Читать книгу The History of Blood Transfusion in Sub-Saharan Africa - William H. Schneider - Страница 11

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 basic anesthesia and antisepsis. Adding the ability to do transfusion could save lives, but so, too, could doing even more operations that did not require it.

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 services and laboratories served other hospitals as far as transportation of blood would allow. The Dakar federal transfusion center went to the furthest extreme when it attempted to provide blood not just for Senegal but all of French West Africa.

Following the Red Cross model in British colonies, blood was usually expected to be donated voluntarily during this period from the Second World War to independence, but French colonies generally followed the metropole model, where the government set a price to compensate for the effort to make a blood donation.¹⁶ There were pressures, however, that produced a mixture of paid and voluntary donation everywhere. In some of the British colonies, for example, there were hospitals that did not rely entirely on Red Cross voluntary donors; thus there was already a mixed approach before independence.¹⁷ Likewise, both the Red Cross volunteer system of collection and the Dakar center recruited unpaid donors from the Westernized African classes and workforces: army personnel, civil servants, and factory workers, but above all older schoolchildren and prisoners. The practice in Senegal was that if donors came to give blood at the transfusion center, they were paid for their trouble and fed, but donors at mobile units on-site were not. The question of who donated and who used blood will be examined in greater detail in chapters 4 and 5. Both groups grew significantly during this time period. The most important categories of patients receiving transfusions were general medicine (including accidents and emergencies) and surgery, along with maternity services and pediatrics if these specialties were available.

After independence, the organization of transfusion services entered a new phase, with most countries accelerating expansion by building provincial hospitals to serve regional needs better. This was also in response to the higher cost and slowness of transport that occurred in the centralized model. Other countries, which had never been able to centralize, such as Nigeria and Congo/Zaire, left it to the local hospitals to arrange for their own transfusion services, sometimes with the assistance of the Red Cross, sometimes with a paid service, and sometimes both. Thus, after independence there was a general swing away from centralization and its high costs, toward a middle position of mixed organization with limited regional services at best, and hospital-based means to supplement or complement blood collection and testing. In general, this move was driven by the continued increase in the use of transfusion and the corresponding need for more donors, which had accelerated in the last ten to twenty years of colonial rule.

Transfusions in French African Colonies after the Second World War

In most African colonies, the Second World War diverted resources elsewhere and reduced the practice of blood transfusion. The major exception to this, as mentioned above, was Senegal, where shortly after the Allied invasion of North Africa planning began for the Pasteur Institute in Dakar to collect and ship blood to the front. This development had significant repercussions for the organization of transfusion services, not just in Senegal but all of French West Africa.

In September 1943 the Dakar Pasteur Institute was instructed to prepare test sera for blood group determination of European and African troops stationed in Dakar and the Senegal-Mauretania colonies. In addition, the Pasteur Institute was to ship test sera to all colonies in French West Africa. By the end of 1943 over six thousand vials were prepared and 449 Africans and 166 Europeans had been tested.¹⁸ In 1944, Gaston Ouary, a surgeon in the colonial medical service at the African hospital in Dakar, was sent for training to the blood transfusion center established in Algiers by Edmond Benhamou.¹⁹ After Ouary’s return, he and two other colonial medical officers, Yann Goez and Jacques Linhard, secured the equipment necessary to set up a service at Dakar, including writing a manual for training personnel to draw blood and perform transfusions. In February 1945 these personnel, under the direction of the Pasteur Institute, began their transfusion service in an American army barracks on the outskirts of Dakar. By the end of the war enough blood was collected to provide over 225 liters for transfusion, mostly in the form of plasma but also some whole blood that was shipped to troops in Italy.

This wartime development also had an immediate impact on civilian blood transfusion, because once a source of blood was available, it was also used by the main civilian hospital in Dakar and the military Hôpital principal.²⁰ In fact, French colonial authorities were quite aware of these extended benefits from the start. Thus, when Ouary returned from his training in Algiers, the transfusion manual he wrote with Goez and Linhard in November 1944 was not just for wartime use.²¹ As the head of the French colonial health service, Marcel Vaucel, stated in his introduction, the authors of the book had a double purpose: “to describe the new technique for their distant comrades, [and] to expand the uses of blood transfusion in tropical locales.” Benhamou repeated this in the conclusion to his preface: “We are sure that blood transfusion in all its forms (fresh whole noncitrated blood, stored whole blood, blood products) has a large future in our colonies, and that the notes so brilliantly edited and perfectly illustrated by Médecins-Commandants Ouary and Goez, and Médecin-Capitaine Linhard, will significantly aid in the diffusion and expansion of this heroic therapy, in war as in peacetime.”²² And, as the authors themselves put it, “We thought it useful to make these [scientific and technical developments] known to our comrades in the empire, who work without access to publications and who find it impossible to follow the medical progress achieved during this war.”²³

The report that Ouary wrote to his superiors upon his return indicated the implications for infrastructure that predicted some of the subsequent developments of transfusion services in most African colonies and independent countries. “Today those who must care for the wounded demand larger and larger quantities of blood. Such an increase in transfusion has necessitated the creation of a new organization.” He pointed out that the Algiers center included:

• a laboratory to prepare the different types of blood, furnished by its own collection sources, mobile teams both lightly and fully equipped, and secondary fixed centers

• a warehouse to provide equipment and biochemical supplies

• a training center for reanimation-transfusion teams²⁴

Following the plan of the Colonial Health Department, the Pasteur Institute continued the blood collection service in Dakar after the war; and although the amount of blood collected dropped to less than thirty liters in 1946, donations steadily grew thereafter.²⁵ In 1949 the two large Dakar hospitals (Hôpital le Dantec and Hôpital principal) had organized transfusion services, the one in le Dantec being housed in a new surgery wing completed that year, with twenty-four beds dedicated to “reanimation.” Louise Navaranne, a doctor who accompanied her husband, Paul, to Dakar when he was assigned to the surgery service of le Dantec, directed the reanimation center. In 1950 she reported almost four hundred transfusions with whole blood and plasma supplied by the transfusion service.²⁶

At this same time, credits were voted to establish a federal transfusion service that opened in 1951 to serve all colonies in French West Africa.²⁷ In a letter to the governor general of French West Africa, the director of public health for the federation, Léon Le Rouzic, gave four reasons for the creation of the federal transfusion center, some of which proved to have clear foresight, combined with others that never saw the light of day. They were:

1. The important increase in the number of serious accidents occurring each day in Dakar and its environs.

2. The capital of AOF [l’Afrique Occidentale Française] has an airport that has become a crossroads of international airlines, and health facilities must possess a maximum of resources in case of an airline accident. It is noticeable that foreigners are concerned about the means at our disposal in this regard.

3. This facility will become part of the health facilities of greater Dakar.

4. The transfusion center will be a federal facility, with blood and plasma capable of being sent at any time to facilities in the interior by regular airlines or planes (military or civil) required for this.²⁸

Linhard, who had trained in obstetrics at Bordeaux a few years following Ouary in the 1930s and was coauthor with him of the transfusion manual for use in the colonies, became the first director of the transfusion service in Dakar. The reports of the service quickly showed that sufficient donors were found that met the greatly increased demands for transfusion. After six months of operation, the Dakar center reported 3,508 donations of 300 to 350 cc each from almost two thousand donors. Of these 1,384 were Africans, mostly civil servants (the Europeans were military), and none were women. Within three years, according to the center’s 1954 report, it drew blood from over twelve thousand donors, all but five hundred of whom were Africans.²⁹ Significantly, and uniquely for sub-Saharan Africa, the Dakar transfusion service had facilities for freeze-drying plasma, which was useful for shipments to the other colonies.³⁰ The increased supply of blood and plasma made it possible for le Dantec Hospital to increase its blood transfusions dramatically, according to the use of blood products at the hospital before and after the opening of the new transfusion center.³¹

Most of the blood and plasma were distributed by train to Senegal and the French Sudan, and by air to the major cities of French colonies throughout West Africa: Bamako, Conakry, Abidjan, Niamey, Ouagadougou, Lomé, and Cotonou, as well as Douala, Cameroun (a UN protectorate administered by France). This regional approach, and the possibilities it implied for centralized services and quality control, proved to be exceptional and temporary. For reasons of cost, increased demand, and the growing political-independence movements, separate transfusion services were soon created in each colony.

TABLE 2.1. Blood and plasma use, le Dantec Hospital, Dakar, 1950–52

Year	Whole blood (250 cc units)	Plasma (350 cc units)
1950	180	207
1951	384	286
1952	1,146	675
Source: “Rapport annuel, Hôpital Central Africain,” 1950–52, box 32, IMTSSA.

Before the establishment of the blood collection service in Dakar, there were reports of transfusions in the French Congo as early as 1933 and 1934. Additional evidence shows transfusions there in the late 1940s as well.³² Likewise, there is indirect evidence of transfusions from lab reports of blood group testing in French West Africa in 1939, most likely from the Dakar hospitals but also in the French Sudan between 1940 and 1945. Gabon reported blood group tests in 1950 and 1951, and, along with Togo and the French Congo, it established agreements in 1950 on the price paid for blood given by local donors, in accordance with the national agreement negotiated in 1949 between the Ministry of Health and the Fédération nationale des donneurs de sang de France et d’Outre-mer.³³

These accounts suggest a pattern outside Dakar that followed the interwar record in Belgian and British colonies, where the individual interest of doctors or other circumstances determined the use of transfusions. And colonial health services moved doctors around fairly regularly. Thus, for example, the transfusions done in the French Congo in 1950 followed the appointment of Ouary as surgeon at Brazzaville Hôpital général after he left Dakar. In 1955 he was chief of the surgery service in Tananarive, Madagascar.³⁴ Likewise, when Togo completed construction of a new hospital in Lomé in 1954, Amen Lawson headed the bacteriology department, and unilaterally started a paid blood donor service, because it was much cheaper and more responsive to immediate needs than service from Dakar.³⁵

TABLE 2.2. Total blood units supplied, Centre fédéral de transfusion (Dakar), 1950–58

Note: Units are either 250 cc whole blood or 350 cc plasma. Three blood products were produced at the center: Whole blood, liquid plasma, and dried plasma.

Source: Unclassified records, CNTS Dakar.

The reports of overall blood and plasma production through 1958 give an indication of the number of transfusions in French West African colonies for which the blood was supplied.³⁶ Of note was the rapid growth but quick leveling off of donations and units produced, likely due to costs, plus the very high rate of blood donation by the local population. African donors made up the vast majority from the start, and there was a steady growth of whole-blood collection. Plasma remained a significant portion of production but leveled off after 1954.

Detailed reports have not been found about where shipments went from the federal transfusion service in Dakar, and it was only in 1955 that an official category was created for blood transfusion in the annual French colonial medical reports. Nonetheless, based on intermittent reports, it is clear that transfusion was widely used, and in some places regularly established, in French West and French Equatorial African colonies by 1956.³⁷

Given the widespread ability to do transfusions, it follows that the main initial effect of the Dakar service, as far as West African and Cameroon colonies are concerned, was to expand the practice. In other words, this was likely an unusual case of increased supply stimulating demand. Then by the late 1950s, as demand in the colonies began to exceed the ability of Dakar to supply blood and blood products, especially at a reasonable price, the hospitals in the other colonies developed their own local sources. Sometimes this was done publicly and openly, as in 1957, when the Ivory Coast officially voted to create its own blood transfusion service. The minutes of the territorial assembly reported the health minister’s testimony: “A blood bank is indispensable to the colony at this time because of the increase in patients who can benefit from whole blood and whose needs are always urgent in nature. The center in Dakar, he said, has prices that are too high. He has been forced on several occasions to order blood directly from France.”³⁸ Other colonies, such as Togo, did not require such dramatic action. A hospital might simply ask a patient’s family to find a donor, or develop a more systematic way of insuring blood for transfusion quickly and affordably. In any case, the trend was clearly toward a decentralization of blood collection that foreshadowed the pattern for the period of independence.

TABLE 2.3. Transfusions reported with whole blood and plasma, French African colonies, 1955–56

Colony	1955	1956
French West Africa
Ivory Coast	79	695
Dahomey	—	286
Guinea	164	—
Upper Volta	25	40
Niger	148	182
Senegal	—	—
Dakar Hospitals	577	867
Other	1,054	293
Togo	—	180
French Equatorial Africa
Ubangi-Shari	37	33
Congo	55	116
Gabon	63	22
Cameroon	—	273
Source: Annual medical reports for each colony, 1955, 1956, IMTSSA.

The evidence about blood transfusions in former French African colonies is very broad but unfortunately also very shallow. It provides a fairly complete account of when and where and how many transfusions were done over a large part of West and Central Africa, but there is less evidence about who gave blood and for what purposes. One particularly intriguing feature is that the population of the Dakar region was essentially donating blood for all of West Africa during most of the 1950s. Moreover, the blood donation rate (for example, 14,181 donations in 1957 for a population of 234,500) was 6,047 per hundred thousand, easily the highest found anywhere in Africa and well in excess of the two-to-four-thousand per hundred thousand rate that became the standard for donations in Europe and North America. The reason why so much blood was donated is only partly explained by tradition and military troops stationed in Dakar. It was likely also the result of the French policy of a 500-franc (CFA) payment for a donor’s time, plus refreshments (a sandwich and a drink).³⁹

More will be said later about who donated, but overall these French records emphasize the colonial administrative part of the story. Of note here is that with only a few exceptions, the doctors and administrators remained largely anonymous, thanks to the centralized bureaucratic system of French reporting. Fortunately there is much richer evidence about the history of blood transfusion in the British and Belgian colonies, because of the participation of the Red Cross societies. Although their records are also biased toward documenting the work of Europeans involved, their detail permits a better indication of the Africans who were the patients, donors, and part of those who organized and administered the transfusions.

Transfusions in the British African Colonies after the Second World War

Blood transfusion in the British African colonies, as in the French colonies, ultimately depended on a doctor’s decision to use the procedure for patients. That decision, however, was strongly influenced by the state of local health facilities, including the existence of a hospital and a readily available blood supply. After the 1920s any doctor in Africa who was intent on doing so could give a blood transfusion to a patient in a Western hospital by finding a donor from the hospital staff, the patient’s family, or like Lambillon, even from convalescing patients. This search could require some effort, and it stands to reason that if a supply of blood were available, doctors would be more inclined to give transfusions to patients. In this scenario the doctor would be the bottleneck limiting blood transfusions. If patients were in need of transfusion, a service organized for recruiting donors and processing blood might persuade a reluctant doctor to give transfusions. In British African colonies, local Red Cross branches frequently served that purpose in facilitating transfusions.

When the government of French West Africa, for example, took steps to continue a blood supply after the Second World War, it stimulated the use of transfusions in hospitals, not just in Dakar and Senegal, but elsewhere in West Africa. This approach, however, differed significantly from what happened in the British African colonies. For, unlike the French colonies where the government took the lead, it was the local Red Cross branches who took the initiative in the British colonies, either to respond to a request by a hospital or medical service to find blood donors or to initiate the idea by approaching the medical authorities with an offer to find volunteers to donate blood. As Percy Oliver pointed out at the British Empire Red Cross Conference in 1930, blood donation was “a very fine form of service for Red Cross members.”⁴⁰

Records show that Europeans in Africa began the process, and in some settler colonies such as Kenya and Southern Rhodesia, all parties (patients and donors, as well as doctors) operated in a segregated system, at least for a while.⁴¹ But that did not remain the case for long. In places like Tanganyika and Uganda, let alone Nigeria or the Gold Coast, there simply were not enough Europeans to operate a separate transfusion system. And even in the settler colonies the increased government expenditures on health services after the Second World War meant that transfusions and other medical treatments had to be extended to African patients. The ethos, not to mention practical politics at the time, would not allow such blatant racism. Once doctors decided that transfusion was appropriate for African patients, there were not enough Europeans to serve as donors to meet the rapid rise in demand as Africans agreed to take advantage of the treatment. European patients might insist on a European blood donor, but this quickly became a marginal part of the blood transfusion service compared to the large African population in the colonies that needed and donated blood for transfusion.

In British colonies there was a scattered record of blood group testing before 1945, according to annual laboratory reports that indicate widespread but probably infrequent use of transfusion. The lack of published articles by British authors between the wars suggests no sustained attempts at treatment or service like there were in the Belgian Congo. A Red Cross chapter could organize a panel of donors on a small scale for occasional use by a local hospital, which was the case in Kenya as early as the 1930s. The Southern Rhodesia Red Cross had larger ambitions when it launched the National Blood Transfusion Service in 1939, but the plan was cut short by the outbreak of the Second World War.⁴²

The introduction of transfusions on a regular basis in most British African colonies came after the war. Table 2.4 summarizes the record, drawn often from government and Red Cross reports.⁴³

TABLE 2.4. Blood transfusions reported in British colonies, 1947–62

Sources: Published annual reports of colonial government medical departments, and Red Cross reports, 1947–62, BRC London.

The early and significant use of transfusion in Uganda is clearly shown by table 2.4, as is the late start in the West African colonies of Nigeria and the Gold Coast. It does not follow, however, that lack of data means that transfusions stopped, especially after the first reports. It was much more likely that reports were simply not filed. Table 2.4 shows that by 1953 all these British colonies except one reported transfusions whose numbers were at least in the hundreds and grew at an accelerated rate during the 1950s to ten thousand or more annually in a few colonies by 1960.

The increase in transfusions in settler colonies of East and southern Africa after 1945 occurred because black Africans were included, and the Red Cross branches in these colonies were very much involved in the process. In Southern Rhodesia the Red Cross branch at first attempted to supply all blood needs, including the needs of African hospitals, by using white donors, according to the head of the British Red Cross overseas branches who visited there in 1948. By 1950, however, a separate African blood bank was established in Bulawayo.⁴⁴ The Kenya Red Cross branch reported the establishment of a blood transfusion service in 1947 at King George VI Hospital, the main hospital in Nairobi (now called Kenyatta National Hospital), with 248 blood donations reported that year. In the second half of 1948 the pathology laboratory of the Nairobi European Hospital (now the Nairobi Hospital) reported that 191 Africans were typed as blood donors for family and friends.⁴⁵ In Northern Rhodesia the Red Cross branch was asked to establish a blood transfusion service in the colony, beginning in 1950 at the African hospital at Lusaka, while in West Africa, the Red Cross involvement came a few years later and depended on relations between the local branches and hospitals.⁴⁶ To summarize, by 1953 all major British colonies in Africa had organized blood transfusion services.⁴⁷

TABLE 2.5. Beginning dates of Red Cross Branch Blood Collection Service in British African colonies after World War II

Kenya	1947
Nyasaland	1948
Tanganyika	1948
Uganda	1948
Northern Rhodesia	1949
Basutoland	1951
Gold Coast	1952
Nigeria	1953
Sierra Leone	1956
Gambia	1959
Sources: Joan Whittington, “Report on the Nyasaland Local Branch,” June 9, 1948, Acc 0287/46 Nyasaland; Whittington, “Report on Visit to Tanganyika Territory,” June 9, 1948, Acc 0287/60 Tanganyika; “Report for the Year 1948 from the Uganda Central Council Branch,” Acc 0287/63 Uganda; “Report to British Red Cross from Lusaka,” October 25, 1949, Acc 0076/38(1); “Miss Borley’s Report,” November 1950, Acc 0076/6(1); Gold Coast, “Summary Report for 1952,” Acc 0287/33 Gold Coast; Nigerian Central Council, “Annual Report,” 1952, 5, Acc 0076/36(1); Sierra Leone Branch Red Cross Society, “Annual Report,” 1956, Acc 0076/48(2); M. D. N’Jie, “Red Cross Week, 9th–14th March, 1959,” March 20, 1959, Acc 0076/21(2) Gambia, all in BRC London archives.

It is impossible in this study to provide a detailed history of blood transfusion in each colony, but closer examination of the records in Uganda and the Belgian Congo provides examples of the complexities not revealed in the broader survey of developments.

Transfusions in British African Colonies: The Case of Uganda

One of the most interesting and successful efforts at establishing a transfusion service was in Uganda, where local health authorities asked the Red Cross branch to establish a blood transfusion service in 1948. The response surprised everyone, as Uganda developed the first colonywide blood transfusion service in a sub-Saharan African state. Because of the extent of activity, Uganda also provided an early indication of who donated blood, even if the record of who received transfusions is still not very well documented.⁴⁸ The details are worth examining, not because they were typical but because they illustrate the possibilities.

On May 4, 1948, a meeting of the self-styled Sub-committee of the British Medical Association in Uganda called for “setting up a Blood Transfusion service to meet the demands for blood transfusion for all races in the vicinity of Kampala and in exceptional circumstances, in any part of the Protectorate.”⁴⁹ Several features of the three-page report were telling. First, there were only four members present, although they represented the surgical staff and pathology laboratory of Mulago Hospital, the biggest and most important government hospital in the protectorate. Included was Ian MacAdam, a recently arrived surgeon who remained in Uganda until 1972 and helped build the hospital’s reputation with doctors that he attracted, including subsequent Nobel laureate Denis Burkitt. Second, it is clear from the document that transfusions were already being practiced both at Mulago Hospital and Mengo Hospital, the first Western hospital established in 1897 by missionary Albert Cook in Kampala. Part of the justification for setting up the service, as the report pointed out, was that the necessary staff were already at Mulago Hospital for such things as lab work and sterilizing equipment. “For several years,” reported the president of the Uganda branch of the Red Cross in 1949, Mengo Hospital “had obtained blood, in cases of dire necessity, from dressers [doctors’ assistants] and students.”⁵⁰

To establish a more reliable blood supply for more frequent transfusions, the subcommittee pointed out, what was needed—in addition to refrigeration, transport, and identification of adequate donors—was an “organizing secretary.” This was an overt appeal to the British Red Cross in London to supply the equipment and personnel. The May 4 request spelled out quite clearly what the duties of the secretary should be:

(a) the propaganda for Blood Transfusion

(b) accurate records of donors

(c) the organizing of blood collection

(d) the responsibility for equipment

(e) liaison between the various major hospitals

“She” the report went on, specifying the secretary’s gender, “should be responsible to a joint committee appointed by the BMA.”⁵¹

The Red Cross branch in Kampala was so enthusiastic in its desire to cooperate that it hired the wife of a physiologist at Mulago to be a part-time secretary and installed her in an office with telephone, stationery, and index cards, even though it did not yet have the resources for the other equipment. For that, the Uganda branch sent a request to London for funds, specifically to Joan Whittington, the director of the British Red Cross overseas branches, who had visited Uganda earlier in the year. While awaiting approval, the Uganda branch began publicity and lectures to educate and motivate potential donors.⁵² London quickly approved the request for £750 to purchase a refrigerator, a van, donor sets, needle-sharpening equipment, bottles, and other supplies and equipment.

Some features of the new blood transfusion service, such as recruiting donors at schools, colleges, and missions, set a pattern that was followed not just in Uganda but most African colonies and countries. Other early practices, such as typing all potential donors but contacting only those with blood type O, were abandoned as soon as demand required more donors. In the first year of activity, 456 potential donors were recruited at ten schools, colleges, and the police training academy, with 228 found to be “universal donors.” The initial goal was to have a supply that permitted transfusion of ten pints per week, although first reports were that the average was only six per week by January 1949. In addition to stepping up recruitment of donors, the service adopted a policy for stored blood that also gave an indication of use. The policy stated that stored blood would be used “for emergency cases only, until the day the bleeding team replenishes the [blood] bank with a fresh supply, after which the previous week’s supply is made available for non-emergency transfusions such as anemia cases.” To dramatize the importance of storage, the president of the Uganda Red Cross branch reported that fifty of the first eighty-one transfusions “have undoubtedly proved to be life-saving in accident cases and where cases have been suffering from post-operative shock.”⁵³

The demand for the transfusion service grew quickly at Mengo and Mulago Hospitals. The 1949–50 annual report for the Red Cross branch in Uganda quoted one surgeon as saying, “The field of surgery has been greatly widened by the Blood Transfusion Service and surgeons have been able to perform operations which were hitherto too dangerous or else entirely impossible.”⁵⁴ The target of ten transfusions per week was met and doubled in 1949 but remained steady at around seven hundred transfusions per year until the mid-1950s, when the annual total surpassed one thousand per year. The expansion was possible because of more persuasive and extensive recruiting, including the making of a film that was dubbed into the local language and later exported to other African colonies and countries (see chapter 5).

The hospitals, meanwhile, intensified their efforts to persuade friends and relatives of patients to donate blood, not just before but after transfusion. As a 1956 Uganda Blood Transfusion Service report described it, “The Red Cross Blood Transfusion worker at Mulago Hospital, Mr. Emmanuel Muwonge, goes round the wards regularly and speaks to relatives and friends of patients needing blood transfusions. He explains the need and the technique to them, and, if they are willing to give blood he makes the necessary arrangements and assists the doctor.”⁵⁵ The result, it went on, was that one patient who received three pints of blood, thus saving his life, had relatives and friends who donated a total of nine pints to the service. For the whole year of 1956, Mulago Hospital received 339 pints of blood in this manner out of a total of 1,407 pints collected for the entire protectorate.⁵⁶ That same 1956 report announced the intent of Jinja Hospital to organize another transfusion center for Busoga Province, in the east, and an Asian subcommittee was created to establish an Asian blood bank in Kampala.

The generally good records of the Uganda Red Cross document the expansion of transfusion before independence that reflected even further growth of services at provincial hospitals. By 1958 there were transfusion services at Mbale and Gulu, as well as Kampala and Jinja. In 1962 the last report of the transfusion service before independence indicated that nine thousand pints of blood were collected, still mostly in and around Kampala. By this time the majority of blood processed at the Nakasero Hill transfusion center was drawn by mobile units at numerous locations including colleges, high schools, training centers, prisons, a convent, and the airport at Entebbe. The list of provincial collections was equally impressive, based on statistics for selected years between 1957 and 1965.⁵⁷

TABLE 2.6. Blood donations reported, Uganda, selected years, 1957–65 (pints)

*Total for 1963 from separate source.

In 1948 when the Uganda Red Cross branch responded to the call for a transfusion service, its president observed that her organization’s reputation “carries considerable weight” that might help the project succeed. “It was felt therefore that if this blood transfusion service were started under the auspices of the Red Cross, it would win the confidence of the African far more than a Government-sponsored project.”⁵⁸ Whether true or not, already by 1952 the newly appointed governor of Uganda, Sir Andrew Cohen, attended the annual meeting of the Red Cross branch and made special note of the success of the blood transfusion service. His speech paid tribute and also made the following prophetic observation:

If the Red Cross and other voluntary bodies can start new services, this may become so popular and may come to be regarded as so necessary and essential that eventually they will become part of the fabric of the Government, and Government, whether willingly or unwillingly, will be forced to take over those services and run them themselves. That is how public affairs go. We have an excellent example of this, if I am not wrong, in the Blood Transfusion service, which is a fine service which you are now running and which eventually no doubt will become the responsibility either of local government or of Central Government.⁵⁹

As the use of transfusion expanded both in Kampala and Jinja, as well as at up-country hospitals in other parts of the protectorate, the government (both of the colony and subsequently of the independent country) took a more enlightened approach, giving the Uganda Red Cross Society a subsidy to continue its part in the transfusion service, rather than taking it over completely as a government service. By the time of independence, however, tensions were growing between the two parties because of increasing costs and the inability of the Red Cross or government to meet them. Sue Maltby, a British Red Cross worker in Uganda, stated in a report at the end of 1959 that the blood transfusion service, “continues to expand at an alarming rate,” with the result that it was always short of money. When the Red Cross asked for an increase in government subvention, it was refused. Members responded with letters written “to the minister from Lady Crawford [wife of the governor of Uganda],” followed by meetings, revised estimates, and more meetings. Only after all that, Maltby reported, was the Red Cross promised an extra £500 for 1959. And for the next year they agreed to an increase from £750 to £2,500 (current value of $60,000), “but not before we held the biggest pistol possible to their heads,” she concluded.⁶⁰

When the women in the Red Cross were the wives of the doctors using the transfusion services, these matters could be worked out “within the family.” With the increasing use of transfusion and more turnover in Red Cross volunteers, however, the delicate balance between those using the blood that was provided by those doing recruiting, bleeding, testing, and storing was upset and disagreements resulted. Although the Red Cross had been offered government resources to help with the costs of its responsibilities, the Red Cross complained that the funding did not cover their rapidly rising costs. This was similar to what eventually happened in Zambia (former Northern Rhodesia) after independence.⁶¹