Читать книгу The History of Blood Transfusion in Sub-Saharan Africa - William H. Schneider - Страница 10

1 BLOOD TRANSFUSION BEFORE THE SECOND WORLD WAR

Blood transfusion is one of the most important lifesaving discoveries of modern scientific medicine. The first effective procedures were demonstrated only at the beginning of the twentieth century, although attempts in its present form began shortly after William Harvey’s discovery of blood circulation, in the seventeenth century. Long before that, most cultures had recognized the significance of blood, which played a prominent role in many rituals and customs of healing.¹

The history of how blood transfusion was introduced to Africa is important beyond its dramatic role in saving lives. As a well-defined medical procedure that was unprecedented in traditional society, transfusion provides a clear case of how an innovation of modern technology, relatively new to Western medicine itself, was introduced to Africa. As a result, it offers an example of Africans’ responses to Western medicine, as well as Westerners’ views of Africans and appropriate medicine for them. In addition, although blood transfusion was similar to other new medical technology such as x-rays or anesthesia, it is much richer in its human and social complications because of the symbolic and cultural significance attributed to blood.

Another revealing feature of transfusion is that it required a weighing of risks and benefits for patients, in this case the potential for the dramatic saving of life compared to the risk of dangers such as disease transmission. Transfusion thus offers an indication of how well these subtle and complicated judgments were made in the African setting. This latter point has become dramatically more important since the 1980s, following the emergence of new infectious diseases such as AIDS. Transfusion, an obvious lifesaving procedure, also opened a new means that had never existed before of transmitting pathogens between humans with unprecedented efficiency. Historian of medicine Mirko Grmek recognized early in the AIDS epidemic (1989) that blood transfusion

was rapidly developed [after the First World War] and became one of the most effective and frequently used therapeutic methods. Still, it was only toward the middle of the century that the practice of transfusion opened a gap in the barrier which, from an epidemiologic point of view, separates the blood of one human being from that of others. . . . For the microorganisms [certain viruses], blood transfusion had formerly been a narrow path, used only in exceptional occasions for transmission of some sporadic infections. Today it has become the royal road requiring delicate and difficult monitoring.²

Evidence of the First Transfusions

The first issue of the Annales de la Société belge de la médecine tropicale (1921) contained a report by Belgian doctor Émile Lejeune that described a patient he treated on the East African front at the end of the First World War. Lejeune had gone to the Belgian Congo after graduating as a young doctor from the University of Louvain in 1911 and very quickly gained notice by establishing one of the first services that went regularly out to villages to test, treat, and inoculate large numbers of Africans. In fact, it became the model for the much more famous and widely implemented campaigns of Eugène Jamot, beginning in Cameroon in the 1920s.³ When the First World War broke out, Lejeune and other doctors in the Congo were mobilized and went to the East African front, where the British were engaged in what turned out to be a four-year campaign against a German-led force in Tanganyika. The mobilization of Africans and Europeans produced a far greater number of casualties from disease than combat, and Lejeune helped staff the hospitals that were established to care for the sick and wounded.⁴

Among his patients was a European officer of colonial troops who suffered from hemoglobinuria (blackwater fever),⁵ and Lejeune prescribed a standard course of cure: “treatment by all normal measures: physiologic serum, injections of hypertonic saline solution, adrenaline, Murphy sugar [drip].” After a few days without improvement Lejeune was discouraged. “General conditions are frankly becoming bad; the patient is very weak, delirious; the pulse, despite medication to stimulate it, is hardly perceptible and very accelerated.”

Lejeune consulted his colleague, Dr. Giovanni Trolli, who was also there on temporary duty from the Belgian Congo Medical Service, and they concluded that the situation was “desperate.” Lejeune therefore decided “to attempt a blood transfusion as the ultimate therapeutic trial.” To be sure, the transfusion he gave was a measure of last resort, but the patient’s fever broke the next day, and although his blood count took longer to return to normal, he was discharged and returned to Europe in two months.

Thus was reported one of the earliest records of a blood transfusion in sub-Saharan Africa (excluding South Africa and Rhodesia). Whether it was in fact the first transfusion (likely not), this case reveals a number of things about the beginning of blood transfusion there. First, it was surprisingly early. It occurred in 1918, only fifteen years after the reports of the first successful transfusions in Europe and America that ushered in the era of modern use of a long–dreamed of therapy: giving the blood of one human to another. In fact, it was not until after the First World War that techniques were worked out that made the procedure viable for widespread use in Europe and America.⁶

Second, Lejeune showed that transfusion was feasible in the African setting. Admittedly, he was a European-trained doctor who treated a European patient, using blood drawn from another European. This reflected one of the main reasons noted by scholars for the beginning of tropical medicine: care for colonial interests, European settlers, administrative officials, and Africans employed in mining and other colonial enterprises. But with the exception of settler colonies, such as Kenya and Rhodesia, the number of Europeans in Africa was quite small. In the Congo Free State of Leopold II, there were around five hundred Europeans in 1901, and an estimated twenty-five to thirty doctors, mostly in the towns of Boma and Léopoldville. This number grew to fifty-nine doctors in 1910, not counting those employed by missionaries and private companies.⁷ So, to provide for the minimum health needs of relatively few Europeans, there was obviously a capacity to care for some Africans, even if that paled in comparison to what their numbers and disease burden required.⁸

By the end of the nineteenth century, the most important setting for the practice of modern biomedicine was a hospital. So where Lejeune did his transfusion was similar to others established by the new colonial governments in sub-Saharan Africa, usually in ports, colonial capitals, or areas of important economic activity, where significant numbers of Europeans were likely to be living. These hospitals were numerous enough in some parts of Africa by the First World War to establish many Western medical practices in the African colonies. There were government hospitals in British East Africa—in Entebbe, Mombasa, and Nairobi—within ten years of colonial rule, and by 1919 the Germans had established hospitals in Tabora, plus the Ocean Road and Sewa Haji facilities in Dar es Salaam.⁹ Although their benefits eventually reached the African populations, more or less, how much is not the point here. Rather it is that by 1918 the level of medical infrastructure and knowledge in sub-Saharan Africa was sufficient to practice blood transfusion.

To illustrate this point, consider that Lejeune used 500 cc of citrated blood, “from a healthy, solid European, with no apparent defects,” but he did not match blood types. Although test sera and a method to determine compatibility were greatly improved by war’s end such that results could be done in minutes, it is not surprising that Lejeune was unaware of this, given his very remote location.¹⁰ But even without test sera, there were procedures to guard against incompatibility that involved giving a small amount of blood to the patient at first, to see if there was an adverse reaction, before transfusing the remainder. This was crude but effective and justifiable if the life of a patient was at stake.¹¹ In fact, this is exactly what Lejeune did in his 1918 transfusion. He reported giving an “anti-anaphylactic injection” of 5 cc of blood from the donor and waiting five minutes to see of there was a reaction before transfusing the rest of the blood. So Lejeune was aware of blood groups, their importance in transfusion, and a way to match blood, in effect in vivo.

In concluding remarks, obviously aimed at other doctors practicing in Africa, Lejeune pointed out the implications of his success: “All doctors in the Congo have seen patients die in this manner [complications from hemoglobinuria]. The successful results we obtained could be repeated in other cases of this type. . . . Transfusion is an operation that can be done anywhere. Blood was drawn by means of strong needles on a Dieulafoy syringe. . . . Transfusion is nothing more that an intravenous injection. I did it slowly (a quarter of an hour).”¹²

It is impossible to say with certainty when the first blood transfusion was made in Africa. It is a very large continent, the number of Western doctors was small, and the records of practice were quite varied. Reports published by doctors such as Lejeune were among the important sources describing the beginning of blood transfusion. Because it was an unusual practice at first, transfusion was likely deemed noteworthy by both doctors and medical journals that published accounts of their experience. Informative as these accounts may have been, they certainly did not record every transfusion, and in any case, once the novelty soon wore off, they would be of less interest. For example, neither Lejeune nor Trolli published again on transfusion, but it is likely that they practiced what Lejeune advocated in his 1921 article when they returned to the Congo in the 1920s. Both, in fact, served there for an extended period, with Trolli becoming chief medical officer of the colony in 1925 and Lejeune remaining in the Congo as a private physician in northern Katanga after finishing his government service.¹³

Other important sources of information were the routine medical services reports that became routine in African colonies by the 1920s. The standard forms for surgical interventions did not mention transfusion, however, until much later, when the procedure was more widely used. Generally, it was only after transfusion services were established by hospitals, usually beginning in the late 1940s, that medical reports provide a continuous record of transfusions.

There is nonetheless indirect evidence of transfusions before that time, such as the accounts of laboratory tests found in the annual medical reports. Hospital laboratories kept good records of examinations and analyses that had become part of hospital routines, and many included blood group tests in their annual reports, often well before the surgical reports began recording transfusions used in an operation or treatment. These blood group determinations could only have been for transfusion purposes, since paternity and forensic testing were almost unheard of in Africa at this time. In fact, these exceptions were duly noted when they were occasionally performed.¹⁴ Laboratory reports, therefore, provided a sustained, if indirect, record of blood transfusion beginning between the wars.

Starting with the example of Lejeune, plus the direct and indirect evidence in published articles and unpublished reports, it appears that the first transfusions were done in Africa at the beginning of the 1920s. This means that the conditions necessary for a transfusion—a patient in need, a donor, and a doctor with knowledge and means—existed at a relatively early time, even compared to the first transfusions in the world in the modern era, which began only in the decade before the First World War. The record also shows, however, that only after the Second World War were transfusions done widely and in large numbers in Africa. Understanding this timing requires further examination of questions about the setting in which the introduction of this lifesaving Western medical technique took place.

Blood Donation and the Uses of Transfusion in Africa

There were three broad conditions required for transfusions to take place in Africa or anywhere else: patients in need, a source of blood, and facilities with someone knowledgeable of a method to transfuse the blood. The first two of these conditions depended on Africans’ attitudes toward Western medicine, and more specifically whether they understood the need for transfusion and were willing to do something as unusual as donate and receive blood. Surprisingly, these were not the biggest hindrances or limiting influences on when blood transfusion began. To be sure, there was a natural reluctance to do something as unusual as allow blood to be taken from or introduced into one’s body; and there are numerous anecdotal examples and a few systematic studies of resistance to, as well as persistent racist observations about, the inability of Africans to understand Western medicine. For example, Meghan Vaughan has described the resistance of Africans in northern Nyasaland to smallpox eradication efforts in the 1930s. In addition to compulsory infliction of some pain, the measures also entailed, “the curtailment of movement, the segregation of villages, the banning of funerals and the burning of victims’ huts.”¹⁵

These examples were exceptions to the general and relatively quick acceptance by Africans when Western medicine became available. There was not only little resistance but Africans also eagerly responded when its effectiveness was demonstrated. An early example was the rapid success of the Anglican doctor Albert Cook, who came to Uganda in 1897. In fact, his fellow missionaries already there were afraid the Africans’ acceptance would distract them from religious conversion. Shortly thereafter a Church Missionary Society dispensary in the colony attracted over two hundred patients a day within months of opening.¹⁶

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 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 metropole had invested significantly in health facilities for Africans to support economic activity (e.g., mining), or where there was sufficient development of health infrastructure to reach Africans.

One example of the knowledge of transfusion and willingness of Africans both to donate and receive blood can be found in South Africa. Although an area not included in this study, conditions were similar enough to illustrate the point early on. In a 1921 paper, J. H. H. Pirie of the South African Institute for Medical Research described testing for blood types that was inspired by the research of Ludwik and Hanna Hirszfeld during the First World War. They had done blood group tests on thousands of troops, including 250 Africans, and found striking differences in the proportions of the ABO blood types depending on country of origin.³⁷ What made it possible for Pirie to verify these results was his observation that “blood transfusion is a procedure which has now become so frequently employed . . . that a brief review of the preliminary tests required in order to ascertain the suitability of the donor’s blood may not be out of place.”³⁸ Pirie did not say whether he used existing blood tests of black Africans receiving transfusions, or if he tested subjects especially for his study, but his article at least demonstrates that blood transfusion was practiced routinely in 1921 at two hospitals in South Africa, where his colleagues provided him access to blood tests.

Early Transfusion Services in the Belgian Congo

There is noteworthy evidence of doctors in the Belgian Congo who followed the suggestion to repeat the successful results described in Lejeune’s report of transfusion. Although, there was little European settlement in the colony, Belgian authorities made significant investments in health in the 1920s and 1930s because of business and mining interests and a government expectation of productivity benefits from healthier subjects.³⁹ In fact, there were reports from at least three different locations where transfusion began in this large colony before the Second World War. Although the doctors likely soon knew of each other’s work, the opportunities developed independently, and there was no effort at coordination by the colonial government. Because Belgian colonial administrators took advantage of a variety of sources for medical services, the government increased the number of health facilities but hindered centralization. This same independence probably made the introduction of transfusion more likely because of multiple influences, but expansion was less likely because of limited resources.⁴⁰

Of the three places where transfusions were reported, the one most similar to other colonies was in the capital of Léopoldville. There the Hôpital des congolais grew into a large general hospital for Africans between the wars, and although postwar plans for a new one never were achieved, additional space and updated equipment were added to serve the growing population of the capital. Unlike Kenya, Nigeria, or Uganda, where new hospitals were built with the latest facilities, including blood banks, transfusions increased at the Leopoldville hospital without much fanfare.⁴¹ For example, as early as 1939 a doctor in the pediatric service of the Hôpital des Congolais began transfusions for severely anemic infants from a variety of causes including (malaria, worms, malnutrition, and syphilis).⁴² He had previously done the procedure in Rwanda. By 1956 over seven thousand transfusions were done annually for these cases.⁴³ The Queen Astrid Laboratory, which serviced the hospital, reported the preparation of test sera for determining blood types as early as 1947, and by 1954 it reported doing over sixty-four hundred blood group tests.⁴⁴ The initiative for a more central blood collection and processing service started only in 1953 and from a facility in Léopoldville with outside connections: the Congo Red Cross. In fact, this outside association provoked a conflict with the Hôpital des congolais, which had its own recruitment of donors.

One of the doctors at the Hôpital des congolais who did blood transfusion after the Second World War was Joseph Lambillon, the head of the maternity service. He had first done transfusions in Africa shortly after he went to the Congo in 1938 to work in the eastern Kivu region at a hospital in Katana that was supported by the University of Louvain. Fresh from two years as an assistant in one of the top surgery services in Belgium, Lambillon was eager to introduce modern medical practices that were appropriate for the Congo. In 1940 he published an article, coauthored with the other doctor at the hospital, entitled “Étude de l’organisation d’un service de transfusions sanguines dans un centre hospitalier d’Afrique.”⁴⁵ The report, in fact, referred to only thirty transfusions, but Lambillon was less interested in claiming credit for a new procedure than he was eager to demonstrate, like Lejeune before him, the viability of transfusion in the African setting. He concluded, “This note has no pretensions of innovation. But it permits us, in the end, to underscore that in the colonial setting blood transfusion is very easily done, thanks to the large number of chronic patients that are in all the native hospitals who can serve as donors. Transfusion has the very big advantage of being a striking treatment that above all is not costly, a fact which is of great importance in native medicine.” Lambillon thus showed it was not lack of donors, nor Africans’ rejection of the value of blood transfusion that stood in the way of using the lifesaving procedure. Doctors simply needed to use it.

The one place where Lambillon’s efforts most likely had an impact was at another hospital run by the University of Louvain in Kisantu, at the other end of the colony in Lower Congo. As late as 1934, this hospital reported no transfusions, despite its unusual link back to a major medical faculty in Europe. It was in the same year Lambillon’s article appeared (1940), however, that doctors at Kisantu began to treat severely anemic infants with blood transfusions. Once they had begun, they did so in a very systematic and extensive way. Throughout the 1940s and into the next decade, Kisantu Hospital treated over six hundred infants, most under a year of age, with over twenty-two hundred transfusions annually by 1949.⁴⁶

The most unusual and earliest report of transfusions in the Belgian Congo, however, was in yet another location with unique resources and opportunities to do blood transfusions: the medical service of the Union Minière du Haut Katanga. In 1924 doctors at the African hospitals at Panda and Elisabethville (later, Lubumbashi), in Katanga Province, published the results of studies using transfusion therapy for African workers with pneumonia. This was a cross between serum therapy and transfusion, since blood was drawn from convalescing pneumonia patients and then given to patients with active cases of pneumonia. An initial test on forty-five patients was followed by a larger study of 238.⁴⁷ The results, however, were not definitive. Although doctors recognized the risk of introducing different pneumonia strains, they concluded, “comparing our results overall, this method is the best that we have a chance to use. Compared with various other treatments and colloid therapy, . . . it represents serious progress.”⁴⁸

An even more innovative transfusion technique was reported in a 1934 note by Dr. George Valcke about an autotransfusion he practiced on an African woman in Katanga who had hemorrhaged after giving birth. He withdrew blood from her abdominal cavity, filtered it, and then reintroduced it to her as a transfusion. Valcke, who served in the Congo for over twenty years before returning to Belgium in 1933 to head the Leopold II Clinic in Antwerp, indicated he had learned the technique from Professor Joseph Sebrechts of the Catholic University of Louvain, one of the most famous Belgian surgeons, who gave a demonstration in Elisabethville in 1930.⁴⁹ Valcke’s brief 1934 note responded to a lengthy article on the work of the obstetrical clinic at Kisantu Hospital, which made no reference to transfusions.⁵⁰ The doctor in charge, Antoine Duboccage, mentioned that among several cases was a severe hemorrhage ending in death. Valcke noted that Duboccage should have used the autotransfusion method. Despite this suggestion, it took a change of personnel at the Louvain hospital and the report of Lambillon’s work before transfusions began in Kisantu for anemic infants.

An indication of how widespread transfusion was practiced in the Belgian Congo, and possibly other colonies in sub-Saharan Africa by the Second World War, can be found in a thesis written at the Prince Leopold Institute of Tropical Medicine in Antwerp in 1950. In it the author (listed only as L. Kok) described giving over a hundred blood transfusions in the Belgian Congo “to natives as often as possible over a dozen years.” That this was not unusual is made clear in the opening sentence, which bore out the prediction of Lejeune thirty years earlier: “Today blood transfusions are done on a large scale everywhere and have even become part of regular practice.” Admitting that this was not the case “at interior posts where conditions are not always favorable,” Kok nonetheless gave as the principal reason for the wide use of transfusion “the efficacy of the procedure, the simplicity of instrumentation, and the lack of specialized and expensive medicines during the war.”⁵¹

The thesis provided few details about location, except for one reference to Katanga. It concentrated instead on practical techniques such as obtaining donors, in which case Kok went first to the immediate family or friends of the patient, with a preference for young females “who agree more voluntarily than the men,” and if unavailable then made a request to infirmary personnel. Compatibility testing was done by the simple mixing of blood drawn from donor and patient. Wasserman tests were done if time permitted, and 250 cc of blood was typically drawn into a mixture with sodium citrate. Blood was given to the patient in the sickbed, and the author stated, “in over a hundred blood transfusion done in ten years I never encountered serious shock.” He described the risk of transmitting various diseases, with some (e.g., tuberculosis, sleeping sickness) being more serious than others. By taking precautions such as examining potential donors, he concluded that “the danger of transmitting illness by blood transfusion is not very serious.” As to the illnesses most frequently and effectively treated by transfusion, the first was anemia, the most common cause of which was hemorrhage during a difficult childbirth; next was toxic anemia from worms; and, behind that, anemia from advanced cases of malaria. The author’s ultimate conclusion: “Blood transfusion, despite the difficulties inherent in the native setting, . . . can be used more with very satisfactory results.”⁵²

Early Transfusion in the British Colonies

There was far more variety in the number of British colonial holdings in sub-Saharan Africa, but like the Belgian Congo there was a similar pattern in how new health facilities were developed. This development included initial investments before the First World War that followed colonial interests at ports, capitals, and business enterprises. Medical missionaries were also active, but unlike the Congo, there were significant settlers in Kenya and southern Africa.⁵³ Beginning in the 1920s the expansion of hospitals and European-trained doctors followed a policy to move health facilities out of the capitals to rural areas where missionaries had mostly been providing Western medical care. “A government hospital is a tangible sign of Government activities which is understood by every native,” argued J. L. Gilks, principal medical officer for Kenya in his 1921 annual medical report.⁵⁴ “It is a fact which cannot be gainsaid, that the provision of medical attendance, even of the crudest and most primitive description, is the best form of advertisement for any form of activity among natives.” In 1925 there were twenty-three colonial medical service doctors in Kenya and twenty-five in Uganda. Ann Crozier’s study found that a total of 424 colonial service doctors had served in Kenya, Uganda, and Tanganyika by 1939.⁵⁵

A very rich source of evidence about transfusions in British African colonies before 1939 comes from the British Red Cross, which created branches in the colonies. In the settler colonies of Kenya and Southern Rhodesia, for example, blood donor panels, or lists of donors, were established in the 1930s as a way of obtaining more reliable sources of blood for transfusion both for Africans and Europeans. This method of donor recruitment was developed between the wars in the large cities of Britain, France, and the United States,⁵⁶ where hospitals compiled lists of volunteers who were pretested for blood type and screened for illness. They were to be called, even on short notice, to have blood drawn when a transfusion was needed. Not only was this system inspired by the need for a more reliable source of blood for transfusions, but volunteering on these panels was seen as an activity to draw volunteers to help start Red Cross branches in the British colonies. The most obvious significance of establishing blood donor panels was to stimulate interest in transfusions by Western doctors already in place and with knowledge of the procedure. In effect, this was a case of supply stimulating demand.

The pioneer of this model of blood donor service was Percy Oliver, who was invited to give a talk at the 1930 British Empire Red Cross Conference, held in London, relating his experience of over a decade in that city. Shortly after the First World War, Oliver, his wife, and other members of a local Red Cross division in the London neighborhood of Camberwell answered a chance call from a local hospital to give blood for a transfusion. Until then, hospitals had relied on nurses, orderlies, or other hospital staff to serve as donors when no family member was available who matched the blood type of a patient in need of a transfusion. Oliver contacted other members of his neighborhood division, and over the years hospitals in London came to rely on this ready source of blood for transfusion. Oliver and his wife were called when the need arose, and the volunteer was sent to the hospital, where blood was drawn and given to the patient. Oliver reported that the organized service, which began in 1921, provided over 1,360 donations in 1929.⁵⁷

The London conference was an opportunity for representatives from dozens of branches of the British Red Cross in colonies and dominions around the world to meet as well as to hear speeches and reports of activities. Oliver was one of the first plenary speakers, because his London Blood Transfusion Service was a very successful and highly visible program of the British Red Cross. At the 1930 conference he recommended work with blood donors “to all delegates as a very fine form of service for Red Cross members,” but he warned them not to serve simply as a channel to recruit donors to be placed in the hands of the hospitals. His “bitter” experience was that the chapter needed to act “as a buffer between the institutions and the donors, to protect their interests.”⁵⁸

It did not take long for members in both Kenya and Southern Rhodesia, where Red Cross branches had been established only a few years earlier, to start blood transfusion services. The 1932 annual report for Kenya stated, “A blood transfusion service has been organized and has a panel of 24 donors, including 10 members of Toc H [a service club started by WWI veterans], for whom lectures on the subject were arranged.” The same year the Southern Rhodesia branch reported, “a Blood transfusion service has been organized and a number of VAD [Voluntary Aid Detachment] members have enrolled as donors.”⁵⁹ Indirect evidence of blood transfusions in Northern Rhodesia is contained in a March 1931 administrative report from the commissioner of Northern Province about banyama, or vampire men, the rumors about which were being fueled by appeals for blood donors and transfusion in the province.⁶⁰

As the numbers indicate, this was a small start, and in subsequent years the numbers did not grow very quickly. The Kenya Medical Research Laboratory, in Nairobi, reported annual blood group tests in the 1930s of between ten and thirty individuals each year. The Rhodesian Red Cross branch stated in 1939 that the number of volunteers had risen to 903, with 650 of them grouped. “No life will be lost for lack of a willing donor,” the 1939 annual report proudly boasted.⁶¹ In fact, that same year Southern Rhodesia proclaimed with much fanfare the establishment of a “National Blood Transfusion Service,” including a new building. This was, of course, a premature and hollow boast, partly because of the limited numbers, but also because it ignored the problem of saving the lives of all Africans. In any event, the war quickly put an end to such plans, yet this is at least an indication of the technical feasibility of a blood transfusion service in Africa.

These examples are telling of the practice of transfusion that can be found in the published literature and unpublished colonial reports before the Second World War. Yet they are not complete. For example, they do not discuss transfusion in French colonies, which will be covered in the next chapter, nor do they include unpublished or otherwise unrecorded individual cases, like Lejeune’s patient whose desperate conditions also prompted transfusions to save lives. In the end it is impossible to know the full extent of transfusion during this period because it simply was not always judged worthy of reporting. In fact, regular inclusion of transfusion in French colonial medical reports did not begin until 1955. Only rarely did a hospital or colonial report mention the establishment of a transfusion service, as in 1949, when the two big hospitals of Dakar did so. There were also reports of a handful of transfusions in surgery services of hospitals in the French Congo in 1933 and 1934.⁶² Another example of an exception that demonstrates the case in point, comes from Sierra Leone, a fairly small British colony (1931 census of 1,768,480), with few Europeans, and not particularly noted for significant investment in health or other Western development. Yet in 1936 the annual report of the pathology laboratory of Connaught Hospital in Freetown mentioned grouping seven blood donors (six African), a figure that rose to thirty-six (twenty-five African) in two years. Similar scattered examples show the widespread ability, even if limited in practice, to do blood transfusion in sub-Saharan Africa before the Second World War.⁶³

In Uganda, for example, blood grouping was first reported by the Kampala Medical Laboratory in 1931. There were similar reports from Tanganyika in 1932 and the Gold Coast in 1935.⁶⁴ The 1939 annual health service report for French West Africa stated there were 140 blood group tests by hospital laboratories (24 for Africans), a figure that rose to 891 the following year (813 for Africans).⁶⁵ In the Belgian Congo, similar sources reported 18 blood group tests in 1929 in Katanga, rising to 46 (22 for Africans) in 1939. Similarly, the bacteriology laboratory in Léopoldville reported 75 blood group tests (27 for Africans) in 1937.⁶⁶ Figures from these reports are, therefore, undoubtedly a low estimate of transfusions done, since they could be and certainly were also done using blood donated by a relative or member of a hospital staff, without assistance of donor panels, and without being reported.

TABLE 1.1. Transfusions reported (more than 10 annually) in African colonies by World War II

Colony	Date and notes
Belgian Congo	1924 Haut Katanga, 300 patients; 2 other locations by 1940
Uganda	1931 first blood-grouping reports from Kampala
Kenya	1932 Nairobi, 24 donors
Tanganyika	1932 first blood-grouping reports
French Congo	1933 Brazzaville
Ethiopia	1935 first report of transfusion service in Addis Ababa
Gold Coast	1935 first blood-grouping reports
Sierra Leone	1936 first reports, 38 in 1938
Rhodesia	1939 report of 903 donors
Senegal	1940 report of 813 blood groupings, French West Africa
French Soudan	1941 300 blood-grouping reports
Sources: D. Spedener, “Le traitement des pneumonies des noirs par transfusion de sang des convalescents,” Bulletin médical du Katanga 1 (1924): 234–38; Germond, “Statistiques des cas de pneumonie traités par transfusion de sang de convalescents,” Bulletin médical du Katanga 1 (1924): 243; Uganda Protectorate, Annual Medical and Sanitary Report, 1931, 49; Kenya Colony and Protectorate, Medical Research Laboratory Annual Report, 1933; Tanganyika Territory, Annual Medical and Sanitary Report, 1932, 67; Inspection générale du Service de santé, AEF Colonie du Moyen-Congo, “Rapport annuel,” 1933, 111, and 1934, 124, box 117, IMTSSA; R. Ghose, “History of Blood Transfusion in Ethiopia,” Ethiopian Medical Journal 31, no. 4 (April 1963): 208; Gold Coast Colony, Departmental Reports, 1935–1936, 44; Sierra Leone, Annual Report of the Medical and Sanitary Department, 1936, 51; Report of the British Red Cross Society for 1939, 92, 95; AOF, Service de santé, Rapport annuel, 1940, 79; AOF, “Inspection générale des services sanitaires et médicaux, Rapport annuel 1941,” 115, box 4, IMTSSA.

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.