the colonial period. This meant that each hospital found its own source of donors to give blood on call or to donate regularly to a blood bank if the hospital had storage facilities. Only later and with outside financial assistance, usually prompted by a crisis or disaster, were independent African countries able to implement the centralized
