be appreciated, such as the fortuitous and simultaneous but independent discovery of blood group compatibility, which required almost a decade and more rapid testing before matching donors and patients became a routine part of transfusion.23
A key turning point in these new developments was the mobilization of resources and the great needs of the First World War, which offered both an opportunity and the need to refine procedures in order to give transfusions more easily and quickly.24 These innovations, in turn, helped spread the practice in civilian medicine after the war, although transfusion still took a number of years to be widely used in medical care. Systems of obtaining donors were organized between the world wars, and as a result, the number of blood transfusions in Europe and North America grew steadily. By 1938 transfusion services in major cities (New York, London, Paris) reported five to nine thousand transfusions per year,25 with rates of one to two hundred per hundred thousand population. This was substantial but modest as compared to more than ten times that rate after 1945.
The Second World War dramatically increased military demand, and the number of donors grew along with the development and adoption of new techniques to collect and preserve blood. After the war, these methods were rapidly introduced to meet growing demand throughout the United States and Europe, as the various collection services shifted and expanded their wartime organizations to meet civilian needs. In the Netherlands, there were 43,000 registered donors by the time the Germans invaded in 1940. Given the conditions of German occupation, that number declined during the war. After liberation and the rebuilding of health services, however, there were eighty thousand Dutch blood donors by 1953 (in a population of 10.5 million). That same year Belgium, with a population of 8.8 million, had 47,000 blood donations, while the Canadian Red Cross reported 345,000 bottles donated (in a population of just under 15 million).26 The National Blood Transfusion Service in the United Kingdom reported over three hundred thousand transfusions annually in the immediate postwar years, a figure that climbed steadily, surpassing 1 million in 1958 (about two thousand per hundred thousand population) and reaching 1.7 million in 1972. By 1953 the United States was collecting over 4 million blood donations annually with a national transfusion rate of 2,490 per hundred thousand. The 2005 U.S. Nationwide Blood Collection and Utilization Report indicated over 15 million units collected, making the annual blood transfusion rate in the United States approximately 5,230 per hundred thousand total population or 8.6 percent of the donor age population (18–65 years).27 Comparable figures exist for England and France.28
While there were many differences in the systems employed in different countries, blood transfusion services were institutionalized and became widely available in the United States, Europe, and most developed countries in the dozen years following the Second World War. This included well-organized donation, storage, and distribution methods, and testing for known contaminants. Scientific journals—such as Transfusion, established in 1947 by the American Association of Blood Banks, and Vox sanguinis, which began in 1951 and is published by the International Society of Blood Transfusion, which also began holding international congresses in the 1930s—provided means for sharing new discoveries and administrative innovations.29
The Knowledge and Motivation to Use Transfusion in Africa before the Second World War
The key to understanding the introduction of blood transfusion to Africa is that it was practiced by doctors in hospitals. As a result, it was the availability of hospitals and doctors with the knowledge and desire to use the procedure that was most important in determining when transfusion was used, rather than Africans’ willingness to give or receive blood. There is ample evidence that these resources existed in Africa following the First World War, when the practice of Western medicine was broadly introduced to Africa.30 By then hospitals had been built in the colonial capitals and large ports and towns. Although the extent of services varied, there was usually one chief hospital in a colony where Europeans and Africans could be treated, and often another large hospital only for Africans. These hospitals provided a base of knowledge, service, research, and training to support the expansion of Western health and medical care to the rest of the colony. Smaller towns and regional centers could subsequently develop district hospitals that varied quite widely in size and service, but each typically had at least one European doctor.
In this setting, doctors with knowledge of blood transfusion were most likely to be found in the large hospitals established in the capitals and ports at the beginning of colonial rule, and the number of doctors and hospitals increased in most colonies in the 1920s and 1930s. For example, when Trolli became head of the Belgian Congo health services in 1925, he did a census of services and found ninety-seven government doctors and thirty-six doctors attached to companies or religious orders. Then, when King Albert I and Queen Elisabeth of Belgium visited the Congo in 1928, upon their return they persuaded the Belgian parliament to create funding, including an endowment for FOREAMI (Fonds Reine Elisabeth pour l’assistance médicale aux indigènes) that was planned by Trolli and set up in 1930 for disease campaigns. By the late 1930s FOREAMI employed twenty-seven Belgian doctors, plus sanitary agents and African assistants.31 Likewise in all of French West Africa, there were only thirty-seven doctors in 1890, but by 1910 that number had grown to 140.32
In British East Africa, European doctors were assisted by Indian-trained assistant surgeons, and in the French colonies by graduates of the African medical school in Dakar. An effort was made to train indigenous “dressers” in East Africa in the 1920s, but with the limited exception of Uganda, the numbers were not significant.33 In any case, there is no evidence that these non-Europeans had the responsibility to do transfusions on their own, although they helped greatly to fill the staff of hospitals and assist European-trained doctors, who might be more inclined to do transfusions in an appropriately staffed hospital. In Dakar, the École de médecine de l’Afrique occidentale française was established in 1921 and by 1934 it graduated 148 “doctors” (although not recognized by European standards) and 191 midwives, who were drawn pretty evenly (between 40–70 each) from the colonies of Senegal, Soudan (French Sudan), French Guinea, and the Ivory Coast.34 On the eve of the Second World War, one history of the French colonial medical service states there were 165 doctors in French West Africa, supplemented by 34 civilian doctors, 32 Russian “hygienists,” and 184 African doctors from the Dakar school.35 The hospitals were mostly government facilities, and the doctors were employed by the government as well, but in many colonies there were also hospitals of varying size and levels of care established by missionaries and other philanthropic organizations, plus hospitals created by companies in mines and plantations. The colonial governments quickly found it useful to provide subventions to retain the philanthropic institutions, because it was cheaper than replacing these facilities with government ones.
Depending on their training, the growing number of physicians in Africa came increasingly to know about blood transfusions and the techniques refined during the First World War that spread into civilian practice in Europe during the 1920s and 1930s. As the years progressed, new doctors coming to colonial posts were even more likely to know about blood transfusion from their training in British, French, and Belgian medical schools. As the example of Lejeune has shown, many of the transfusion techniques that had been simplified during the First World War were within the means of most doctors to learn and practice. If lives could be saved close to the battlefields of Europe, they could also be saved in a hospital setting in Africa. The equipment necessary included a syringe or other device to withdraw blood from a donor, plus sodium citrate to delay coagulation before the blood was introduced into the vein of the patient.36
Since need and sources of blood were not limiting conditions, transfusions first took place in Africa between the wars, where there were doctors trained recently enough and with the means to introduce the latest new procedures. Surveying the continent, one finds these conditions in a number of locations. First and foremost were places with sufficient European populations to warrant Western hospitals: South Africa, Rhodesia and Kenya, Mozambique and Angola, plus cities in other colonies with significant European business or government activity. In addition there were colonies with fewer Europeans, but where the
