organization with at best limited regional services, but also hospital-based means to supplement or complement the collection, testing, and distribution of blood for transfusion. Hospitals thus developed a number of options for blood collection, all of which were driven by an increase in the use of transfusion for medical care and the corresponding need for more donors.
The final phase in the development of African transfusion services began after the economic crisis of the mid-1970s, when African countries were unable to provide resources to continue, let alone keep up with, new techniques in transfusion medicine. This constraint limited their ability to draw and store blood or extend transfusion to more remote regions. Problems were exacerbated by growing concerns with testing and safety, such as the need to screen for hepatitis B, a new disease that was discovered well before the appearance of HIV. One response was to seek funding from developed countries, especially in Europe, North America, and in Japan. When successful, the result was a recentralization of transfusion services because donor countries found that it was more efficient and safe and gave them better ability to monitor how funds were used. For example, foreign assistance in Burundi and Rwanda followed this pattern, as did Ethiopia, but not all countries were able to secure outside funding. Other pressure for centralization came from the growth of programs at the World Health Organization and the International Red Cross, both of which helped secure funding and coordinated offers of technical assistance for setting standards of blood safety beginning in the mid-1970s. They also co-sponsored the first African blood transfusion workshops, beginning in Burundi in 1976 and the Ivory Coast in 1977. Thus, when the AIDS crisis hit Africa, less than a decade later, mechanisms to support and coordinate efforts to monitor and insure a safe blood supply were already in place.
Three crucial features of blood transfusion in Africa are particularly noteworthy compared to elsewhere: what transfusions were used for, who donated blood, and safety. One surprising finding is that reluctance of patients to receive the blood of others offered relatively little impediment to the adoption of transfusion in Africa. To be sure, as elsewhere, there were fears and myths that arose and for the most part were allayed by practitioners. Moreover, the needs were so extensive, and the successful results of transfusion were so dramatic, that if anything, the overuse of transfusion became a bigger problem than resistance on the part of patients. Hospital records are scarce in the early period, but after the 1980s statistics show that transfusions were done increasingly for maternity and pediatric (anemia) use. Other evidence of the uses of transfusion includes posters from the Red Cross archives, which, in an effort to encourage Africans to donate blood, prominently featured how the blood would be used.
Another surprising conclusion is that sufficient donors were generally found in Africa so that the blood supply was able to meet the growing use of transfusion. The best explanation for this success in meeting the need for blood donation was the flexibility of these practices. Most notably, hospitals were innovative in how they adapted to their circumstances in order to secure blood donors. This pragmatism ran counter to some expectations of resistance and irrational opposition by Africans. One way to interpret this was that the “medicine” given to Africans in transfusion, blood, was possessed in the same amount and with the same control by Africans as anywhere else in the world. There were few or no drug companies or expensive chemical manufacturing or rare materials that had to be purchased. As far as donors were concerned, therefore, the history of blood transfusion offers a good example of Africans’ ability to organize and adapt their health care well when the materials were available to them.
With some significant exceptions, the most important institutions in finding ways to obtain blood for transfusions were hospitals. Initially, donors were found as needed, from family, friends, and those willing to be on call. Later, donors were provided food and drink and in some places payment, both officially and unofficially. Most important in this process was not whether donors were “voluntary” or paid, since in Africa notions of obligation and compensation were more complicated than in Europe or North America. Rather it was the size and facilities of hospitals or collection centers that dictated whether blood was drawn for immediate use, as with smaller hospitals, or for storage and distribution to other hospitals, as with larger facilities.
The main finding about the history of risk from blood transfusion in Africa is that those giving transfusions were well aware of risk from the start, and that is not surprising given the disease environment. That does not mean there was much that could be done to prevent most disease transmission through transfusion. For example, malaria is not screened to this day in countries where it is endemic (most of sub-Saharan Africa). If potential blood donors with malaria were screened, the wide prevalence of the disease would mean drastically reducing the number of transfusions, and those transfused would face exposure to the disease in any case.
The blood transfusion practices in sub-Saharan Africa were incapable of detecting HIV, as was the case initially with even the most sophisticated screening in more developed health care systems. In contrast, Africans did not have the resources to improve immediately their ability to detect and screen for the virus once it was recognized. As a result, given the wide use of transfusion, it was unfortunately an important reason for the initial spread of AIDS. Yet African health officials were not without means to understand and respond to the new danger, thanks to forty years of experience and a framework of appreciating long-standing health risks. Both by screening high-risk donors and taking advantage of outside support for testing for HIV, as well as technical advice and training, the reduction of AIDS transmission through contaminated blood transfusion was one of the quickest and most successful responses to the epidemic in sub-Saharan Africa.
1 BLOOD TRANSFUSION BEFORE THE SECOND WORLD WAR
Blood transfusion is one of the most important lifesaving discoveries of modern scientific medicine. The first effective procedures were demonstrated only at the beginning of the twentieth century, although attempts in its present form began shortly after William Harvey’s discovery of blood circulation, in the seventeenth century. Long before that, most cultures had recognized the significance of blood, which played a prominent role in many rituals and customs of healing.1
The history of how blood transfusion was introduced to Africa is important beyond its dramatic role in saving lives. As a well-defined medical procedure that was unprecedented in traditional society, transfusion provides a clear case of how an innovation of modern technology, relatively new to Western medicine itself, was introduced to Africa. As a result, it offers an example of Africans’ responses to Western medicine, as well as Westerners’ views of Africans and appropriate medicine for them. In addition, although blood transfusion was similar to other new medical technology such as x-rays or anesthesia, it is much richer in its human and social complications because of the symbolic and cultural significance attributed to blood.
Another revealing feature of transfusion is that it required a weighing of risks and benefits for patients, in this case the potential for the dramatic saving of life compared to the risk of dangers such as disease transmission. Transfusion thus offers an indication of how well these subtle and complicated judgments were made in the African setting. This latter point has become dramatically more important since the 1980s, following the emergence of new infectious diseases such as AIDS. Transfusion, an obvious lifesaving procedure, also opened a new means that had never existed before of transmitting pathogens between humans with unprecedented efficiency. Historian of medicine Mirko Grmek recognized early in the AIDS epidemic (1989) that blood transfusion
was rapidly developed [after the First World War] and became one of the most effective and frequently used therapeutic methods. Still, it was only toward the middle of the century that the practice of transfusion opened a gap in the barrier which, from an epidemiologic point of view, separates the blood of one human being from that of others. . . . For the microorganisms [certain viruses], blood transfusion had formerly been a narrow path, used only in exceptional occasions for transmission of some sporadic infections. Today it has become the royal road requiring delicate and difficult monitoring.2
Evidence of the First
