Sample text for Blood : an epic history of medicine and commerce / Douglas Starr.
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The drama ended, as do so many these days, in a courtroom. This particular chamber was long and low-ceilinged, with a wide dais at its front for the eight black-robed judges. Each of the four defendants sat flanked by tall policemen who gazed impassively from under the brims of their trademark pillbox hats. In keeping with the formality of French courts, the prosecuting and defense attorneys wore flowing black robes, which would dramatically sweep behind them as they rose to make a point. The only visible flaw in the decorum appeared among the audience members, some of whom wore T-shirts bearing inflammatory slogans. There were audible exceptions to decorum as well, as people would moan or shout "Non!" at a defendant's response, or when one man, the most vocal of the plaintiffs, would, as his doctor walked past, loudly hiss "Assassin!"
The plaintiffs in this trial were dying of AIDS. They charged that they had been infected through the negligence of the defendants--high officials in the French national transfusion service. In France, where the government until recently held a monopoly on blood and its derivatives, these men were supposed to ensure the safety of blood products. Instead, they allowed thousands of the nation's hemophiliacs to inject blood-derived clotting factors they knew to be contaminated. The defendants had done so because of a complicated mixture of paternalism, economics, and to some extent the limits of science, but the victims saw the incident more starkly. To them the affair was a matter of betrayal. The doctors on trial in the summer of 1992 were supposed to have embodied all that was noble in the French transfusion tradition--altruism, medicine, business, and technology. Instead, during the years of the "contaminated-blood affair" they came to symbolize the cynicism and expediency of a money-driven age.
The sense of betrayal surfaced in many places beyond the courtroom in Paris. For more than a decade the theme has been sounded in one locale after another throughout the world. In America, patients have filed hundreds of civil suits against doctors, drug companies, and even their own patient organizations, for abandoning their health to the expediency of the marketplace. In England, AIDS-infected hemophilia patients castigated their national transfusion service with reacting too slowly to the threat of emerging viruses. In Japan, patients charged that the government and drug companies criminally concealed the contamination of blood products; as a result, some of the nation's most revered doctors have gone to jail. In Canada, the scandal of contamination spread so wide that the government held a series of hearings across the country that convulsed the nation with anger and shame.
Why those scandals erupted is one of the underlying questions of this book, a history of human blood as a resource and humanity's attempts to understand and exploit it. Blood is one of the world's most vital medical commodities: The liquid and its derivatives save millions of lives every year. Yet blood is a complex resource not completely understood, easily contaminated, and bearing more than its share of cultural baggage. Indeed, the mythic and moral symbolism of blood, which has been with us since ancient times, subtly endures. It clouded professional judgments and public perceptions in the AIDS scandals of France, Canada, and Japan, among others.
If one considers blood a natural resource, then it must certainly rank among the world's most precious liquids. A barrel of crude oil, for example, sells for about $13 at this writing. The same quantity of whole blood, in its "crude" state, would sell for more than $20,000. Crude oil, as we know, can be broken down into several derivatives, including gasoline, distillates such as diesel, and petrochemicals. Blood can be separated into derivatives as well. Spun in a centrifuge, it divides into layers--red cells on the bottom, a thin intermediary layer of platelets and white cells, and an upper tea-colored layer of plasma. Each layer, in turn, can be used as various therapeutic products. Red cells can be transfused directly. White cells and platelets can be used to restore resistance or clotting ability to patients undergoing chemotherapy. Plasma, a resource in its own right, yields albumin for restoring circulation, clotting factors for patients with hemophilia, antibodies for vaccine production, and several other reagents and pharmaceuticals. Taken as a whole, the value of the derivatives in a forty-two-gallon barrel of crude oil would raise its price to $42. The price of the same quantity of completely processed blood would increase its value to more than $67,000.
Of course, blood is not processed by the barrel or handled in quantities anywhere near those of oil. (Only about sixteen million gallons of blood and plasma are collected annually worldwide--the equivalent of thirty-two Olympic-size swimming pools.) Indeed, the world market for blood and its derivatives probably does not exceed $18.5 billion per year, versus $474.5 billion for petroleum. Yet one cannot avoid comparing the two resources. Just like the oil industry, the blood trade involves collecting a liquid resource, breaking it into components, and selling the products globally. Red cells, being perishable, tend to remain within national borders, but certain portions of blood--plasma in particular--are traded among multinational companies and on a worldwide spot market. Just as with oil, one region has become the premier harvesting ground, providing much of the resource for the rest of the world. The United States, with its liberal rules regarding collection, has become known as the OPEC of plasma.
No wars have been fought over blood as they have been for oil, but the movement of blood has played an important role in our wars. A major anxiety about D-Day, for example, was whether enough blood could be stored to supply all the wounded that military planners had projected. In preparation for the Persian Gulf War, the military shipped massive quantities of blood to the battle zone for what they thought would be thousands of casualties. (Good fortune proved them wrong.) Such collections have always been secret, since intelligence services know that the mobilization of blood is a sure sign of an impending attack.
If the analogy between blood and oil is provocative, it is where the comparison breaks down that the story of blood becomes especially compelling, and life-changing to those who have been caught in its sweep. For one thing, oil does not transmit disease, a critical consideration in the blood trade. A slip in quality control at a refinery may result in the loss of a few dollars, but a mistake in blood processing can infect thousands of people. Second, whereas oil companies pay handsomely for drilling rights, blood collectors pay nothing or very little for their raw material, since donating is thought of as an act of human kindness. Such an arrangement, however admirable, can distort people's judgments. Think, for example, how the leaders of the oil industry would react if Saudi Arabia provided crude oil for free: They would bend over backward (even more than they currently do) never to offend their benefactors. So it had been with the blood collectors: When faced with the necessity of refusing blood from certain people to minimize the spread of viral disease, they found themselves reluctant to offend their cherished donors. As a result, public safety was compromised.
The most telling difference between the two resources, however, is the one that reaches into our cultural past. Though oil serves as a critical resource, it carries no particular cultural baggage. Blood, in contrast, is laden with meaning. The descriptive cliché, "the elixir of life," barely touches on the liquid's mystical, religious, and patriotic significance. The Bible mentions blood more than four hundred times: "The life of the flesh is in the blood," says Leviticus, equating blood with life itself. Blood is considered so holy in the Old Testament that the law specifically forbids its consumption, which is why Jehovah's Witnesses, who interpret the Bible literally, refuse transfusions. The Egyptians saw blood as the carrier of the vital human spirit, and would bathe in the liquid as a restorative. It is because blood conveyed strength to the Romans that gladiators were said to have drunk the blood of fallen opponents. Doctors from the medieval to the Victorian era assumed blood to have fantastical powers, draining it to remove evil humors, transfusing it to pacify the deranged. Our own culture attaches great value to blood, with the blood of Christ as among the holiest sacraments, blood libel as the most insidious slander, the blood-drinking vampire as the most odious demon.
The symbolic power of blood does not confine itself to mythology, for it has affected the behavior of doctors in modern times. The Nazis, in their perversity, refused transfusions from non-Aryan blood donors--condemning their armies to chronic shortages--and composed intricate charts of the presumed blood-related traits of the various races. Even the democracies were tainted by blood prejudice: During World War II, as America fought a racist enemy, the military maintained separated blood stocks from black and white donors for fear of offending white soldiers' sensibilities. Most recently, the persistent belief that blood products collected among their countrymen had to be inherently pure contributed to bad decision-making in the tainted-blood scandals of France and Japan.
Thus, the story of blood cannot be limited to the twentieth century, when doctors began to use it for transfusions. The narrative reaches back into antiquity, as an undercurrent to the history of medicine and civilization. It spans the globe over the course of several centuries, periodically surfacing in dramatic ways, from the first blood experiments, during the Age of Enlightenment, to the genetic-engineering labs that one day may render transfusion obsolete.
The story of blood is one of metamorphosis, of a liquid that became symbolically transformed as society learned how to deconstruct and manage it. As such, the history divides itself into three eras, each reflecting the spirit of its age.
The first period, described in the section "Blood Magic," involves the transformation of blood from a magical substance to a component of human anatomy, capable of being isolated and studied. This section covers the period from antiquity to the early twentieth century, the time when the concept of blood moved from the magical to the biological; when blood became recognized as a therapeutic liquid transfusible from one creature to another. It is a measure of the symbolic power of blood that the first transfusions were used to treat not blood loss or anemia but insanity.
The second era, covered in the section called "Blood Wars," describes the transformation of blood from a scientific curiosity to a strategic materiel. During the first few decades of the twentieth century, medical scientists began to master the resource, learning the techniques of mass collections, storage, and the separation of plasma. These advances occurred just in time for World War II, the greatest spilling of blood that the world has ever known. That conflict decisively altered blood's cultural significance--from the mother liquid of all health and disease, to a strategic resource, devoid of mystical overtones yet essential to human enterprise. The change became irreversible when Dr. Edwin J. Cohn of Harvard, working under a military contract, found a way to fractionate plasma into its many constituents. This technology, analogous to the "cracking" of oil, along with the freeze-drying of plasma, gave the Allies an enormous advantage over the Axis powers, whose blood-related technology was primitive. It also set the stage for a postwar global blood industry.
The final section, "Blood Money," describes how the liquid that saved so many lives became the basis for a global industry. A small group of drug companies dominates the plasma business, analogous to the "Seven Sisters" of oil. In their quest to harvest the resource, those drug firms set up "plasma mills" in America's skid rows, buying from the residents, who often included drug addicts and indigents. Later, seeking new sources of raw material, they imported plasma from the Third World, notably Central America--a practice of dubious safety and morality. So politically explosive was the idea of harvesting the resource from the poorest of the poor that in one Central American country the populace rose up, destroying the facility and sparking a revolution. Meanwhile, the business of whole blood boomed as surgical advances such as open-heart surgery and organ transplants required ever-larger transfusions. (A single liver transplant may require fifty units of red cells.) Whole blood, collected on a nonprofit basis by the Red Cross and community blood banks, became the target of fierce competition as the "benevolent" collectors struggled for dominance.
If the global blood business has been tainted by an element of exploitation, it must also be seen as tremendously beneficial. Countless lives have been saved by transfusions, not to mention plasma-derived pharmaceuticals. People with hemophilia, who have been using clotting factors since the late 1960s, have seen their average life expectancy double. Yet the same therapeutics that brought life to so many have also transmitted disease: If blood and plasma products could be routinely distributed among millions, so too would any pathogens they harbored. During the blood-products boom of the 1970s, blood-related hepatitis rates soared, killing tens of thousands of hemophiliacs and transfusion recipients. By the end of the decade, doctors thought they had solved the hepatitis problem, only to be confronted by another virus that spread in an identical pattern--HIV. Though tainted blood products only caused a small portion of the AIDS epidemic (the disease was mainly spread through sexual contact and intravenous drug use), they took an enormous toll. More recently, another public health crisis has begun to unfold--the silent epidemic of blood-borne hepatitis C. It is ironic that, after all the transformations of blood wrought by modern medicine, HIV and other viruses revived the medieval image of blood as the bearer of evil humors and death.
Today we confront a resource simultaneously safer and more threatening than before. Many nations, having learned from the AIDS crisis, have instituted virus screening-and-removal procedures. This has made blood more expensive, an ominous development in an era of shrinking health budgets. Furthermore, we can no longer complacently assume safety, since new diseases threaten to emerge. Meanwhile, poor nations, with little access to modern equipment, face unprecedented risks of blood-borne diseases. In order to address the inherent risks of the resource, some companies are creating artificial blood substitutes, immune to the pathogens that afflict humans. Even if those products someday appear, they will likely be expensive, prolonging the disparity between nations that have modern blood products and those that do not. Thus blood distribution, like that of other critical resources, will continue to raise questions of equity and social justice.
This, then, is the story of blood--the chronicle of a resource, the researchers who have studied it, the businessmen who have traded it, the doctors who have prescribed it, and the lay people whose lives it has so dramatically affected. The book is also a challenge to those who distribute, regulate, and use the resource. Indeed, a lasting tension in the history is how we view this most human of commodities. Is it a gift of charity or simply a pharmaceutical? Can a single resource be both, and if so, what are the safest and most ethical ways to manage it? The answers to such questions will determine the future of this precious, mysterious, and hazardous material.
Library of Congress subject headings for this publication: Blood banks History