How We Came To Bank On BloodJoan O'C. Hamilton
An Epic History of Medicine and Commerce
By Douglas Starr
Knopf 441pp $27.50
Does the publisher of Douglas Starr's excellent Blood: An Epic History of Medicine and Commerce actually expect to sell many copies? Whoever chose the title, certain to scare off the squeamish, and the subtitle, which makes the effort sound like a dry, dense survey text, has really done this book a disservice. In fact, the brave and curious will enjoy a brightly written, intriguing, and disquieting book, with some important lessons for public health.
In his "chronicle of a resource," Starr covers an enormous amount of ground. He gives us an account of mankind's attitudes over a 400-year period towards this "precious, mysterious, and hazardous material;" of medicine's efforts to understand, control, and develop blood's life-saving properties; and of the multibillion-dollar industry that profits from it. He describes disparate institutions that use blood, from the military and the pharmaceutical industry to blood banks. The culmination is a rich examination of how something as horrifying as distributing blood tainted with the HIV virus could have occurred.
The book begins with a historical look at centuries of lore about blood--in particular, the belief that blood carried the evil humors of disease and required occasional draining. As recently as the Revolutionary War, bloodletting was widely employed to treat fevers. The idea of using one person's blood to heal another is only about 75 years old--although rogue scientists had experimented with transfusing animal blood at least as early as the 1600s. The first transfusion experiments involved stitching a donor's vein (in early cases the physician's) to a patient's vein.
The book's most interesting section considers the huge strides transfusion science took during World War II. Medicine benefited tremendously from the initiative to collect and supply blood to the Allied troops and from new trauma procedures developed to administer it. It was then that scientists learned to separate blood into useful elements, such as freeze-dried plasma and clotting factors, paving the way for both battlefield miracles and dramatic improvement in the lives of hemophiliacs.
Sabotaged by notions about the "purity" of their racial groups' blood, Japan and Germany lagged well behind the Allies in transfusion science. Once they realized they were losing injured troops the Allies had learned to save, they tried to catch up, conducting horrible and unproductive experiments such as draining blood from POWs and injecting them with horse blood or polymers.
The massive wartime blood drives laid the groundwork for modern blood-banking, which has saved countless lives. Unfortunately, these developments also set the stage for a great modern tragedy--the spread of AIDS through the international blood supply.
During the early to mid-1980s, Starr says, 10,000 American hemophiliacs and 12,000 others contracted HIV from transfusions and receipt of blood products. Blood banks both here and abroad moved slowly to acknowledge the threat of the virus and in some cases even acted with criminal negligence, allowing the distribution of blood they knew was tainted. This is not new material. But Starr's insights add a dimension to a story first explored in the late Randy Shilts's And the Band Played On.
Starr obtained memos and other evidence used in Japanese, French, and Canadian criminal trials over the tainted-blood distribution. (American blood banks enjoyed legal protections that made U.S. trials more complex and provided less closure for those harmed.) His account of the French situation is particularly poignant. Starr explains that in postwar France, giving blood was viewed as a sacred and patriotic act. Prison populations were urged to give blood as a way to connect more with society. Unfortunately, the French came to believe that such benevolence somehow offered a magical protection to the blood itself and that it would be unseemly to question volunteer donors about their medical history or sexual or drug practices. Combined with other factors, including greed and hubris, this led to tragedy. Some blood banks were collecting blood from high-risk groups as late as 1990, well into the crisis. And France, along with Canada, Japan, and even Britain, stalled approval and distribution of safer, American heat-treated plasma products when they became available, in part because they were giving their domestic companies time to catch up with scientific advances.
Is the blood supply safe now? Screening procedures and technology have gotten much better. Yet it's disturbing to read Starr's contention that a person receiving multiple transfusions today has about a 1 in 90,000 chance of contracting HIV--far higher than the "one in a million" figure that blood bankers once blithely and falsely quoted. Moreover, new pathogens threaten to emerge and spread through the increasingly high-speed, global blood-product network faster than science can stop them. This prompts Starr to argue that today's blood stores are "simultaneously safer and more threatening" than when distribution was less sophisticated.
There is so much drama, power, resonance, and important information in this book that it would be a shame if the squeamish were scared off. Perhaps the key lesson is this: The public health must always be guarded against the pressures and pitfalls of competitive markets and human fallibility.