William Schneider
Indianapolis, Indiana, United States

One of the cornerstones of the WHO Blood Safety program is the voluntary donation of blood. According to the WHO Fact Sheet No. 279 (June 2015), all Member States are urged “to develop national blood systems based on voluntary unpaid donation.” The reason is,

An adequate and reliable supply of safe blood can be assured by a stable base of regular, voluntary, unpaid blood donors. These donors are also the safest group of donors as the prevalence of bloodborne infections is lowest among this group.

Despite this strong statement, as of 2015 in seventy-two of the countries reporting to WHO on blood donors, less than half were voluntary and unpaid. The reasons are complicated and persistent, as indicated by the fact that the resolution referred to in the WHO statement was passed over forty years ago at the 28th World Health Assembly in Geneva, May 1975, following an international scandal in blood trafficking.¹

Background

The question of paid versus voluntary donation of blood dates back to the 1920s, when the Red Cross first became involved in transfusion thanks to Percy Oliver’s work at a neighborhood branch (division) in London. Responding to a call from a local hospital for blood transfusion donors, Oliver appealed to chapter members. Based on the response, he organized a list of potential donors “on demand,” pretested for type, and screened to prevent transmission of disease.² This soon became a model for other but not all countries.³

In Paris, for example, several hospitals cooperated to develop a shared list of potential donors, and the French government provided small payments for their “loss of time, travel expense and possible fatigue.” In New York City, a union of donors was organized who negotiated a price for giving blood with a guarantee to stay healthy. Nonetheless, Oliver’s voluntary system became the model that most countries with Red Cross societies adopted in the 1920s and 30s.⁴ During the Second World War, the great increase in need for blood was met in part by troops in the field but also by appealing to the patriotic duty of citizens on the home front to voluntarily donate blood. During and after the war some governments turned the practice over to the national Red Cross organizations, for example in Canada, Netherlands, Switzerland, and Finland.⁵

Another wartime development, however, led to an increase in the postwar sale of, or “trafficking in” blood: Edwin Cohn’s discovery of plasma fractionation.⁶ By separating blood into its several components such as plasma (which could be dried for conservation), platelets, and white cells, many more patients could be treated for illnesses than simply replacing whole blood. Cohn went further and fractionated plasma into its several protein components, the most important of which was gamma globulin, which proved especially useful in treating measles, hepatitis, and polio until a vaccine was developed.⁷

By the mid-1950s these products were in such demand that for-profit blood banks were started in the United States, where donors were paid for whole blood that went to hospitals, as well as plasma sold to drug companies whose most important product was gamma globulin to treat diseases.⁸ Plasma collection also increased with the use of plasmapheresis, a new technique that routed the blood from the donor to a machine that drew off only the plasma, then sent the other blood components back into the body. Because plasma regenerated much more quickly than whole blood, plasmapheresis donation could be repeated more frequently than whole blood. By 1970 this procedure was used at the plasma centers in the US, typically located close to the most frequent donors, skid row and college campuses. In addition, there were some prison programs.⁹

The immediate causes prompting new blood policies

After 1970 there was new attention to payment for blood thanks to two publications. One was Richard Titmuss’s book The Gift relationship: From Human Blood to Social Policy, which appeared in Britain in 1970 and criticized the practice of payment for blood donation in the U.S. and the increased risk of transmitting hepatitis compared to Britain, which used voluntary donation of blood. Examples of the scrutiny in the press during the months that followed included a series of stories in the New York Times and a four-part series of articles the next year in the Chicago Tribune by a task force that included Philip Caputo.¹⁰ The opening headline was, “Lifesaver Is Potential Killer: Find Blood of Paid Donors Polluted with Hepatitis.”

It was another New York Times exposé article published January 28, 1972 that set off Zarco Hantchef and his Red Cross allies. Richard Severo’s article “Impoverished Haitians Sell Plasma for Use in the U.S.” described a large-scale operation run by Hemo-Caribbean in Port-au-Prince, Haiti. Created by a Miami businessman in collaboration with a Haitian politician, the company collected plasma (5-6,000 liters every month), froze it, and shipped it to companies in the U.S. and Europe for fractionation.¹¹ Although Hemo-Caribbean was forced to close at the end of 1973 because of the negative publicity, blood was also reported being shipped to the U.S. and Europe from several other Latin American countries, including Mexico, Belize, the Dominican Republic, Costa Rica, El Salvador, Colombia, and Nicaragua.¹²

Response of the League of Red Cross Societies and WHO

When the Severo article appeared, it was of great concern to Hantchef and the directors of the European Red Cross blood programs. There was little they could do directly to influence U.S. blood policy or practice, but over the years one of their main responsibilities was to assist blood collection for transfusion services in developing countries. This had begun in 1946 when the Board of Governors of the League of Red Cross Societies (LRCS) passed a resolution stating that the extensive transfusion experience of the Red Cross in wartime should be made available to countries “where adequate blood transfusion does not exist.” At the time, the LRCS secretariat represented sixty-five national societies, over half of which were involved in transfusion practices, some even directing their countries’ entire service.

The responsibility at the LRCS for this coordination of blood programs was initially placed under a Medico-Social Office which in 1949 hired Zarco Hantchef (1910-2002) as an assistant, who became the main coordinator and director of the league’s blood program for the next twenty-five years. Born in Bulgaria, Hantchef came to France in 1928 at age eighteen, where he received his medical degree in 1935.¹³ His medical service during the Second World War included assistance to refugees, and when he joined the LRCS he was immediately sent to crisis locations in Palestine and Lebanon. After 1949 Hantchef was also sent to represent the LRCS at crucial meetings on blood transfusion in conjunction with the International Society for Blood Transfusion (ISBT), a professional organization of transfusionists that held periodic congresses beginning in the 1930s.

During the rest of the 1950s and into the 1960s Hantchef helped develop transfusion services, especially in countries where no organized service existed. In the process, he organized the First Red Cross Seminar on Blood Transfusion, which met just before the 7th congress of the ISBT in Rome in 1958.¹⁴ Seminars were then held at subsequent ISBT congresses in Tokyo (1960) and Stockholm (1964). Hantchef also created an Ad Hoc Working Group of Blood Transfusion Experts in 1961 to meet when necessary.

Initially, the main goal of Hantchef’s program was to stress the importance of voluntary donation. By the late 1960s this was given increased urgency because of the discovery of blood contaminated with hepatitis and the isolation of Factor VIII from plasma, which was extremely useful for treating hemophiliacs and thus increased the demand for plasma to be processed by pharmaceutical companies.¹⁵ As a result, before the Severo article in 1972, Hantchef was well aware of efforts by some companies to avoid closer scrutiny and lower costs by turning to new sources of blood collected in poor countries, which were then shipped out for fractionation and sale in the worldwide medical market. In a letter to the head of the Netherlands Red Cross blood program in 1967 following a visit to Latin America, Hantchef reported finding many private blood banks and “‘vampires” who were becoming millionaires.¹⁶ Hantchef also heard that companies approached African countries to set up blood collection.¹⁷

In response to Severo’s revelations, Hantchef took advantage of the network of committees, organizations, and colleagues he had developed over twenty years. By 1973, he noted, national Red Cross organizations in 104 countries “recruited donors and promoted voluntary (i.e. unremunerated) blood donation to a greater or lesser degree.” In twenty of those countries they collected blood and maintained transfusion centers, and in sixteen of those the Red Cross “assumes the entire responsibility for the national programme.”¹⁸ Drawing on these resources and programs, Hantchef held a series of meetings, beginning with the LRCS of Health and Social Service Advisory Committee in September 1972 in Geneva, to take up the question of “trade in human blood (purchase, sale, export, import).”

Hantchef subsequently participated in at least nine major meetings with transfusion experts, health officials, and others interested in the problem. The most lasting result of this work was the resolution passed by the World Health Assembly, the governing body of the WHO, in May 1975 on the “Utilization and Supply of Human Blood and Blood Products.” It first noted “the extensive and increasing activities of private firms in trying to establish commercial blood collection and plasmapheresis projects in developing countries,” and “the higher risk of transmitting diseases when blood products have been obtained from paid rather than voluntary donors.” As a result, the resolution urged member states to develop blood services based on voluntary donation, and also “to enact effective legislation governing the operation of blood services and to take other actions necessary to protect and promote the health of blood donors and of recipients of blood and blood products.”¹⁹

Passage of the WHA resolution was immediately followed by a meeting to decide how to proceed. It was co-sponsored by the LRCS and WHO and held in Geneva in December 1975, and from the list of participants, it was obvious how extensive a coalition had been created.²² The group best represented by far on the committee of fifteen were the thirteen blood transfusion service directors, seven of whom were with Red Cross programs. But equally as noteworthy were the observers from some of the world’s largest plasma fractionation companies: Cutter, Baxter, and Alpha in the U.S, Behringwerke (Hoechst) in Marburg, and Hoffman-Laroche in Basel.²¹

Attendees presented results of their experience, such as a Finnish pilot project using plasmapheresis on voluntary donors to meet national plasma needs, as well as other trials in Bern, Baden-Wurrtemberg, and London. After lengthy discussion, all agreed these approaches should be continued, but admitted that “voluntary agencies could not provide for the full needs of the world at the present time.” Therefore, while recognizing and condemning “irresponsible commercialism,” they concluded, ” the world needs the participation of private enterprise because their products are still very much required today.”

On the contentious issue of plasmapheresis, a wide disparity was found between the amount of plasma allowed from a donor in Europe (10-15 liters per year) compared to the U.S. (50 liters). The attendees agreed on a compromise acknowledging “not more than 13-15 liters of plasma should be removed annually from healthy donors,” while no plasma should be taken from “undernourished or otherwise unhealthy donors.” Yet they also acknowledged that in the U.S. the taking of fifty liters per year “would still have to be considered a safe limit in that country,” and that lowering the limit to fifteen liters “would make it much more difficult to practice commercial plasmapheresis.”

Final recommendations included an agreement that national health authorities should have the responsibility for blood transfusion services in all countries, completely independent of any control by commercial interest. In addition, in places where it may still be necessary to enlist the cooperation of commercial firms to produce plasma fractions, priority should be given to establishing plants as part of national transfusion services or on an intercountry basis. Most important for Hantchef was that non-profit national blood transfusion services should rely upon voluntary unpaid donors, with plasmapheresis only used to cover any deficit of plasma needed for the preparation of clinically useful derivatives. The remaining recommendations were not controversial, such as sharing any surpluses collected and that national health authorities should have the responsibility for blood transfusion services in all countries.

Conclusion

The long-term impact of Hantchef ‘s work was a legacy of international collaboration between programs and blood experts. Their guiding resolution, however, was under WHO, which meant that enforcement had to rely on national laws and public pressure. As a result, voluntary transfusion donation continued to grow, but payment continued for plasma donation. At this very time, the early 1980s, the whole world abruptly became aware of a much greater threat to the blood supply: the AIDS epidemic. As disastrous and dramatic as this was, when the threat to the blood supply was recognized, the earlier international response of experts to the “vampire” trade in blood had at least established a framework and record of cooperation that helped bring swift action to screen blood supplies for HIV contamination.²²

References

1. World Health Organization, ” Twenty-eighth World Health Assembly, Geneva, 13–30 May 1975 WHA28.72 Utilization and supply of human blood and blood products,” http://www.who.int/bloodsafety/en/WHA28.72.pdf.
2. Kim Pelis, ” ‘A Band of Lunatics down Camberwell Way’: Percy Lane Oliver and Voluntary Blood Donation in Interwar Britain,” in Medicine, Madness and Social History, eds. Roberta Bivins and John V. Pickstone (Springer, 2007), pp 148-158.
3. Susan E. Lederer, “Banking on the Body: Historical Perspectives on the Sale of Flesh and Blood,” ISPS Journal 5 (2005), 67-76; Sophie Chaveau, “From Human Blood to Blood Products. Blood Collection and Blood Derived Products in France after 1950: A Third Way of Standardising Therapeutic Agents ?,” in Christian Bonah, Christophe Masutti, Anne Rasmussen and Jonathan Simon (eds.), Harmonizing Drugs. Standards in 20th-century Pharmaceutical History, (Paris: Editions Glyphe, 2009), p. 181-201.
4. William H. Schneider, “Blood Transfusion between the Wars,” Journal of the History of Medicine and Allied Sciences 58, no. 2 (April 2003), 197-99.
5. G. Alsted, “Observations on the Establishment of Blood Transfusion Services,” March 1951, archives of the International Federation of Red Cross and Red Crescent Societies, Geneva, (hereafter cited as IFRC), A0657/2.
6. Angela N. H. Creager, “’What Blood Told Dr. Cohn’: World War II, Plasma Fractionation, and the Growth of Human Blood Research,” Studies in History and Philosophy of Science Part C (1999) 30 (3):377-405; Douglas Starr, Blood: An Epic History of Medicine and Commerce (New York: Harper, 2000), 163-185.
7. J. M. Dwyer, “Thirty years of supplying the missing link. History of gamma globulin therapy for immunodeficient states,” Am J Med. 1984 Mar 30;76(3A):46-52.
8. Starr, 186-197.
9. Leon Anderson, Kit Newell, and Joseph Kilcoyne, ‘‘Selling Blood’’: Characteristics And Motivations Of Student Plasma Donors,” Sociological Spectrum: Mid-South Sociological Association, Volume 19, Issue 2, 1999, 138-9.
10. Chicago Tribune (September 12-15, 1971); New York Times (January 25, 1971 and March 3, 1972), the LA Times (January 31, 1971) and the Washington Post (March 12, 1971); Starr, 228-9; Clark C. Havighurst, “Trafficking in Human Blood: Titmuss (1970) and Products Liability,” Law and Contemporary Problems, Vol. 72, No. 3, 2009, 1-15.
11. Richard Severo, “Impoverished Haitians Sell Plasma for Use in the U.S.,” New York Times (January 28, 1972).
12. Starr, 233.
13. “Zarco Hantchef, Curriculum Vitae” (1948);  “Exposé des Tirtres et Travaux du Z. S. Hantchef,” (1952); “Note biographique,” (1966), IFRC A0650-2.
14. Hantchef Speeches and Articles, 2/3 1954-55, 1960-68, IFRC AO896/1.
15. C. K. Kasper, ” Judith Graham Pool and the discovery of cryoprecipitate,” Haemophilia (2012), 18, 833–835.
16. Hantchef to Van Loghem, February 20, 1967,  IFRC, AO911/2.
17. E.B. Schindler, “Burundi Red Cross Blood Donor Service”, p. 7, A0917 Burundi 1974
18. reported in Teheran, October 1973
19. See “http://www.who.int/bloodsafety/BTS_ResolutionsAdopted.pdf, accessed September 16, 2013.
20. “Meeting on the Utilization and Supply of Human Blood and Blood Products,” Vox Sang. (1977) 32: 367-373.
21. Piet J. Hagen, Blood: Gift or Merchandise (1982), p. 120.
22. William H. Schneider, The History of Blood Transfusion in Sub-Saharan Africa (Athens, OH: Ohio University Press, 2013), 153-72

Acknowledgement

The author would like to acknowledge the helpful consultation of Juhani Leikola and the extensive assistance of Grant Mitchell at the archives of the International Federation of Red Cross and Red Crescent Societies.