Blood

Blood
Author: Douglas Starr

Overview

This thrilling account of the turbulent history of blood chronicles the evolution of the scientific and cultural understanding of what remains an enigmatic natural substance. In charting its journey from its ‘primitive religious reverential stage’ to its contemporary status as an industrialised product, the book depicts blood in all its contradictions, being a ‘gift‘ and ‘a precious‘ medicine on one hand, and as a marketable ‘commodity‘ on the other. And as the book describes our ever-changing relationship with blood, it argues that ‘in every epoch’ it was seen as ‘more than it really was’, and that humanity has always seen it as ‘a reflection of their image and understanding of themselves‘. The book’s gripping narrative of the history of blood-related practices is most enlightening, featuring such outdated activities as bloodletting and animal-to-human transfusion, to the modern-day technologies that enable the transfusion of countless blood components. Further enhancing the book’s appeal are its fascinating anecdotes which highlight both the positive and negative sides of the history of blood, and these are depicted in such stories as the sophisticated Dutch ‘underground blood collection and processing system‘ that thrived under German occupation, and the Japanese biological warfare experiments on prisoners of war. And this twin legacy of blood lies at the book’s key lesson, the author stressing that it is ‘only by accepting the dual nature of blood products’ that we will ‘use them with sufficient care and intelligence (pages 3-14, 17-30, 115-116, 143-154, 160-162, 344 and 356).

Human blood with red blood cells, T cells (orange) and platelets (green). ZEISS Microscopy on Flickr. https://www.flickr.com/photos/zeissmicro/14255918978

Synopsis

The history of human blood transfusion was expectedly a core theme of the book, and the author narrated this on the background of the earliest attempts which failed because doctors then ‘knew nothing about sterile procedure, blood groups, or how to prevent blood from clotting in their needles and tubes’. Although the book credited the earliest successful attempt to obstetrician James Blundell in 1818, it emphasised that ‘the modern era of transfusion medicine‘ did not begin until 1908 when the ‘noted French researcher’ Alexis Carrel transfused a newborn baby with her father’s blood. Noting that Carrel’s direct blood transfusion method was for a long time the ‘procedure of choice‘, the author nevertheless pointed out that it was bedevilled by imprecision, ‘trauma and pain‘. In its enlightening account of the advances that enhanced the effectiveness and safety of blood transfusion, the book described such innovations as the ‘multiple syringe method‘ of Edward Lindeman, and the stopcock of Lester Unger. Amongst the later notable contributions to the development of blood transfusion the book described were the anticoagulant work of Richard Lewisohn which made sodium citrate ‘standard procedure’ in the prevention of blood clotting; the work of Percy Lane Oliver in establishing a directory of volunteer blood panels; the development of blood banks pioneered by Bernard Fentus and V. N. Shamov; and the plasma fractionation system established by Edwin Cohn which ‘laid the groundwork for blood-component therapy as practiced today’ (pages 31-44, 48-49, 53-56, 67-71, 101-106 and 184).

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One of the most significant breakthroughs in the history of blood transfusion was the discovery of the ABO blood group system by Karl Landsteiner in Vienna. In recounting this history, the book gave a detailed account of how Landsteiner came about the concept after he observed that ‘agglutination occurred among blood samples from healthy individuals’. The author showed that Landsteiner’s research was of the highest ‘precision, simplicity, and clarity‘, and that this was consistent with his ‘most rigorous yet uncluttered way’. The book further characterised Landsteiner as ‘a painfully shy man who completely submerged his ego for science’, and as a scientist ‘known for his unwavering seriousness‘ who ‘abhorred all forms of attention or recognition’. Landsteiner’s work, which eventually won him a Nobel prize, was however overlooked ‘for years’, the book explaining that it was ‘a dozen years after’ that Reuben Ottenberg read Landsteiner’s work and became inspired to introduce pre-transfusion cross-matching – an intervention that the author said eliminated the 35% risk of post transfusion reaction. As is often the case in the history of medicine, the author also regretfully observed that it was not until the 1920s that ‘blood typing would become standard practice’. Other pioneers who the book lauded for their contributions to refining the blood transfusion system included Spanish haematologist Federico Duran-Jorda, American Surgeon Carl Walter, and Black American physician Charles Drew (pages 38-40, 44-45, 59, 81-83, 98-100 and 180-181).

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Of the varied blood disorders that the book explored, heameophilia stood out for its devastating poignancy, and for the advances that greatly improved the fortunes of its victims. Describing the disease as ‘a dreaded condition in which the blood fails to clot’, the author illustrated the tragedy that accompanies it with the story of Nicholas, Queen Victoria’s grandson and heir to the Russian throne, whose affliction the author said ‘sped the downfall of an empire’. The narrative also described how blood component transfusion transformed the care of people with haemophilia, noting how home-based infusions of fresh-frozen plasma replaced the use of ice packs and whole blood transfusion. The author however noted that this progress came at the price of a higher risk of infection with hepatitis and HIV because the components are produced from pooled samples of thousands of blood donors. The author illustrated the harrowing consequences of this risk by narrating the history of the tragic ‘iatrogenic epidemic‘ that blighted the haemophilia population around the world when Factor VIII supplies were contaminated by HIV. The author attributed this catastrophe to the erroneous regulatory decisions that enabled ‘thousands of hemophiliacs throughout the world’ to ‘freely‘ infuse themselves ‘with a product that they should have been regarding with utmost suspicion‘ (pages 45-47, 219-225 and 279-282).

Blood. swxxii on Flickr. https://www.flickr.com/photos/frostnova/3482996630

The HIV epidemic formed a much wider theme of the book on account of the universal impact of its blood transmission . In exploring this topic, the author traced the course of the HIV epidemic from its first emergence in homosexual males, through to its contamination of the blood supply system – a development which the author said evoked ‘fear and indecision‘ because ‘no one really knew what to do‘. This situation led to such controversies as the exclusion of homosexuals from donating blood, and the resistance of the blood banks to adopt hepatitis B core antibody as a surrogate screening test. In explaining why some countries did much better than others in minimising the blood transmission of HIV during the epidemic, the author credited the successful countries with having ‘diligent people in charge who fostered rapid response, open communications, and close control over the source of their supplies’. In contrast, the author showed how poor transfusion practices in France led to the ‘contaminated blood affair‘, and he used this episode to stress the importance of always minimising the threat of blood (pages 266-276, 286-292, 298-300, 306-321, 330-338 and 355-356).

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The commercial dimension of blood was an equally well-developed theme of the book, and this described how the product was gradually commercialised, a process that it said was began by Americans who ‘saw nothing wrong with trading blood for money‘. To demonstrate how ‘the blood-selling business got quickly out of hand‘, the author described how the introduction of plasmapheresis ‘propelled’ the trade in plasma and led to the springing up’ of ‘hundreds of plasma centres’. The book also highlighted the unethical practices which sullied the global trade in plasma products, for example by the way businesses sourced blood-rich placentas from developing countries which were ‘rife with poverty, malnutrition, and hepatitis‘. The author was particularly scathing of the free market capitalism that came to dominate the American blood transfusion system which he said was typified by problems of shortages, waste, litigation, poor distribution, and ‘anarchy in blood pricing‘. A more favourable picture of the business of blood was however evident in the positive picture the book painted of the role played by the American Red Cross in establishing a national blood bank service (pages 57,  110-111, 207, 208, 227-237 and 246-249). 

Blood. Tom Magliery on Flickr. https://www.flickr.com/photos/mag3737/5127180176

Opinion

In a strictly chronological account, this book sets out an exhaustive history of blood covering its disorders and treatments, and complemented by excellent storytelling and illustrative historical anecdotes. The book is supplemented by vivid photographs which brought the text to life. Apart from the author’s tendency to explain away and excuse historical bad practices, such as racial blood transfusion policies, his commentary was most enlightening and put the themes he discussed in helpful historical context. His detailed personality profiles of the pioneers of blood transfusion also enhanced the book, as did its global focus and its seamless and refreshing medical and war history narrative.

Overall assessment

With gripping story telling, this book chronicles the emergence of blood as a life saving treatment, the narrative stressing the incremental innovations that transformed blood transfusion from a crude and risky endeavour, to a sophisticated and safe service. Apart from profiling blood therapies, the book is also educational in its profile of key blood disorders. Its comparative commentaries on the different blood transfusion services across the globe will particularly be helpful for health system planners and policy developers. The lesson of how corporate greed sustains risky healthcare practices and hinders safer innovations also came through loudly throughout the book. The book also teaches lesson of building on the works of previous innovators, a practice that is essential for healthcare, and I recommend it to all doctors.

Book details

Publisher, Place, Year: Perennial, New York, 1998,
Number of chapters: 17
Number of pages: 449
ISBN: 9780688176495
Star rating: 5
Price: £21.05

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