Given these possibilities, then, perhaps the most crucial change after 1945 was that more European doctors went to Africa who were likely to be trained in the use of transfusion. This followed from a variety of underlying developments, including growth of health infrastructure in the colonies, growing demand from increasing population pressure, and the surprising postwar economic recovery of Europe, including expanding medical training. By the time of independence it is estimated that there were 450 Western-trained medical doctors in Uganda and 750 in Kenya.7 The figures for the Belgian Congo were 731 doctors in 1959 (mostly with the government, but about one-third employed by missionaries and private companies), working in 422 hospitals (1957 report) averaging over 110 beds.8
The result was that even if they had no plans upon arrival to devote the time and resources to transfusion, these doctors could be persuaded to do so by something at the local level as simple as the availability of blood or the visit of a guest doctor who demonstrated new techniques. On the broader level, when colonial health authorities invested in large modern hospitals in the capitals of Africa, they were equipped with the latest facilities, including operating rooms, plus support services for radiology, anesthesia, and transfusion. Once a blood service and accompanying blood banks were established, their use quickly spread as people came from far away to take advantage of them. Even though doctors in the provinces did not set up their own service, they referred their patients to larger hospitals with the resources for transfusion until the smaller hospitals eventually made arrangements to do it themselves.
In the British and Belgian colonies, there was an outside stimulus to the introduction of blood transfusion: branches of the British and Belgian Red Cross. Because of their experience in collecting blood on the home front during the Second World War, national Red Cross societies all over the world became leaders in adapting their expertise in blood collection to peacetime operations: recruiting blood donors and in some places, processing blood for transfusion. This was the case in the United States, many European countries, Canada, and Australia, to mention just a few examples.9 The Red Cross expertise was transferable to the colonies, where even though transfusion remained a hospital operation, Red Cross volunteers certainly made it easier to begin or expand transfusion by helping assure adequate donors and in many cases providing funds for equipment and supplies to store blood. This was less the case in the French colonies, because in France a national transfusion service emerged after 1945 out of collaborative efforts between the hospitals and governments dating back to the interwar years, with little or no participation by the French Red Cross.10
All colonial medical department directors were overwhelmed by the health problems in their districts. Moreover, their budgets were small, and requests for additional funds exceeded the resources and competed against one another to make services available to meet basic medical needs. As a result, viewed from the colonies, an organization like the British Red Cross held out the promise of a significant source of volunteer staff time to recruit donors, not to mention funds for such things as transportation, equipment to draw blood, and refrigerators to store it for transfusions. The Red Cross also enjoyed a formidable reputation for beneficence that bolstered confidence in any new scheme. Thus, in whole colonies such as Uganda, Northern Rhodesia, and the Belgian Congo, the Red Cross was asked to run the transfusion services, at least initially.
Despite these immediate advantages, there was a condition imposed by Red Cross involvement in blood transfusion that prompted an ongoing debate and controversy: insistence that blood donation be voluntary, that is, with no remuneration for the donor. This had become part of the ethos of the transfusion service in Britain from its start, after the First World War, and was especially championed by its founder, Percy Oliver (see chapter 1). It spread to other European Red Cross societies involved with blood collection, as in Belgium, the Netherlands, and Switzerland, where they eventually ran their countries’ blood programs.11
This ethos did not, however, take root automatically in African societies. As will be seen, it was difficult to find adequate numbers of Africans to give blood on an anonymous, voluntary basis. When demand grew for the procedure after the 1950s and 1960s, hospital transfusion services had to adopt other means of securing blood. This was done either by direct remuneration, or by requiring patients to find a family member or friend either to be the donor for the patient or give blood as replacement to the blood bank. In addition, almost all donors were given refreshments, cigarettes, and sometimes cash. As a result, transfusion in most African countries was hospital-based by the 1970s, except in such places as Senegal and Uganda, where the newly independent countries continued and expanded the centralized blood services created during the colonial period. This meant that each hospital found its own source of donors to give blood on call or to donate regularly to a blood bank if the hospital had storage facilities. Only later and with outside financial assistance, usually prompted by a crisis or disaster, were independent African countries able to implement the centralized model of blood supply using anonymous, voluntary donors.
The Organization of African Blood Transfusion Services: General Trends and Periods
Before 1945 blood transfusion was organized in Africa by hospitals. It was decentralized, and transfusions depended primarily on the available facilities and the doctor’s knowledge. This favored transfusion at bigger hospitals in capital cities where there might be three or four doctors and at least one surgeon, or hospitals with special outside links, such as ones supported by the University of Louvain and the Union minière in the Belgian Congo. Likewise, the practice of transfusion might be started in a hospital because a doctor who had practiced transfusion at one location might bring that experience and repeat it at a new hospital assignment. This was the case with Joseph Lambillon when he moved from Kivu to Léopoldville in the Belgian Congo health service during the Second World War, and also with Gaston Ouary when he moved from Dakar to Brazzaville in the French colonial health service after the war.12 That did not necessarily guarantee the overall increase of transfusion, since after a practitioner moved, his successor might not be knowledgeable or interested in continuing to do transfusions. Thus, when Lambillon left the Kivu hospital at the end of the Second World War, his transfusion instruments lay idle until the early 1950s, when a new doctor, Louis Legrand, arrived from Brussels who was schooled in newer transfusion techniques that he introduced.13
In addition to the doctor’s decision to use transfusions, the selection of donors in this initial period also influenced whether the procedure was done in a particular setting. For example, in 1940 Lambillon stressed the possibilities of blood donation from recovering patients in African hospitals, but more typically family members were asked to donate. As to the uses of transfusion, there was some experimentation with transfusion for pneumonia as early as the 1920s in Katanga, because of the high incidence of that disease among mine workers, but more typical were surgery cases and difficult obstetrical deliveries. The experiment with anemic infants at Kisantu Hospital in the Congo in the early 1940s proved to be the precursor of a practice that became more widespread and particular to the African setting in the 1950s and 1960s.14
To summarize, by 1939 transfusion was known to doctors in most capitals and big hospitals in sub-Saharan Africa. Connections back in Europe and the small world of colonial medicine facilitated this. The extent to which transfusions were done varied depending on local circumstances such as the interest of doctors and surgeons or the existence of a Red Cross branch.
The policy decisions and other developments that led to widespread introduction of transfusion after the Second World War also brought an attempt to centralize transfusion services. Thus, when a new hospital was built in the 1950s, as in Ibadan, Nigeria; Kampala, Uganda; and Lomé, Togo, or an existing one was enlarged, especially with a surgery wing, as in Nairobi, it typically included the standard services for modern operations, such as expanded laboratory facilities and a blood bank.15 Because this gave big hospitals, usually in the capital, the facilities that other hospitals did not have, their blood collection, testing, and banking facilities often became at least citywide services and, where feasible, sometimes reached nearby district hospitals. In large and relatively prosperous colonies such as Kenya and Uganda, the transfusion