by George Crile’s wife, who assisted at one of his first successful transfusions.12
Most histories of transfusion have emphasized technical discoveries. A classic case is the first chapter of Geoffrey Keynes’s Blood Transfusion (1922),13 which describes the attempts beginning with Richard Lower in England and Jean-Baptiste Denys in France in the 1660s, following William Harvey’s discovery of blood circulation. Keynes also mentions the efforts of James Blundell in the first part of the nineteenth century, but the main purpose of the book is to demonstrate the much more successful techniques discovered after 1900, which were first used on a large scale during the Great War (1914–18), in which Keynes (whose older brother, John Maynard Keynes, was the famous economist) had recently served. Subsequent histories, usually in the form of articles or introductory chapters of transfusion texts, have also focused on new techniques developed during the rest of the twentieth century.14 Those histories freely skipped around time periods and locations to document the discoveries and innovations of those who built on their predecessors around the world to perfect the increasingly important medical procedure.
This book differs from most of those histories in its focus on one geographical area. Only recently have there been such histories—for example Susan Lederer’s Flesh and Blood (2008), which examines the history of both organ transplantation and blood transfusion in the United States.15 That book illustrates one reason for focusing on a specific geographical area: it permits greater detail about how a medical procedure such as transfusion is affected by and has a broad impact on society. This might be true for other medical procedures, yet for blood transfusion it is especially interesting because the main therapeutic “medicine” is blood from another person. The impact of transfusion is dramatic and lifesaving.
In addition, a geographical focus makes it possible to identify features of the practice that are peculiar to that setting, hence it is useful for comparative study. The conditions in sub-Saharan Africa were so different from those in the United States or Europe that one can easily see the value of identifying what was similar and what was different in its history. For example, the fact that there was no analogous treatment in traditional African medicine meant that the introduction of blood transfusion offers an excellent case of how modern biomedicine is adopted or modified in settings outside modern societies, a question of great importance in global health today. Sub-Saharan Africa, for purposes of this study, includes all of Africa south of the Sahara, with the exception of South Africa, where the very different political, social, and demographic circumstances of white rule, especially after 1900, produced a health system that was very different from the rest of sub-Saharan Africa. For example, a 1975 editorial in the South African Medical Journal reported that 86 percent of blood in South Africa was donated by whites, while at least 60 percent of patients were estimated to be black.16
Approaching the History of Transfusion in Africa
The research for this book is an attempt to help answer the question about the role of transfusion in the origin of the AIDS epidemic by showing in detail when, where, and how blood transfusion was introduced to Africa.17 Because there is very little scholarly study of the subject, another goal of this book is to describe the major changes in the introduction and expansion of blood transfusion from the first reports of the practice, during colonial rule in the 1920s, to independence and the appearance of AIDS, at the end of the twentieth century. But blood transfusion is not a remote, detached medical procedure. On the contrary, it requires people to have blood taken from them, as well as patients willing to have the blood of others placed in their bodies. As a result, the history of blood transfusion reveals a number of features of African societies that adopted this novel medical treatment, including who donated blood, the uses of transfusion, the question of risk from contaminated blood, and the extent to which transfusion might have spread HIV and other diseases.
The sources used for this history include the records of most of the colonial powers in Africa—Britain, France, and Belgium—as well as several European Red Cross societies and the International Federation of Red Cross and Red Crescent Societies (IFRC). Major medical libraries and archives around the world also provided published and unpublished reports of the African health services, and four African countries provided surprisingly good records of hospital and transfusion services. A number of former health officers who worked in Africa were of great assistance in answering questions and occasionally providing more detailed histories of their service.
There are limits worth noting in a book of this scope. First is the difficulty in providing enough depth of analysis for an area so large and diverse as sub-Saharan Africa. Even limiting the study to the British, French, and Belgian colonies, it is impossible to give the depth of treatment that all colonies warrant. In an effort to resolve this problem, Kenya, Uganda, Senegal, and the Congo/Zaire18 have been chosen for more extensive examination because of their size, geographical variety, and availability of records. Hopefully subsequent studies will follow on these and other histories. A second problem is the lack of records about the Africans who made up the donors and patients. This book does not pretend to be a social history of transfusion, but it is hoped that indirect evidence from numbers and observations will provide enough detail to represent not only the subjects of transfusion but also in this case the source of the “medicine” (blood) for treatment. Finally, and related to the previous point, this subject risks amplifying the divide and stereotypical differences between Western and traditional medicine. To be sure transfusion was not a practice with any analog in traditional African medicine, but that does not mean that opposition or incompatibility were inevitable. In fact, a major finding is that transfusion was adopted quickly and with relatively little resistance. Moreover, there were definite differences in the practice in Africa compared to Europe and elsewhere, such as securing donors and uses of transfusion, which means that this was not a simple process of adoption of Western medicine.
The essential requirements for transfusions to begin in Africa were doctors trained in the techniques, donors, and patients in need of and willing to receive transfusions. The first reports in Africa were in the early 1920s, and organized transfusion practices had been developed before the Second World War. The records between the two world wars show not only that all conditions existed in sub-Saharan Africa that were necessary for blood transfusions; they also suggest that the numbers were limited primarily by the availability of Western medical doctors and facilities to do transfusions. There is also an indication of how innovation took place, usually through connections to people and resources outside the usual colonial medical structures, for example, the Red Cross, missionaries, universities, and mining companies.
Transfusion became a regular part of modern medical treatment in sub-Saharan Africa from 1945 to independence. The means by which this occurred differed significantly according to the colonial ruler. For example, in francophone Africa the government attempted to implement a policy of centralized blood collection in Dakar, Senegal, to supply blood to all colonies in French West Africa. In the British and Belgian colonies local initiatives and the Red Cross were much more important in creating transfusion services. In Uganda, this practice led to the Red Cross expanding the number of collection centers from the capital, Kampala, to other regions of the protectorate. The common underlying reason for growth everywhere was the Africans’ acceptance of donating and receiving blood. Equally important were the increased expenditures in colonies on health, particularly new hospital construction, because transfusions were done in the hospital setting. In addition, new and simpler techniques developed during the Second World War made transfusion easier to practice in sub-Saharan Africa.
Following independence, in the 1960s, transfusion continued to grow in Africa and the organization of services entered a new phase. Most newly independent countries accelerated expansion by building provincial and district hospitals to serve regional and local needs. These hospitals usually had the ability to do transfusions, but with only a few exceptions governments left it to the local hospitals to arrange for their own blood collection, sometimes with the assistance of the Red Cross and unpaid donors, sometimes with a paid service, and sometimes both. Thus, there was a general swing away from centralization and its high costs,
