A later example was the speed, surprising to some Western observers, with which Africans generally accepted injections and other Western medicines. This was frequently noted by outsiders who feared overuse by patients demanding injections or medicines, no matter the condition. One medical officer who served in Uganda beginning in the late 1930s reported cases where blood donors thought that the act of donating blood had the curative power of an injection because a needle was used.17
Blood transfusion required even more explanation, especially for donors, but it was one of the Western medical techniques whose value was immediately and obviously demonstrable, in Africa as elsewhere. When Grace Crile, wife of the American surgeon George Crile, described the results of his first transfusion on a human, which she assisted as a nurse in 1906, she recalled, “I stood at the foot of the operating table and witnessed the miracle of resurrection.”18 Thus, in large measure, because it worked so well, transfusion became a part of modern medicine throughout the Western world soon after a safe way was found to transfer the blood from donor to patient, at the beginning of the twentieth century. The experience of the First World War helped resolve some initial problems, and in the 1920s transfusion shifted from wartime use for injuries sustained in battle to its more common civilian uses to replace blood loss from various accidents and diseases, as well as in childbirth. All these conditions existed in Africa, as well as another endemic to the region, severe anemia.
Many expressed doubt that Africans would allow their blood to be taken or subject themselves to such a radical procedure as introducing the blood of another into their bodies. For example, early reports of transfusion in the Belgian Congo relied on recovering patients in hospitals as the source of blood, people with little power to decline.19 Likewise, a similar approach was used to persuade African troops in Kenya to donate blood during the Second World War, but there was so much resistance that a special study was done to learn why.20 In Senegal, one of the early practitioners of transfusion, Gaston Ouary, expressed strong doubts about Africans donating blood for fear of becoming weak from blood loss or somehow contracting the disease of the patient receiving blood.21
These fears and occasional reluctance to donate blood proved not, however, to be the obstacle that some Western observers feared. In the end, the obvious benefit that a transfusion produced was coupled with adaptation and persuasion to obtain the necessary blood donors. Writing in 1960, at a critical juncture on the eve of independence in many African countries. H. C. Trowell, a British physician at Mulago Hospital in Kampala, Uganda, quickly dismissed the potential problem of finding blood donors. In “Transfusion,” a section in his Non-infective Disease in Africa, he stated, “It is not proposed to discuss the social prejudices against blood transfusion in Africa, as within a few years these are usually overcome, and then it is usually the shortage of staff and apparatus, rather than the shortage of donors, which is the limiting factor.”22
In fact, the overall pattern was not so different from that in the West, where a variety of methods and motivations, from patriotism to payment, have been used to secure adequate blood for transfusion. Yet according to most studies, less than 9 percent of the U.S. population (of donor age 18–65 years) donates blood in a given year. In Africa a combination of voluntary donation, appeals to obligations from family and friends, and payment have historically been used to secure an adequate blood supply.
The Development of Transfusion Technology to 1950
Of all the things that determined when and how blood transfusion came to Africa, in shortest supply were the facilities and someone knowledgeable about the procedure. Doctors were simply not available in large enough numbers in Africa to introduce blood transfusion on a wide scale until after the Second World War. The techniques they used were adaptations of those worked out in Europe and America in the first half of the twentieth century. These methods strongly influenced when, where, and how transfusion was practiced in Africa, hence it is worth reviewing them, because in the end, transfusions were given in Africa essentially as elsewhere: in hospitals, by doctors or their assistants. Thus, even more than other procedures of Western medicine, such as drug prescriptions or injections, the history of blood transfusion in Africa was linked directly to the two most important institutions of Western medicine: hospitals and doctors.
Patients and healers have long thought blood had curative and restorative power, but the effective medical use of blood transfusions is a relatively modern innovation. It was only after Harvey’s discovery of the circulation of the blood, in the seventeenth century, that there was demonstrable proof of the potential benefit of transfusion, and not until the beginning of the twentieth century that effective blood transfusions entered the realm of scientifically based medical practice.
Surgeons took the lead in developing the effective techniques of blood transfusions at the beginning of the twentieth century; hence patients were treated in a hospital setting with sterile conditions, with anesthesia if necessary, and careful monitoring. These conditions were indispensable for the first effective transfer of blood from a healthy donor to a patient; in fact the initial transfusions were done by connecting the artery of a donor to the vein of a patient. This lifesaving, although long and delicate, procedure was repeated by surgeons in a number of locations who quickly added such basic refinements as measuring the amount of blood donated and preventing clotting. The discovery that sodium citrate delayed coagulation meant the end of so-called direct transfusion, where blood drawn from a donor was immediately given to the patient, usually in the same room. Now, the drawing of donors’ blood into a syringe or tube could be separated from the procedure of giving it to the patient. The result immediately made transfusion easier, but the procedure remained under the supervision of a doctor. Other changes took longer to 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