The records between the wars, therefore, show that all conditions existed in sub-Saharan Africa that were necessary for blood transfusions to take place: availability of donors, willing patients, and technical ability to do 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 a hint of how innovation took place, usually through connections to knowledge and resources outside the established colonial medical structures (e.g., Red Cross, universities, mining). With this overview of the interwar period as a base of reference, the changes can be better appreciated that took place during and after the Second World War that dramatically spread and increased the use of blood transfusion in Africa.
2 BLOOD TRANSFUSION FROM 1945 TO INDEPENDENCE
There was sufficient Western medical infrastructure to make blood transfusions possible in Africa between the world wars, but this did not immediately lead to large numbers of transfusions. The rapid increase came after the Second World War, for a number of reasons. The explanation of how this rapid growth happened in most colonies is best understood by the changes in general conditions that increased the number of hospitals and brought more doctors to Africa who were able to use transfusions.
The period after 1945 in the history of modern health care in Africa is usually subsumed together with the rest of colonial rule and contrasted with the dramatic growth of health facilities after independence. Compared to the interwar colonial period, however, there was a sharp increase in hospital construction and training of medical personnel after 1945. Construction of new and modern hospital facilities after the Second World War was not only the most visible evidence of these investments but also the one with the greatest direct impact on transfusions. In French West Africa, for example, thanks in part to the FIDES (Fonds d’investissements pour le développement économique et social), created in 1946, the number of “general hospitals” rose from two in 1938 (both in Dakar) to twelve in 1952, with a corresponding rise in the number of hospital beds from 1,630 to 3,810. In Belgium the Van Hoof–Duren Plan of the 1940s called for the creation of a medical-surgical center with 100 to 150 beds in each of the 120 administrative sectors of the colony.1 Similar projects were supported by the Colonial Development and Welfare Acts of 1940 and 1945 in Britain, such as a ten-year plan in 1946 for health in Nigeria that established a medical school and university hospital at the University of Ibadan in 1948.2
The growth of health facilities after the war created more places where transfusions took place, while at the same time changes in techniques during the war made it even easier to practice them. Among the most important innovations was the ability to store whole blood as well as to separate and freeze-dry plasma. Although the latter technique was never widely used in Africa, in those places where electricity and refrigeration came to hospitals, it was feasible to have “blood banks” (in the sense at least of being able to store blood). The latter by no means replaced the practice of drawing blood from a donor at the time of transfusion in many parts of Africa, but the overall result of changes in transfusion practice during the Second World War was to make its use in treatment of patients much more routine. This was reinforced by changes in training and practices in Europe that made doctors who came to Africa after 1945 much more familiar with transfusion.
Conditions in Africa during and after the Second World War
With one important exception, the immediate effect of the Second World War was to hinder the use of transfusion in African colonies because resources were diverted elsewhere. In addition, there was almost no fighting in sub-Saharan colonies that might have prompted the need for transfusion, and generally the region was too remote to be a source of blood for troops fighting elsewhere. Kenya reported limited blood donations for military and civilian patients during the war, but there were no programs in British Africa, such as were instituted in India or Australia, whereby large-scale blood collection services were established to support the fighting front.3
The exception came toward the end of the war in French West Africa. After the Allied landings in North Africa in November 1942, the French set up a transfusion service in Algiers, and in 1944 Gaston Ouary was sent there from Senegal to learn the new techniques. Ouary was a surgeon who had occasionally given transfusions before the war at the so-called Hôpital indigène (later Hôpital Aristide le Dantec) in Dakar.
More will be said later about how this visit changed blood transfusion in Senegal and the rest of French West Africa. Of note here is how much Ouary was immediately impressed by the new techniques he saw in Algiers. In the report he filed with authorities upon his return, in November 1944, Ouary compared what he had just learned in Algiers with prewar transfusions he had done. “Transfusion then,” he explained, “gave the impression of a minor surgical intervention with all the necessities implied.” A syringe was used to withdraw the donor’s blood, which was then immediately given to the patient. The French called this procedure arm-to-arm transfusion, requiring the donor to be next to the patient. Ouary explained the limits imposed by this procedure: “Transfusion is thus a veritable minor surgical intervention, possible only in well-equipped health facilities by a competent doctor, most often by the surgeon on duty. One or both must devote a rather long time for preparation and execution, which would not be a major inconvenience if it was the only urgent task to accomplish.”4 Thanks to new techniques developed for the much larger scale of blood transfusion during the Second World War, Ouary went on to explain what these techniques permitted:
The apparatus today permits transfusions almost as easily as an intravenous injection of artificial serum. It requires a sterilized bottle containing an anticoagulant solution of sodium citrate which is attached to sterilized tubing for the collection and injection of blood. An essential feature is that the injection tubing always includes a filter required to prevent small clots. This filter was not part of earlier apparatus. . . .
In sum, the technical progress today permits numerous transfusions, easily and rapidly in any location, because it has become possible to store blood in one form or another as well as to transport and inject it without complicated equipment.5
Doctors and Decisions about Transfusions
Even with these technical improvements, in the end the decision to do a transfusion was like the decision to use any scarce Western medical resource in places such as mid-twentieth-century Africa. Doctors still faced “urgent tasks” with only limited resources to accomplish them, and there was no obvious answer to the question of whom or what to care for first. For example, when colonial powers decided to build expensive state-of-the-art Western hospitals after the war, they justified it by the need to set standards high if medical care in Africa was to be taken seriously by Western medicine. The common counterargument was that the money would help far more Africans if invested in more facilities that were less expensive.6 Likewise, a doctor in a regional hospital could do hundreds of surgeries, with only