supply using anonymous, voluntary donors.
The Organization of African Blood Transfusion Services: General Trends and Periods
Before 1945 blood transfusion was organized in Africa by hospitals. It was decentralized, and transfusions depended primarily on the available facilities and the doctor’s knowledge. This favored transfusion at bigger hospitals in capital cities where there might be three or four doctors and at least one surgeon, or hospitals with special outside links, such as ones supported by the University of Louvain and the Union minière in the Belgian Congo. Likewise, the practice of transfusion might be started in a hospital because a doctor who had practiced transfusion at one location might bring that experience and repeat it at a new hospital assignment. This was the case with Joseph Lambillon when he moved from Kivu to Léopoldville in the Belgian Congo health service during the Second World War, and also with Gaston Ouary when he moved from Dakar to Brazzaville in the French colonial health service after the war.12 That did not necessarily guarantee the overall increase of transfusion, since after a practitioner moved, his successor might not be knowledgeable or interested in continuing to do transfusions. Thus, when Lambillon left the Kivu hospital at the end of the Second World War, his transfusion instruments lay idle until the early 1950s, when a new doctor, Louis Legrand, arrived from Brussels who was schooled in newer transfusion techniques that he introduced.13
In addition to the doctor’s decision to use transfusions, the selection of donors in this initial period also influenced whether the procedure was done in a particular setting. For example, in 1940 Lambillon stressed the possibilities of blood donation from recovering patients in African hospitals, but more typically family members were asked to donate. As to the uses of transfusion, there was some experimentation with transfusion for pneumonia as early as the 1920s in Katanga, because of the high incidence of that disease among mine workers, but more typical were surgery cases and difficult obstetrical deliveries. The experiment with anemic infants at Kisantu Hospital in the Congo in the early 1940s proved to be the precursor of a practice that became more widespread and particular to the African setting in the 1950s and 1960s.14
To summarize, by 1939 transfusion was known to doctors in most capitals and big hospitals in sub-Saharan Africa. Connections back in Europe and the small world of colonial medicine facilitated this. The extent to which transfusions were done varied depending on local circumstances such as the interest of doctors and surgeons or the existence of a Red Cross branch.
The policy decisions and other developments that led to widespread introduction of transfusion after the Second World War also brought an attempt to centralize transfusion services. Thus, when a new hospital was built in the 1950s, as in Ibadan, Nigeria; Kampala, Uganda; and Lomé, Togo, or an existing one was enlarged, especially with a surgery wing, as in Nairobi, it typically included the standard services for modern operations, such as expanded laboratory facilities and a blood bank.15 Because this gave big hospitals, usually in the capital, the facilities that other hospitals did not have, their blood collection, testing, and banking facilities often became at least citywide services and, where feasible, sometimes reached nearby district hospitals. In large and relatively prosperous colonies such as Kenya and Uganda, the transfusion services and laboratories served other hospitals as far as transportation of blood would allow. The Dakar federal transfusion center went to the furthest extreme when it attempted to provide blood not just for Senegal but all of French West Africa.
Following the Red Cross model in British colonies, blood was usually expected to be donated voluntarily during this period from the Second World War to independence, but French colonies generally followed the metropole model, where the government set a price to compensate for the effort to make a blood donation.16 There were pressures, however, that produced a mixture of paid and voluntary donation everywhere. In some of the British colonies, for example, there were hospitals that did not rely entirely on Red Cross voluntary donors; thus there was already a mixed approach before independence.17 Likewise, both the Red Cross volunteer system of collection and the Dakar center recruited unpaid donors from the Westernized African classes and workforces: army personnel, civil servants, and factory workers, but above all older schoolchildren and prisoners. The practice in Senegal was that if donors came to give blood at the transfusion center, they were paid for their trouble and fed, but donors at mobile units on-site were not. The question of who donated and who used blood will be examined in greater detail in chapters 4 and 5. Both groups grew significantly during this time period. The most important categories of patients receiving transfusions were general medicine (including accidents and emergencies) and surgery, along with maternity services and pediatrics if these specialties were available.
After independence, the organization of transfusion services entered a new phase, with most countries accelerating expansion by building provincial hospitals to serve regional needs better. This was also in response to the higher cost and slowness of transport that occurred in the centralized model. Other countries, which had never been able to centralize, such as Nigeria and Congo/Zaire, left it to the local hospitals to arrange for their own transfusion services, sometimes with the assistance of the Red Cross, sometimes with a paid service, and sometimes both. Thus, after independence there was a general swing away from centralization and its high costs, toward a middle position of mixed organization with limited regional services at best, and hospital-based means to supplement or complement blood collection and testing. In general, this move was driven by the continued increase in the use of transfusion and the corresponding need for more donors, which had accelerated in the last ten to twenty years of colonial rule.
Transfusions in French African Colonies after the Second World War
In most African colonies, the Second World War diverted resources elsewhere and reduced the practice of blood transfusion. The major exception to this, as mentioned above, was Senegal, where shortly after the Allied invasion of North Africa planning began for the Pasteur Institute in Dakar to collect and ship blood to the front. This development had significant repercussions for the organization of transfusion services, not just in Senegal but all of French West Africa.
In September 1943 the Dakar Pasteur Institute was instructed to prepare test sera for blood group determination of European and African troops stationed in Dakar and the Senegal-Mauretania colonies. In addition, the Pasteur Institute was to ship test sera to all colonies in French West Africa. By the end of 1943 over six thousand vials were prepared and 449 Africans and 166 Europeans had been tested.18 In 1944, Gaston Ouary, a surgeon in the colonial medical service at the African hospital in Dakar, was sent for training to the blood transfusion center established in Algiers by Edmond Benhamou.19 After Ouary’s return, he and two other colonial medical officers, Yann Goez and Jacques Linhard, secured the equipment necessary to set up a service at Dakar, including writing a manual for training personnel to draw blood and perform transfusions. In February 1945 these personnel, under the direction of the Pasteur Institute, began their transfusion service in an American army barracks on the outskirts of Dakar. By the end of the war enough blood was collected to provide over 225 liters for transfusion, mostly in the form of plasma but also some whole blood that was shipped to troops in Italy.
This wartime development also had an immediate impact on civilian blood transfusion, because once a source of blood was available, it was also used by the main civilian hospital in Dakar and the military Hôpital principal.20 In fact, French colonial authorities were quite aware of these extended benefits from the start. Thus, when Ouary returned from his training in Algiers, the transfusion manual he wrote with Goez and Linhard in November 1944 was not just for wartime use.21 As the head of the French colonial health service, Marcel Vaucel, stated in his introduction, the authors of the book had a double purpose: “to describe the new technique for their distant comrades, [and] to expand the uses of blood transfusion in tropical locales.” Benhamou repeated this in the conclusion to his preface: “We are sure that blood transfusion in all its forms (fresh whole noncitrated blood, stored whole blood, blood products) has a large future in our colonies, and that the notes so brilliantly edited and perfectly illustrated by Médecins-Commandants
