by Rose George
Their patriarch, an elderly man given the honorific Baba-ji, has been an unpaid hospital volunteer for years, bringing milk to the poorer patients. He arrived at seven thirty a.m. every morning, and through this work came to realize that some people needed blood as well as milk. Safdarjung has a reputation for amputations, and each amputation surgery requires at least 2 units of blood. Sometimes 4. They are expected to replace that, but how? “These people are from outside,” says Baba-ji (real name: Mr. Kayast). “From Orissa, Nepal, Jharkhand.” They have an accident, it’s poorly treated, so they come to the city but alone. No friends, no blood.
Every Sunday morning, then, Baba-ji and others come and give blood to strangers. Eleven of them have donated today, and each will ensure their blood goes to a particular patient. The last time Baba-ji donated—he is now too old, as Safdarjung’s age limit for donors is fifty-five—it was for a man in bed number thirty-nine. An amputation. A new national blood policy wants family replacement to be phased out, but it will be difficult. Data released by the National AIDS Control Organization (NACO) of India in 2016 showed that hospitals had demanded blood from ten million Indians over the previous five years to compensate for transfusions given to their relatives or friends.39
NACO would prefer that hospitals relied on all-voluntary blood donor sessions, known in India as blood camps. I set up my own, inadvertently, when I visit Rotary Blood Bank, one of the few independent voluntary-based blood banks, in outer Delhi. The interview was going badly. My hosts were polite, but not illuminating. I was offered a tour of the building, and we entered the donating room, which was empty. The equipment looked clean enough, my frustration was mounting—the woman had just told me that no one sold blood in India, which is nonsense—so I thought giving away millions of white and red blood cells might pass the time. My hosts looked astonished, then delighted. I signed a form, stretched out my right arm, and that was all it took. Now the staff chatted about their families and their work with warmth and openness. Blood spilled, ice broken.
Visiting British journalists are not going to fill the hole in India’s blood supply. They shouldn’t accept my blood anyway: like anyone else who was born in Britain or living there before 1996, I am a global pariah. Until a cure is found for variant Creutzfeldt-Jakob disease, whose infectious prion particles can live for years undetected in our bodies, my blood is considered unsafe anywhere outside my island.
Delightful impromptu replacements for family replacement, like Baba-ji’s group, will not plug the gaps either. But God and gods may. “Guru movement and political party adherents,” wrote Jacob Copeman, a social anthropologist who studied religion and blood in north India, “vie to donate the most blood in a kind of national league of virtuous beneficence.” In 2005, the Dera Sacha Sauda devotional order of north India held the Guinness world record for the most blood donated in a single day: sixty-five bathtubs full, 12,002,450 milliliters.40 Indian medical professionals don’t like massive blood camps. One told Copeman they were “blood massacres” because of all the blood that was wasted due to lax medical standards and an excess of “quality not sufficient” units.41 Nor do they like the family replacement system. They want an anonymous, volunteer-based system because that is the safest. The trouble is, Indians don’t agree with them. You give blood under pressure and only for your kin, not to be nice to strangers. Giving blood brings weakness because it is a life force. Losing it can damage a man’s virility and a woman’s fertility. When Jawaharlal Nehru was photographed giving blood in 1942, he was criticized for damaging his health, which was an important national treasure.42
India’s Supreme Court banned the sale of blood in 1996.43 It has also banned untouchability. Both bans are equally flexibly interpreted and both banned activities flourish happily. In 2008, for example, police acting on a tip-off raided a series of squalid tin sheds near Gorakhpur, Madhya Pradesh, and found blood slaves.44 As Scott Carney reported in The Red Market, poor migrant men were kept in sheds by a local dairy farmer, Pappu Yadhav, and persistently bled to the point of death. Police found five sheds and freed seventeen men, who had been bled twice a week. Some had been imprisoned for two and a half years. Hemoglobin levels in a normal adult male should be 14 to 18 grams per deciliter of blood. The blood slaves had 4 grams.
Yadhav’s setup was extreme but not unique. In 2017, Lucknow police arrested Mohd Arif, known as Shibbu, a former artisan who became a blood broker, buying blood from “donors,” storing it in an ordinary kitchen fridge, and selling it to blood banks and hospitals. He paid agents 500 rupees ($7) to find sellers, paid sellers 1,000 rupees per blood sale, and sold the blood on for 4,000 ($60).45 Hang around outside any hospital and look like you need something, and you will be offered blood for sale. Indian journalists have no trouble finding men such as Pramod, interviewed by Nikhil M. Babu, who offered a troop of “clean boys” who sold blood for 4,000 rupees ($60) a dose.46 In poor farming regions such as Bundelkhand in Uttar Pradesh, where thirty-five hundred farmers have committed suicide in the last five years because of poverty and failed crops, blood is the new crop. It is illegal for hospitals to buy it, but they do, for a pittance. One farmer interviewed by Reuters sold two bottles and was given 1,200 rupees ($18.45).47
When an activist named Chetan Kothari requested data on HIV infections from India’s National AIDS Control Organization, 2,234 people reported that they had been infected from transfusions.48 Self-reporting is problematic: some people with HIV may prefer to blame the blood supply rather than drug use or illicit sex. But getting HIV through a blood transfusion in India is three thousand times more likely than in the United States,49 where the risk is 0.01 percent, as in other high-income countries.50
A hospital as large as Safdarjung hopefully does its screening properly, although the reception booth at the blood bank on the ground floor is ramshackle. Baba-ji and his eight friends and relatives have done their bit. They have their glow. They have given blood for nothing to strangers, as perfect a gift as is possible, and narrowed a small bit of the gaping rift in India’s blood supply. Now India just needs to find millions more people like them, and so does every other country like India.
* * *
Persuading people to give up their blood is not easy. Blood is a scarce and valuable resource. Why should anyone give it up for free? Every blood system will use incentives, even the voluntary non-remunerated ones. In the United States, government regulations forbid any incentive that can be exchanged for cash or be transferred or sold to someone else. Sports and event tickets can be given away, so they are out, but a discounted hotel room is permitted.51 Even so, blood banks have offered pizza, football tickets, ice cream (in a Ben & Jerry’s–sponsored initiative called A Pint for a Pint), haircuts, a day’s gym membership.52 There are other, more coercive ways to get blood. In 2015, Judge Marvin Wiggins, a circuit judge in Alabama, told petitioners in his court to give blood if they didn’t have any money to pay fines. For those who refused and couldn’t pay, “the sheriff has enough handcuffs.” A professor of medical ethics described this as “wrong in about 3,000 ways.”53 Wiggins, as judges are supposed to do, was basing his ruling on precedence, as Susan E. Lederer writes in Flesh and Blood. “In 1940, a Chicago judge ordered Thomas Donohue to contribute blood to the blood bank at Cook County Hospital in lieu of the alimony he owed his wife. (His wife did not welcome his ‘alcoholic transfusions.’)” After the attack on Pearl Harbor, the mayor of Honolulu demanded blood from traffic violators, and in Worcester, Massachusetts, Lederer writes, “sightseeing motorists attempting to view the damage from a 1953 tornado learned that ‘a pint of blood is your admission fee down here.’”54 They paid.
Much thinking is done about how to attract donors. To entice, blood authorities need to understand what motivates someone to give away a considerable amount of their blood supply. Altruism, that most obvious motivator (sociologists actually talk of a “warm glow” effect), turns out to be more complicated than we think: countries that have non-remunerated volunteer d
onor systems can have wildly different rates of donations. In Luxembourg only 14 percent of people give blood; over the border in France, it’s 44 percent. Nor do rates of blood donors match rates of other types of volunteering, which you’d expect if blood donors were just nice people wanting to do good. Instead, as economist Kieran Healey found, what changed donor rates was what kind of institution was collecting the blood. The Red Cross was the most popular. State authorities, such as NHSBT, were the next best. Germany saw donor rates drop when it allowed payments for blood. The lower rates persisted even when the agencies that paid for blood went bust.55
I have a key ring given me long ago when I donated blood that has my blood type on it—A+, the second commonest—but recently NHSBT has moved away from trinkets. Donors, it found, simply want a thank-you. Eighty-three percent of first-time donors remembered staff thanking them. Emotions work better than key rings. In 2012, Stockholm’s blood bank Blodcentralen began sending text messages to people who had donated, telling them that their blood had been used, and for whom. It was a powerful way to humanize what is, after all, an anonymous system, where your blood disappears into a bag, into a back room, into a van, and away. The WHO classes the texts and other technological outreach as “mHealth.” Blodcentralen’s communications manager Karolina Blom Wiberg is more passionate. “Donors, including me, love getting them. They hit you right in the gut when you think that someone has in this instant been helped by my blood.”56
NHSBT decided to try out the texting. “We borrowed it with pride,” says Mike Stredder, head of Donor Services at NHSBT. They weren’t as detailed: NHSBT data allowed them only to tell donors when their blood had been delivered to a hospital, not when it was used. (My last two have gone to hospitals in Derby and Sheffield: you’re welcome, cancer patients, new mothers, trauma victims, and anemic people of Derby and Sheffield.) The response was so positive, says Stredder, “we cut short the trial and just rolled it out because I’ve never seen such overwhelming positive response to anything I’ve ever done in my career, in such a short period of time.”
Donors were reporting that they were going to be donors for life now. Social media comments were overwhelmingly good. In short, NHSBT probably should have done it a long time ago. Also, it’s cheap: it costs only 3 pence (4.2 cents) to send each text, or £35,000 ($49,165) for the whole donor base.57 As efforts to retain donors go, it’s the most successful for decades. Retention is what blood authorities dream of. Perfect donors are the ones who come back. They require less testing; they can be relied upon. They may even turn up during football finals or Wimbledon. Getting new donors is another matter, and particularly the young kind. The donor base is aging, and younger people are giving less blood. Between 2005 and 2015, new donors decreased by nearly a quarter. NHSBT has launched youth-friendly campaigns such as Missing Type, where the letters A, B, and O went missing from various organizations. The prime minister was suddenly living in Dwning Street; people were searching on Ggle and reading the Dily Mirrr. It was smart and accessible, and more successful than, for example, a program in Australia, when the local blood service attempted outreach in universities. Too many underweight young women were coming in and fainting, and then their friends started fainting in sympathy: the outreach retreated.
* * *
“We need black blood.”
I say, “Pardon?,” not because I didn’t hear but because I want to hear this again, because I can’t believe Stredder has said it. Blood and race have such a sensitive history. In the early days of US blood banking, blood bags were labeled as N for Negro or AA for African American, and hospitals as august as Johns Hopkins refused to transfuse Caucasian patients with Negro blood. Lemuel Diggs, who ran the blood bank at Memphis’s John Gaston Hospital, had stored different “colored” blood on different refrigerator shelves, openly. Southern states routinely segregated “white” and “black” blood. Most admitted their policies had no scientific basis. The Red Cross, which refused donations from African Americans for plasma collection, called its reasoning “a matter of tradition and sentiment rather than of science.”58 The US War Department directed that “for reasons which are not biologically convincing but which are commonly recognized as psychologically important in America, it is not deemed advisable to collect and mix Caucasian and Negro blood indiscriminately for later administration to members of the military forces.”59 Nazis did the same, refusing non-Aryan blood and dying of their wounds as a result. In the United States, blood segregation stopped only in 1972, when Louisiana finally repealed its blood label laws (along with the segregation of water fountains, bathrooms, trains, dance halls, and marriage).60
But Stredder is emphatic. Black blood. Not even blood from BAME, an ungainly acronym standing for Black, Asian, and Minority Ethnic. They made appeals for more BAME blood in the past, Stredder tells me, but now they need to be more “robust.” Antigens and antibodies commoner in black people’s blood make it more appropriate for transfusions for sickle-cell anemia, for example, a genetic condition that produces deformed red blood cells (shaped like sickles), leading to anemia, fatigue, and awful pain. Sickle-cell patients can require several transfusions a month, and they can develop immune reactions to “foreign” antigens. The closer the cross match of blood to their own variety of antigens, the better. Black donors are more likely to have the Ro subtype (a version of the rhesus group), and Ro blood is more likely to be used to treat sickle-cell anemia. But only 2 percent of the British population has it.
At Tooting Blood Donor Centre in London, I meet part of the 2 percent. I’d asked to meet a young donor, and Azeez had been suggested, as Azeez had offered his blood, again and again, because it is one of the rarest kinds. It is Ro but also U negative, a combination found only in black people, usually those of African heritage. He was unusual because of his blood but also because of who he was. Neither of us knew what the other looked like, but I had an advantage: if a young, black man walked into the donor center, then it would be him, because donors like him are only slightly less rare than his blood. Numbers of young donors are falling: half of British donors are now over forty-five. Also, Azeez is Muslim. Attracting Muslim donors is another challenge: as one non-donor reported to a NHSBT survey, he didn’t know whether blood donation was permissible, and he was an imam. (Most scholars think it is, as long as money does not change hands and it is done in good faith.) Azeez didn’t need to forensically explore the scriptures: in his mind giving blood was obviously a deed of charity and one of the five pillars of Islam.
He has persuaded some of his friends to donate. This is the most successful way to attract new donors: they’ll come if they know someone who gives blood or if someone in their family has required blood. The UK needs between 1.6 and 1.7 million units a year. That is 6,000 units a day, but NHSBT likes to keep a buffer, and has 30,000 to 40,000 units available on any one day.61 All these numbers make the UK an exception. When the WHO compiled its latest global status report on blood safety with data from 180 countries, it concluded that 112.5 million donations had been made in the reporting year (2013). High-income countries collected almost half of those donations, despite having only 19 percent of the global population. Low-income and lower-middle-income countries, where nearly half the world’s people live, collected only 27 percent.62 NHSBT needs to find 200,000 new donors every year to maintain a safe blood supply. When one of the best blood systems in the world struggles, what chance does everyone else have?
* * *
In the reception area at Tooting Blood Donor Centre, I read a book. Around me are the signs of the ordinary: the noises of the donor center; the cheap supermarket cordial; the chatter of the receptionists about somethings and nothings. All of it makes the place seem unthreatening and soothing. It detracts from the truth about blood donation and transfusion: that it is something that hasn’t happened for very long and that it involves a substance that still defies science’s attempts to understand it. If we could understand how to stop people bleeding, we wouldn’t need so m
uch blood. We can create synthetic hearts. We can build organs on 3-D printers. But despite decades of research and many millions of dollars, we have yet to make blood. What it can do, how it does it, what it can carry, how it works: all these things have some answers but not all. The only sure thing about blood is our enduring fascination with it and its answering mystery.
The book is leather-bound, or fake-leather-bound, and embossed with gold lettering. Both these things expressed the fact that it is worth reading. A prized thing. That is because it is full of life and death. It is the thank-you book, from recipients to donors. I read its pages and think that if I weren’t a blood donor already, this might make me one. The recipients haven’t written much, but their words express their surprise that someone could do something as extraordinary as give away a part of their body to them and want nothing back.
There are two questions on each of the sheets in the blood donor book. The first is “What has this transfusion meant to you?,” then “What would you like to say to your blood donor?” One writes that she now has a better lifestyle, as if a blood transfusion has improved her clothes shopping (she means she can get out of bed). One is thankful that the transfusion “has improved my blood and changed the color from pink to red.”
But the man who best describes the power of blood, this baffling, splendid substance, writes in an elderly hand. He gives no sense of what blood has done for his health or why he needed it, but his economy of words is rich. Under the question “What has this transfusion meant to you?” he has answered, only but sufficiently, “Good.”
Hirudotherapy in Tallinn, Estonia
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