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William H. Schneider, PhD and Ernest Drucker, PhD

William H. Schneider is with Indiana University, the Indiana University Center for Bioethics, and the Center on Philanthropy, Indianapolis. Ernest Drucker is with the Montefiore Medical Center–Albert Einstein College of Medicine, Bronx, NY.

Correspondence: Requests for reprints should be sent to William Schneider, Medical Humanities, Indiana University, 425 University Blvd, Indianapolis, IN 46202 (e-mail: whschnei{at}iupui.edu).

	ABSTRACT

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Blood transfusions transmit HIV more effectively than other means, yet there has been little examination of their role in the origins and early course of AIDS in sub-Saharan Africa. We review historical data in archives, government reports, and medical literature from African and European sources documenting the introduction, establishment, use, and growth of blood transfusions in sub-Saharan Africa. These data allow estimation of the geographic diffusion and growth of blood transfusions between 1940 and 1990.

By 1955, 19 African colonies and countries reported transfusion programs—with national rates of 718 to 1372 per 100 000 by 1964, and urban rates similar to those in developed countries. We estimated 1 million transfusions per year in sub-Saharan Africa by 1970 and 2 million per year by the 1980s, indicating that transfusions were widely used throughout sub-Saharan Africa during the crucial period of 1950–1970, when all epidemic strains of HIV first emerged in this region.

	INTRODUCTION

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THE TRANSMISSION OF blood-borne viruses by unsterile medical practices (including vaccinations, therapeutic injections, blood transfusions, invasive tests, and surgery) are known to be implicated in the contemporary AIDS pandemic¹ and may have played an important role in the origins and emergence of HIV in Central and West Africa in the mid-20th century.² The special importance of blood transfusions and blood products for the transmission of HIV was recognized in both Africa and the developed world in the early years of AIDS because they transmit viral infections far more effectively than any other means.³ According to one recent study, heterosexual transmission has an efficiency of 0.01% to 0.2%; unsterile injections, 0.30%; and maternal–child transmission, less than 30% to 35%. In contrast, blood transfusion is more than 90% efficient.⁴ Despite some initial delays in responding to these risks, most countries now strive to protect their blood supplies and to ensure safe medical injection and disposal practices.⁵ But this was not always the case—especially in the developing world, where even today the blood supply is often not fully protected.⁶

Although the risks associated with transfusion were recognized early, the implications about the origins of HIV in sub-Saharan Africa have been slow to be examined. In part, this followed from the simple fact that the availability in 1985 of the HIV test to screen blood came decades after the emergence of HIV and the onset of the AIDS epidemic in that region in the 1960s. Yet even after the African epidemic was recognized, there has been virtually no examination of the historical role that transfusions might have played in sub-Saharan Africa during this critical period, perhaps because of the common assumption that blood transfusion was not widely practiced there until recently.⁷ For example, in a recent review of competing explanations about the crossover of simian immune viruses to humans, the possible role that the new technology of injections played in opening new means of spreading pathogens among humans is included, but no mention is made of blood transfusion.⁸ Finding no other reference to transfusions in the literature on the beginning of HIV/AIDS in Africa,⁹ we have undertaken this historical overview of the conditions and circumstances surrounding the introduction of blood transfusions into sub-Saharan Africa beginning in the last period of colonial rule (late 1940s to early 1960s), when HIV-1 first emerged in Central Africa.¹⁰ In addition to contributing to the discussion of the origins of HIV, this research also offers a valuable case study of the introduction of new medical technologies in the developing world.

	EARLY DEVELOPMENT OF TRANSFUSIONS IN WESTERN MEDICINE

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Patients and healers have long thought that blood had curative and restorative power, but the 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 early 17th century that there was demonstrable proof of the efficacy of transfusion, and not until after the beginning of the 20th century that blood transfusions entered the realm of scientifically based medical practice. One key turning point in this development was the mobilization of resources and the great needs of World War 1.¹¹ Until then, technical problems concerning the transfer and storage of blood, along with more fundamental disagreements about what to transfuse and why, prevented widespread implementation. Dramatic success was only obtained from new techniques developed after 1900, which were implemented simply to replace lost blood. The number of blood transfusions in Europe and North America grew steadily between the 2 world wars but remained modest in scale. As late as 1938, transfusion services in major cities (New York, NY; London, England; Paris, France) reported only 5000 to 9000 transfusions per year,¹² with rates of 100 to 200 per 100 000 population, compared with more than 10 times that rate after 1945.

World War 2 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 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 civilian needs. The National Blood Transfusion Service in the United Kingdom reported more than 300 000 transfusions annually in the immediate postwar years, a figure that climbed steadily, surpassing 1 million in 1958 (about 2000 per 100 000 population) and reaching 2.8 million in 2001. By 1953, the United States collected more than 4 million blood donations annually with a national transfusion rate of 2490 per 100 000. The US National Blood Donor Research Center reported 15 million units collected in 2001 and estimated 12 million transfusions in 1999 for a rate of 4264 transfusions per 100 000 population. Comparable figures exist for England and France.¹³ Although there were many differences in the systems employed (e.g., Titmuss¹⁴), blood transfusion services were institutionalized and became widely available in the United States, Europe, and most developed countries in the dozen years following World War 2. This included well-organized donation, storage, and distribution methods and testing for known contaminants. Transfusion became part of medical education, and scientific journals, such as Transfusion and Vox Sanguinis, and international congresses provided means for sharing new discoveries and administrative innovations.

In order to describe the introduction, establishment, and growth in sub-Saharan Africa of blood donation, storage, and transfusion capabilities, and the clinical indications for transfusion use in medical practice there, we present data and trends in transfusion rates in sub-Saharan Africa for the time period between 1950, when transfusions were first systematically employed in sub-Saharan Africa, and 1990, by which time the systematic screening of blood donations became widespread in sub-Saharan Africa.

	METHODS

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We reviewed the published historical data and medical literature from African and European sources, plus government and organizational reports documenting the history of blood transfusions in the region from the late 1940s to 1990. This is the first attempt at collecting and interpreting this literature, and although we identified more than 100 studies and reports, we acknowledge the limitations of the data. For example, the late colonial period (late 1940s to early 1960s) is the only time during which records or reports were recorded until the World Health Organization (WHO) data collection efforts of the 1990s. Moreover, although the published literature reflects the strong initial interest of medical officials in colonies and newly independent countries when transfusion was first introduced, the novelty of the procedure wore off after the practice became well established. Another problem is that the available data do not utilize standardized units in reporting collection and transfusion. The names varied (e.g., "units," "bottles," "ampoules"), often without indication of volume, and the amount of blood transfused, which depended on the illness and the kind of patient, ranging from infants to full-grown adults, varied even more. By comparing and extrapolating from a number of reports that included the amount of blood collected and transfused, we have arrived at a rough measure for comparing data. We assumed that an overall average of 300 mL of blood was collected per donation and that the same amount was the overall average amount of blood given per transfusion.

There was sufficient information from our sources—several dozen published articles, plus reports from French and Belgian archives, institutes of tropical medicine, the WHO, and the International Red Cross—to make this preliminary report outlining the timing and extent of blood transfusion in sub-Saharan Africa during this crucial period. To be on the safe side, the application of these data to estimating rates for all of sub-Saharan Africa was very conservative. We utilized all the available data reporting the number of transfusions in a given locality with a known population as though they were the only transfusions that occurred at the time in each locality. This yielded the most conservative rates consistent with existing data. But even large gaps in reporting do not necessarily imply the absence of transfusions. On the contrary, anecdotal evidence suggested that there was and continues to be widespread unreported transfusions because of readily available equipment, simple procedures, and the potential for lifesaving results with few alternative treatments. Thus, it is likely that there were significantly more transfusions than we estimated.

	INTRODUCTION OF TRANSFUSION, INDICATIONS, AND RISKS

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An examination of the introduction of transfusion to sub-Saharan Africa is useful not only as a consideration of whether it may have contributed to the development of the epidemic of HIV/AIDS but also as a case study in the diffusion of medical technology to a less developed setting. Blood transfusion came later to sub-Saharan Africa than to Europe and North America. With the exception of medical services dedicated to resident European and special African populations (e.g., military and colonial personnel or African mine workers),¹⁵ the practice began only during and after World War 2 (Table 1).

Before examining the timing, frequency, and location of transfusion, 2 other questions must also be considered in determining its role in the origins of HIV: the uses of transfusion and concern about contamination. Unfortunately, only a few of the articles and reports describing transfusion services in sub-Saharan Africa before 1980 gave much information about the uses of the procedure. Aside from the obvious goal of replacing lost blood, the poor health conditions and tropical setting of most of sub-Saharan Africa also prompted other uses for transfusion. For example, one of the earliest reported uses was to treat infants with severe anemia, primarily from malaria. This practice began in 1939 in the Belgian Congo and was tried at a number of locations in the colony, most notably the Hospital of the University of Louvain in Kisantu, south of Leopoldville, where more than 5700 transfusions were reported (an average of 4 per patient) from 1943 through 1951. Although it produced some success, transfusion for malaria at Kisantu was replaced with nivaquine treatment.¹⁹ The procedure was used to treat other problems with children, however, as described in a 1965 article by Claude Bouyer at the Hôpital Sici in Pointe Noire, Congo (French)—during an 18-month period, 2413 subclavicle transfusions or perfusions were performed on infants and small children with severe dehydration caused by sickle cell anemia and hookworm infection.²⁰

A report of more varied and probably typical uses of transfusion was contained in a 1962 article by 2 doctors in the rural hospital of Bumbuli, Tanganyika (Table 2).²¹ Over the course of 18 months, they gave 294 transfusions, almost half the time for "anemia." Other reports of indications for transfusion repeated this pattern. For example, a blood bank established in Brazzaville, Congo (French), by the Pasteur Institute in 1955 reported about two thirds of transfusions for surgery and obstetrics in the first 2 years.²² Likewise, the hospitals of Bujumburu, Rwanda, in 1974–1975, University College Hospital in Ibadan, Nigeria, in 1980, and those in Abidjan, Ivory Coast, in 1991, reported surgery, pediatrics, and gynecology as the most frequent indications for transfusion.²³

Tests of donors were reported for other potential diseases including treponematosis, accounting for rejection of 14% of potential donors in Senegal in 1973, and glucose-6-phosphate dehydrogenase deficiency (10% in Senegal). In the first years of the transfusion service in Angola (1951–1954), more than 500 of 1462 potential donors were rejected, most frequently for syphilis (10%), but also for schistosomiasis (4%) and a vague category of "deficiency" (8%).²⁷ Hepatitis B was increasingly recognized as a problem, but only with the ability to test for the Australia hepatitis-associated antigen was there a possibility to do screening. Reports from 2 regions in Kenya showed rates of 5.1% (1971) and 6.6% (1973), whereas a 1973 article indicated 8.73% in Dakar.²⁸ Other diseases such as sleeping sickness were reported as localized or rarely a reason for rejection. These reports indicate a keen awareness of risks and significant but limited ability to protect the blood supply in the early years of transfusion in sub-Saharan Africa. Rarely, if ever, was there a doubt expressed in any of the published or unpublished reports that the benefits of blood transfusion warranted these risks.

	GROWTH OF TRANSFUSION SERVICES: 1940–1975

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Once begun, the subsequent adoption of transfusion was very rapid in sub-Saharan Africa. European countries were eager to introduce the new techniques developed during World War 2 to demonstrate the value of Western technology that accompanied colonial rule, among other reasons. Blood transfusions were initiated in a few colonies of sub-Saharan Africa before and during World War 2 and were expanded significantly after the war until the last years of the colonial period in the early 1960s. As a result, by 1960, with independence imminent, there were significant numbers of transfusions in most African colonies, and the practice of transfusion continued to increase in the first decade of independence.

For the most part, this process began in urban hospital centers, and serial data for the 1950s and 1960s are available from these hospitals in several colonies and countries across sub-Saharan Africa. They show a rapid increase in the number of countries where transfusions were done by the late 1950s (Table 1), paralleled by steady increases in the number of transfusions throughout the 1950s and 1960s. Thus, when the Nairobi, Kenya, Red Cross blood bank began in 1949, it reported 312 African donors.

This grew to 6030 in 1964, and 14 427 by 1968. When the blood bank for the Cameroon’s Central Hospital in Yaoundé was established in 1961, it reported 277 transfusions, which grew to 1352 in 1966, and 4543 by 1972. In Senegal, one of the few African countries that issued regular official reports summarizing national transfusion activities, the growth from 1961 to 1972 is clear: from 1924 transfusions in 1961 to 10 147 in 1965 to 17 241 by 1972.²⁹

Although incomplete, these hospital and country transfusion reports are similar enough to suggest overall trends in transfusion activities in sub-Saharan Africa. First is a trend in availability of records. In the period from 1940 to 1949, reports have been identified for countries representing only 9% of the population; by 1959, that figure is 36%. Data for the 1960s were more difficult to obtain (reports have been found for countries representing 30% of the population), in part because of the dispersion of record keeping after independence and limited government resources. More significant is the fact that the number of transfusions reported in each colony or country grew by orders of magnitude in each decade—hundreds in the 1940s, thousands in the 1950s, and tens of thousands in the 1960s—reflecting both the increase in transfusion activities and the advent of larger-scale systems for their administration.

Taking each country’s population growth into account over these decades and treating the reports as if they were the only transfusions done, we estimated minimal transfusion rates per 100000 population for urban areas of sub-Saharan Africa and for the region as a whole during the first 2 decades of their wider introduction.

The way transfusions began varied by colonial regimes and their legacy of administrative traditions for public health services after independence. In the African colonies ruled by France, for example, the introduction of transfusion was out of wartime needs. Thus, in February 1943, when the Allies landed in Tunisia, they brought with them the infrastructure already developed to support blood transfusion for the wounded.³⁰ Later that year, to supply blood for the troops in North Africa, a blood collection service was created in Dakar, Senegal, that was run by the Pasteur Institute, and in 1945, the last year of the war, almost 225 liters of blood were drawn. Although this quickly dropped off to less than 30 liters the following year, donations steadily grew thereafter to 168 liters of whole blood and plasma in 1950. In 1951, the French government allocated funds to establish a Federal Transfusion Service for all colonies in French West Africa.³¹ After 6 months of operation, the Dakar center reported collecting over 1000 liters of blood from almost 2000 donors. Of these, 1384 were Africans, mostly civil servants (the Europeans were military), and none were women. The blood and plasma was distributed to hospitals in Dakar, but also transported by train and air to the major cities of other colonies throughout West Africa: Bamako, Mali; Conakry, Guinea; Abidjan, Ivory Coast; Niamey, Niger; Ouagadougou, Upper Volta; Lomé, Togo; Cotonou, Dahomey; and Douala, Cameroon.

In the British colonies of East and West Africa there were more frequent reports of difficulties in recruiting blood donors. In Kenya during World War 2, for example, authorities had problems convincing African soldiers to donate blood. A 1945 report described how 2000 East Africans in the military were provided lectures on blood transfusion and a demonstration of drawing blood, followed by an interview. When asked if they would be donors, however, only 10 agreed.³² The reasons were both predictable and surprising. More than half mentioned fear of losing blood that could not be replaced, thus revealing a lack of understanding of human physiology. On the other hand, 31% refused because they thought "their blood was bad," because of hookworm, malaria, syphilis, and so forth, thus suggesting an appreciation of the risks of contagion and disease by blood transfusion. There was no report of fears that Western doctors wanted to steal the blood or organs of Africans, rumors about which had circulated before the war in conjunction with some health campaigns in East and Southern Africa.³³

Despite these initial problems, within 10 years better success was reported in several British African colonies. According to G. M. Edington of the Accra Medical Research Institute in the Gold Coast, it was initially difficult to find donors, but, "as the dramatic effects of transfusion were seen by patients’ relatives, it has become more and more simple to persuade relatives to donate blood and the size of the transfusion service is now limited, not by shortage of donors but by shortage of staff."^34(p71) In Accra, Edington reported that, by 1956, more than 1500 regular donors were enrolled in a transfusion service. A different approach was taken when a new 500-bed hospital opened in Ibadan, Nigeria, in 1957 as part of the new university medical school. Instead of relying primarily on relatives and friends of patients as donors, the hospital decided to establish a blood bank and mounted a systematic campaign that included lectures, radio broadcasts, and a recruiting film, with the help of the Red Cross and medical consultants. A mobile blood collection van was put to use, and, after an unfortunate train disaster in September 1957 demonstrated the value of the blood bank, a list of 1000 regular donors was compiled. By April 1958, there were 260 donations each month, a figure that rose to 460 per month the following year.³⁵ Nonetheless, this success did not persist. In the early 1970s, University College Hospital in Ibadan reported that 89% of transfusion donors came from relatives, although that number declined to 69% by 1979.³⁶

Likewise, the centralized blood service and quality control of French West Africa proved to be short lived. A combination of increased need, high cost of transportation, and looming independence resulted in new blood banks being established in the largest cities of French colonies. Thus, when a new hospital was opened in Lomé, Togo, in 1954, Amen Lawson established a small transfusion service independent of Dakar. For similar reasons in 1957, a separate blood bank was created for the Ivory Coast, initially to serve the hospitals of the capital in Abidjan. The following year, 540 liters of blood were drawn to serve the 1500 beds in the city’s hospitals.³⁷ Baba Sy, the blood bank director, reported that most donors were military (65%), police, or governmental functionaries, with only 10% coming from the general populace. Among the problems he noted were a lack of effective propaganda, fear of "mixing blood" of different peoples, and an unwillingness on the part of the authorities to recruit donors in more populated regions. Africans were not alone in their fear of mixing blood with other peoples. In the United States, blood for transfusion was segregated during World War 2, a practice that continued in some Southern states until the 1960s.³⁸

Blood transfusion was introduced to most other parts of sub-Saharan Africa during this same time period. As early as 1950, the Portuguese established a transfusion center in Angola followed the next year by one in Mozambique. In 1951, in Mashonaland (Southern Rhodesia), a transfusion service began that drew more than 1700 pints of blood by 1958, and reports were published about transfusion services in rural East Africa in 1962, and Pointe-Noire (French Congo) in 1963.

The use of blood transfusion spread beyond the initial programs of large urban hospitals as early as the mid-1950s in those places where colonial powers gave priority and resources to developing Western medical capabilities (e.g., the Belgian Congo and Senegal). By the 1960s, many newly independent countries, eager to expand their health service, promoted a similar process, often with the assistance of the former colonial powers. In fact, one could argue that with independence came a second wave of increased transfusion, spreading first to provincial hospitals and then to rural clinics throughout most of sub-Saharan Africa.

One reason for this continued expansion of transfusion was that many foreign governments wanted to establish friendly relations with the newly independent countries of sub-Saharan Africa and were eager to offer support in the area of health. The Pasteur Institute in Paris, for example, helped establish blood banks in Cameroon and Ivory Coast, where they had previously not existed.³⁹ Accordingly, the number of transfusions in sub-Saharan Africa saw a rapid rise in the mid-1960s. There was likely a leveling off of the rate of expansion in the late 1960s and early 1970s, during which time the struggling economies of newly independent nations suffered many shortages. Other changes thereafter depended on local population demands and resource availability, as well as disruptions associated with the civil wars and armed conflicts of this period. Nonetheless, there were more than 20 000 blood donations annually in Kenya by 1965, almost 13 000 in Tanzania by 1970, 13 000 in Senegal at 4 different blood banks in 1972, and more than 18 000 in Nairobi alone in 1977.⁴⁰ These data indicate a clear trend, increasing steadily from the 1950s to the 1990s, and reaching rates of 1000 to 2000 transfusions per 100 000 population in many urban centers, rates which are comparable to those seen in the United States and Europe during this period.

By the 1970s, the WHO and the League of Red Cross and Red Crescent Societies (LRCS) also provided a significant source of expertise and aid that supported the spread of transfusion in sub-Saharan Africa. This began as early as 1955, when, through the International Red Cross, the Dutch Red Cross made several thousand units of dried plasma available to countries in need. Between 1955 and 1959, shipments were made to the independent African countries of Ethiopia, Ghana, and Liberia.⁴¹ In the 1960s and 1970s, the WHO and LRCS acted as brokers for national governments and Red Cross societies who wanted to help individual African countries establish transfusion and blood collection programs. Notable examples were the Swiss Red Cross, which established a transfusion service for the hospitals in Bujumburu, Rwanda, between 1971 and 1975, the Finns in Somalia, and to a lesser extent, the Canadians in Togo.⁴² A bilateral aid project coordinated by the Red Cross, sent Cyril Levene of the Israeli Blood Group Reference Laboratory to Addis Ababa, Ethiopia, where he reorganized and expanded a blood transfusion service from 1969 to 1971 that eventually processed more than 3000 units of blood.⁴³

From the late 1970s to the mid-1980s, the WHO and LRCS shifted their efforts to establish regional African cooperation on blood supply through workshops and congresses, as well as to provide technical assistance and guidelines for standards of operation. Between 1977 and 1985, Pan-African meetings were held in the Ivory Coast, Senegal, and Zimbabwe, after which time the HIV/AIDS epidemic prompted a whole new approach to transfusion and the blood supply.⁴⁴ In preparation for a WHO/LRCS workshop on the management of blood transfusion services in 1985 at Harare, Zimbabwe, an effort was made to estimate the overall use of blood transfusion by continent. Gathering information from surveys and reports in the early 1980s, Juhani Leikola, director of the LRCS Blood Program, estimated that the annual number of transfusions for the African region of WHO (all of sub-Saharan Africa except Sudan and Somalia but including Algeria) was 1.698 million for a population of 384 million, or a rate of 440 per 100 000.⁴⁵ This is remarkably close to our estimate (Table 4; discussed in the next section).

	POPULATION TRANSFUSION RATES IN SUB-SAHARAN AFRICA

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Extrapolating from these country rates produces a median estimate of approximately 20 million transfusions done in sub-Saharan Africa during the 1980s (range from 18.5 million to 22.2 million; Table 4). By 1990, when the sub-Saharan Africa population reached 500 million, most of that growth was occurring in the urban areas, which had the best access to medical facilities and, in all likelihood, higher rates of transfusions. With the use of our data and the methods of estimation we describe, it appears that 30 to 40 million transfusions occurred in sub-Saharan Africa in the period 1950–1990.

	CONCLUSIONS

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It is remarkable that despite so much evidence of the wide use of blood transfusions during the decades before the emergence of HIV in sub-Saharan Africa, there is almost a total absence of discussion of the significance of these millions of transfusions for the beginning of the AIDS epidemic in Africa. This is explained in part by the fact that when first discovered, the most noteworthy feature about early AIDS cases in Africa was that there was no apparent connection to homosexuality and drug use; hence, heterosexual transmission was the overriding focus of attention. Yet there were reports of the risk of HIV from blood transfusions in sub-Saharan Africa as early as 1985, with estimates of 15% to 18% of blood donors seropositive for human T-lymphotropic virus type III antibodies.⁴⁶ Nonetheless, systematic discussion only came 7 years later in Mann and Tarantola’s encyclopedic AIDS in the World,⁴⁷ published in 1992, and 30 years after the beginning of the HIV epidemic in the region—and this discussion of transfusion risk was understandably devoted to the issue of protecting the blood supply in the future, not its historical role.

The timing of the emergence of the AIDS epidemic in sub-Saharan Africa suggests that transfusions may have played a significant role in the origins of the disease. The oldest sample of the HIV-1 virus came from Zaire (Congo) in 1959,⁴⁸ and all other known epidemic strains of HIV emerged in this region by the mid-1960s.⁴⁹ The first clinical cases of AIDS in Africa most probably occurred in the 1960s and became epidemic by the 1970s—when AIDS cases also likely first occurred in the United States and Europe, but were not recognized as such. The testing of blood for HIV was, of course, not possible until the mid to late 1980s, by which time, according to our findings, 30 to 40 million transfusions had occurred in the region. HIV testing did not become widespread in sub-Saharan Africa until the 1990s and is still far from universal in many parts of this HIV endemic region, where transfusions are more widely used than ever before. The findings of this study argue for a closer look at the role of blood transfusions in the origin and subsequent epidemic spread of HIV in Africa and for renewed efforts to institute blood testing and restrict the use of unsafe transfusions.

View larger version (126K): [in this window] [in a new window]   Blood transfusion center for French West Africa, established in 1951. Source. Linard.18(p953)

View larger version (126K): [in this window] [in a new window]   Patient receiving blood, King George VI Hospital (now Kenyata Hospital), Nairobi, Kenya, 1955. Source. Colony and Protectorate of Kenya. Medical Department Annual Report, 1955.

View larger version (121K): [in this window] [in a new window]   Poster for blood donation, University Hospital, Ibadan, Nigeria, 1957. Source. Una Maclean, "Blood Donation for Ibadan," Community Development Bulletin, 11, no.2 (1960); 27.

View larger version (133K): [in this window] [in a new window]   Blood Transfusion Service, Bujumburu, Burundi, 1976. Translation of caption accompanying picture reads, "In the long corridor of the mission station they sit next to one another: the blood donors and the recipients. In one room, with the doors open, blood is being donated while in the adjoining sickroom, likewise open, blood is being transfused. This obvious juxtaposition is a decisive factor in motivating the donors." Source. Elisabeth-Brigitte Schindler, Burundi Red Cross Blood Donor Service: Organisation and Activities (Basel: Swiss Red Cross, December, 1976).

	Acknowledgments

	Footnotes

 
Peer Reviewed

Contributors
W. H. Schneider did library and archival research, collected data, and wrote initial drafts of the historical material in the study. E. Drucker was responsible for the epidemiological design and data analysis and determination of quantitative projections, estimates, and conclusions. Both authors conceptualized the study, interpreted findings, and reviewed drafts of the article.

Accepted for publication April 23, 2005.

	Endnotes

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1. L. Simonson, A. Kane, J. Lloyd, et al., "Unsafe Injections in the Developing World and Transmission of Blood Borne Pathogens: A Review," Bulletin of the World Health Organization 77 (1999): 789–800; Y. Huytin, The Safe Injecting Global Network (Geneva: WHO, 2001).[ISI][Medline]

2. E. Drucker, P. Alcabes, and P. A. Marx, "The Injection Century: Massive Unsterile Injections and the Emergence of Human Pathogens," Lancet 358 (2001):1989–1992; E. Hooper, The River (New York: Little Brown, 1999).[CrossRef][ISI][Medline]

3. P. van de Perre, D. Munyambuga, G. Zissis, et al., "Antibody to HTLV-III in Blood Donors in Central Africa," Lancet 1 (1985): 336–367; N. Clumeck, M. Robert-Guroff, P. van de Perre, et al., "Seroepidemiological Studies of HTLV-III Antibody Prevalence Among Selected Groups of Heterosexual Africans," JAMA 254 (1985): 2599–2602; J. M. Mann, "Human Immunodeficiency Virus Seroprevalence in Pediatric Patients 2 to 14 Years of Age at Mama Yemo Hospital, Kinshasa, Zaire," Pediatrics 78 (1986): 673–677; T. C. Quinn, J. M. Mann, J. W. Curran, et al., "AIDS in Africa: An Epidemiologic Paradigm," Science 234 (1985): 955–963.[Medline]

4. P. Piot and M. Bartos, "The Epidemiology of HIV and AIDS," in M. Essex, S. Mboup, P. J. Kanki, et al., eds., AIDS in Africa, 2nd ed, (New York: Kluwer, 2002), 202–204.

5. World Health Organization, Blood Safety and Clinical Technology, Strategy 2000–2003 (Geneva: World Health Organization, 2001), available at: http://www.who.int/entity/injection|safety/about/strategy/en/BCTStrategy.pdf, accessed March 6, 2006.

6. Simonson, et al., "Unsafe Injections"; Drucker, et al., "Injection Century"; WHO, Blood Safety and Clinical Technology.

7. Piot and Bartos, "Epidemiology"; I. Bates, "Blood Transfusion," in G. C. Cook and A. I. Zumia, eds., Manson’s Tropical Diseases, 21st ed, (Philadelphia: Saunders, 2003), 245–252. For purposes of this study, the term sub-Saharan Africa excludes South Africa as well as North Africa, because of differences in geography and history, as well as political and economic conditions in the case of South Africa. Blood transfusion was better developed in South Africa albeit for Whites primarily. See J. H. Gear, "Blood Transfusion in Johannesburg: Pre-South African Blood Service," Adler Museum Bulletin 14 (1988): 3–6. Access for Black South Africans is a subject for another study.

8. J. Moore, "The Puzzling Origins of AIDS," American Scientist 92 (2004): 540–547.[CrossRef]

9. Hooper, River; J. M. Mann and D. Tarantola, AIDS in the World (Cambridge, Mass: Harvard University Press, 1992); P. E. C. Manson-Bahr and D. R. Bell, eds, Manson’s Tropical Diseases, 19th ed., (London: Ballière Tindall, 1987).

10. T. Zhu, B. T. Korber, A. J. Nahmias, et al., "An African HIV-1 Sequence From 1959 and Implications for the Origin of the Epidemic," Nature 391 (1998): 594–597.[CrossRef][Medline]

11. K. Pelis, "Taking Credit: The Canadian Army Medical Corps and the British Conversion to Blood Transfusion in WWI," Journal of the History of Medicine and Allied Sciences 56 (2001): 238–277; W. H. Schneider, "Blood Transfusion in Peace and War, 1900–1918," Social History of Medicine 10 (1997):105–126.[Free Full Text]

12. W. H. Schneider, "Blood Transfusion Between the Wars," Journal of the History of Medicine and Allied Sciences 58 (2003): 187–224.[Abstract]

13. National Blood Donor Research Center, Report on Blood Collection and Transfusion in the United States in 1999 (Bethesda, Md: NBDRC, 2000); American Red Cross, FAQ About and Blood Needs, available at http://www.givelife2.org/aboutblood/faq.asp, accessed August 23, 2003. For the United Kingdom, see S.J. Varney and J. F. Guest, "The Annual Cost of Blood Transfusions in the UK," Transfusion Medicine 13 (2003): 205–218; For France, Etablissement français du sang, "Evolution de l’activité," available at http://www.efs.sante.fr/des_chiffres.htm, accessed March 6, 2006.

14. R. M. Titmuss, The Gift Relationship: From Human Blood to Social Policy (London: Allen and Unwin, 1970).

15. D. Spedener, "Le traitement des pneumonies des noirs par transfusion de sang des convalescents," Bulletin médical du Katanga 1 (1924): 234–238.

16. N. R. Hunt. A Colonial Lexicon of Birth Ritual, Medicalization, and Mobility in the Congo (Durham, NC: Duke University Press, 1999).

17. Spedener, "traitment"; J. Lambillon and N. Denisoff, "Etude de l’organisation d’un service de transfusions sanguines dans un centre hospitalier d’Afrique," Annales de la Société belge de médecine tropicale 20 (1940): 279–285.

18. J. Linhard, "Le centre fédéral de transfusion de l’AOF," Médecine tropicale 11 (1951): 951–957.[Medline]

19. A. Lodewyck, "Note sur la transfusion sanguine chez les nourrissons et les enfants," Recueil de travaux de sciences médicales au Congo belge 2 (1944): 157–161; C. S. Ronsse, "Anémies malariennes des enfants et transfusions sanguines; avec observations sur les groupes sanguins des Bakongo," Mémoires Institut royal colonial belge section des sciences naturelles et médicales 20 (1952): 1–64.

20. C. Bouyer, "Perfusions et transfusions par la veine sousclavière chez les nourissons et le enfants," Annales de la Société belge de médecine tropicale 45 (1965): 39–48.[Medline]

21. O. Walter and L. Langlo, "A Blood-Bank Service in a Rural Hospital in East Africa," East African Medical Journal 39 (1962): 702–707.[Medline]

22. "Rapport sur le fonctionnement technique de l’Institut Pasteur de Brazzaville," Archives of Pasteur Institute, 1955–1956, IPO-RAP, Box 11.

23. E.-B. Schindler, Burundi Red Cross Blood Donor Service (Basel: Swiss Red Cross, 1976); A. S. David-West, "Blood Transfusion and Blood Bank Management in a Tropical Country," Clinics in Haematology 10 (1981): 1013–1028; D. Mignonsin, S. Abissey, B. Vilasco, et al., "Transfusion sanguine en Côte d’Ivoire: Perspectives d’avenir," Médecine d’Afrique noire 38 (1991): 723–731.

24. G. M. Edington, "Some Observations on Blood Transfusion in the Gold Coast," West African Medical Journal 5 (1956): 71–75;

25. M. G. Iskander, UNICEF in Africa South of the Sahara: A Historical Perspective (New York: UNICEF, 1987).

26. J. Linhard, G. Diebolt G, and E. Ayité, "Particularités médicales des transfusions sous les tropiques," Bulletin de la Société médicale de l’Afrique noire de la langue française 18 (1973): 293–297. See also, L. J. Bruce-Chwatt, "Blood Transfusion and Tropical Disease," Tropical Diseases Bulletin 69 (1972): 825–862; J. O. Ndinya-Achola, H. Nsanzumuhire, and G. B. A. Okelo, "Some Possible Infectious Hazards Because of Blood Transfusion in Nairobi," East African Medical Journal 57 (1980): 55–59; L. J. Bruce-Chwatt, "Transfusion Malaria," Bulletin of the World Health Organization 50 (1974): 337–346.

27. A. Lessa, L. Mayor, P. de Figueiredo, et al., "Organisation de l’hématologie, l’hémothérapie et la réanimation dans l’Outremer portugais," in Fifth International Congress of Blood Transfusion, Paris 1954 (Paris: Edition Septembre, 1955): 1057–1061.

28. Linhard, Diebolt, and Ayité, "Particularités médicales"; A. M. Parker, K. L. Muiruri, and J. K. Preston, "Hepatitis-Associated Antigen in Blood Donors of Kenya," East African Medical Journal 48 (1971): 470–475; A. B. Nganda and N. Titus, "Hepatitis B Antigen in a Rural Community in Kenya," Transactions of the Royal Society of Tropical Medicine and Hygiene 67 (1973): 663–670.[Medline]

29. Colony and Protectorate of Kenya [later Republic of Kenya], Medical Department, Annual Report, 1949–1968; "Rapport annuel, Institut Pasteur de Cameroun," 1956–1971, Archives of Pasteur Institute, IPO-RAP, Box 39; Republique du Senegal, Ministère de la Santé publique, Activité du Service, 1969–1974.

30. E. Benhamou, "L’organisation de la réanimation-transfusion en Afrique français pendant la guerre," Bulletin de l’Académie de médecine 129 (1945): 195–198.

31. Linhard, "Centre fédéral."

32. K. S. Dewhurst, "Observations on East African Blood Donors," East African Medical Journal 22 (1945): 276–278.

33. L. White, "Tsetse Visions: Narratives of Blood and Bugs in Colonial Northern Rhodesia, 1931–1939," Journal of African History 36 (1995): 219–245; L. White, Speaking With Vampires: Rumor and History in Colonial Africa (Berkeley, Calif: University of California Press, 2000).

34. Edington, "Some Observations."

35. U. Maclean, "Blood Donor Recruitment in Ibadan: The Record of One Year’s Experience," Journal of Tropical Medicine and Hygiene 61 (1958): 311–314; U. Maclean, "Blood Donation for Ibadan," Community Development Bulletin 11 (1960): 26–31.

36. A. S. David-West, "Blood Transfusion."

37. B. Sy, "Fonctionnement de la banque du sang de la Côte d’Ivoire," Transfusion 3 (1960):47–51; "Croixrouge togolaise de Lomé, banque de sang, 1971," attachment to "Rapport d’activite, 1972," Archives of International Federation of Red Cross and Red Crescent Societies (hereafter cited as IFRC archives), AO917.[CrossRef]

38. Schneider, "Blood Transfusion Between"; "Segregated Blood: A Backlash Backfires," Hospital Practice 4 (1969):21 –25; 82–83.

39. "De la naissance d’un Institut Pasteur," 1959, Archives of Pasteur Institute, IPO-RAP, Box 6.

40. Ndinya-Achola, et al., "Some Possible"; J. L. Beecher, "ABO Blood Group Distribution in Some Kenya Tribes," East African Medical Journal 44 (1967): 134–141; A. M. Nhonoli and J. S. Kiango, "The Distribution of Blood Group Frequencies in Mainland Tanzania Africans," East African Medical Journal 51 (1974): 282–289; E. Ayité, E. G. Diebolt, and J. Linhard, "La transfusion sanguine au Sénégal," Bulletin de la Société médicale de l’Afrique noire de la langue française 18 (1973): 289–292; Republic of Kenya: Status of Health, 1980 (Nairobi: Ministry of Health, 1985).[Medline]

41. Correspondence between Van Emden of Dutch Red Cross, Hantchef of the LRCS, and country directors in Ethiopia, Liberia, and Ghana, 1955–1959, IFRC archives, AO 911.

42. Various country files, IFRC archives, AO 916.

43. Cyril Levene, "Ethiopian Red Cross Society, Blood Bank Report," July 1971, IFRC archives, AO 915.

44. For example, see Premier congrès africain de transfusion sanguine, 7–12 Mars 1977, Yamoussoukro, Côte d’Ivoire, actes du congrès (Paris: Institut INNIT, 1981; Atelier OMS/LSCR sur la gestion des services nationaux de transfusion sanguine, 7–11 novembre 1983 Dakar, Senegal, Rapport (Geneva: Ligue des sociétés de la Croix rouge et Croissant rouge, 1984); and Optimal Use of Resources: African Workshop on Management of Blood Transfusion Services, Harare, Zimbabwe, December 2–11, 1985 (co-sponsored by WHO/LRC/FINNIDA).

45. J. Leikola, "How Much Blood for the World?" Vox Sanguinis, 54 (1988): 1–5.[Medline]

46. Van de Perre, et al., "Antibody to HTLV-III"; Clumeck, et al., "Seroepide-miological Studies of HTLV-III."

47. J. M. Mann, D. Tarantola, AIDS in the World.

48. Zhu T, et al. "An African HIV-1 Sequence."

49. P. Sharp, D. Robertson, F. Gao, and B. Hahn, "Origins and Diversity of Human Immunodeficiency Viruses," AIDS 8 (1994): S27–S42; P. Marx, P. E. Alcabes, and E Drucker "Serial Human Passage of Simian Immune Virus by Unsterile Injecting and the Emergence of Epidemic HIV in Africa," Philosophical Transactions of the Royal Society of London, Series B, Biological Sciences 356 (2001): 911–920.

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