Author: Douglas Starr

Publisher: Alfred A. Knopf

@1998

Price: $ 27.50

Northwestern. I lost track of him after that, but I

heard many years later that Bill had died of AIDS,

acquired as the result of a transfusion with infected

blood products. I have always wanted to discover

how such a terrible end could come to such a coura-

geous and wonderful fellow. In the back of my mind

was the vague intention of spending a sabbatical, or

some retirement years, researching that story.

I've been scooped by Douglas starr. In Blood:

An Epic History of Medicine and Commerce, starr

has managed to capture the history, the personali-

ties, the corporate greed and corruption, the

exploitation of the poor and the sick, and the

incredible public health threat of the blood prod-

ucts industry. I now understand how and why Bill

died, and the story makes my blood boil! starr jus-

tifies his historical approach by observing that the

story of blood cannot be limited to the 2Oth centu-

ry, when doctors began to use it for transfusions.

The narrative reaches back into antiquity, as an

undercurrent to the history of medicine and civiliza-

B ill Pruitt was a fellow student in my

undergraduate days at Austin College.

He was the son of Presbyterian mis-

sionaries and he suffered from hemo-

philia. He bore the indignities and restrictions of his

disease with dignity and good humor. When our fra-

ternity pledge class was blindfolded at night and dri-ven several miles into the farmland outside of

Sherman, Bill rode along, as anxious and excited as

the rest of us. We all got out, the blindfolds came

off, and we began to plan our strategy for finding

the way back to campus. The upperclassmen got

back into their cars and drove off, with Bill blind-

folded alongside them. Although he couldn't walk

that distance without risking a major bleed in his

knees, he wanted to share in the uncertainty and

worry that we felt, to maintain solidarity as the

pledge class went through hazing to help mature

our sense of cooperation and self reliance.

After graduation many of us went our separate

ways, I to graduate school at Indiana, Bill to

ISSUE 19, 2000 SCIENCE SPECTRA 75

t\

tion. It spans the globe over the course of several Antoine Mauroy, on the theory that the calf's mildcenturies, periodically surfacing in dramatic ways, disposition would transfer to the madman along \

from the first blood experiments during the Age of with the transfused blood. Despite a near-fatal ~

Enlightenment to the genetic-engineering labs that episode of shock, the madness subsided, giving

one day may render transfusion obsolete. credence to the view that blood was one of the ele- 1

Starr traces this history through three epochs: mental humors that govern the body. Starr's use of )

one covering the period from antiquity to the 20th this example is ironic, as he uses the instance of 1

century, during which our conception of blood Creutzfeldt-Jacob Disease (CJD) to illustrate the 1

moved from the magical to the biological and ther- ongoing danger of transfusion and fractionating

apeutic; a second covering the transformation of plasma. Despite the fact that no transfusion-related

blood from a scientific challenge to a strategic cases of CJD have been identified, Britain has

resource of war and surgery, during which blood, stopped using domestic plasma for pharmaceutical

like oil, came to be reduced to its components production. The rigors of the earliest transfusions

through a process of fractionating plasma; and a are graphically illustrated by Starr, who describes

third, post-World War II period, when blood direct transfusion in which a surgeon would con-

became the basis of a global industry that often nect the circulatory systems of donor and recipient

preyed on the poor and ill of many countries. The to avoid clotting. Not only was sodium citrate not

means that were devised for processing blood available until early 1915, but transfusions often

products contaminated virtually the entire world killed patients since Karl landsteiner didn't discov-

supply, first with hepatitis B, then hepatitis C, then er the basic facts of blood types until 1900, and it

Human Immunodeficiency Virus and other blood- was many years before his work became widely

borne pathogens. It ignited battles in courts and known and generally accepted. In the interim, doc-

Congress over the very ontological status of blood, tors continued to kill their patients with the gamble

whether it is an organ or tissue that is transplanted that blood types would be compatible.or a pharmaceutical that is administered. New technologies for transfusion emerged in

Starr has the reporter's skill of enlivening the 1916; they, along with sodium citrate's ability to pre-

facts of a historical account with vivid sketches of vent clotting, set the stage for the emergence of

people and their personalities. He also has the aes- blood banks and storage of a reliable supply. Part

thetician's knack of identifying the symbolic charac- Two, "Blood Wars: begins with the story of how, in

ter of blood as a once-sacred substance and the 1921, Percy lane Oliver created a list of donors

cultural echoes of that symbolism, bringing them throughout london who could be called in on the

interpretatively into the blood wars between the occasion of emergency surgery. Donors were

non-profit and commercial industries over whether recruited by appealing to non-remunerated volun-

blood should be donated or purchased, provided teers to provide a service to humanity. In France,

at cost or for profit. Finally, he has the dogged per- this voluntary spirit was bolstered by triple-testing

sistence of an investigator, digging away at often for blood type and quarterly health examinations,

deeply concealed facts, lending the entire book the administered by Dr. Arnault Tzanck's Emergency

sense that he personally witnessed, researched, Blood Transfusion Society.sifted and interviewed the events, facts and per- The practice of paying donors a fee began in

sonalities he reports. America. Commodification quickly produced a spi-

The actual research for the book spanned five ral of supply and demand, and paid donation

years, involved travel to nine countries, and entailed became even more common during the depression.

conducting hundreds of interviews and gathering Donor bureaus began recruiting among indigentthousands of documents. Starr details many of the populations, in which syphilis and other diseases

more directly applicable resources in a 53-page set were common. This theme of volunteer versus paid

of notes. The result is a paradox: a highly readable, donors is woven throughout the book as clashing

sometimes gripping, densely packed, 435-page his- values became blurred in organizations that contin-

tory of an essential human substance and its com- ued to give lip-service to volunteerism and as these

plex role in worldwide culture spanning 4,500 years. organizations emerged as dynamic forces in a grow-

Part One, "Blood Magic: explores in three ing international trade in blood and blood products.

chapters the earliest experimentation in transfu- Blood became vital as a strategic resource in

sion. The first transfusion that Starr reports was in 2Oth century wars. Soldiers who were injured in bat-

1667 in France, where Dr. Jean-Baptiste Denis tie could, with the use of transfusion, be returned

transfused the blood of a calf into a madman, to fight much more quickly than those who lan-

76 S c I E N c E S p E CT RA ISSUE 19, 2000

The callous, deliberate ignoring of early warn-

ings of contamination of the range of blood products

by the HIV virus is the most astonishing disclosure in

Starr's book. Even when it' became undeniably evi-

dent that heat-treating Factor VIII killed off

pathogens, corporations, often with the approval of

public health officials, rationalized distributing the

remainder of their contaminated supplies before

making heat-treated ones available. About 20,000

Americans contracted HIV through blood and its

derivatives; these included more than 8,000 hemo-

philiacs and 12,000 blood recipients. In France and

Japan, while the hemophiliac population was known

to be infected, physicians maintained their loyalties

to the blood-processing pharmaceutical houses by

not telling their seroconverted patients of their HIV

positive status; many of these individuals unwittingly

infected their wives, who bore HIV-positive children.

In the chapter that discusses the attempts,

through class-action and individual lawsuits, to gain

compensation for HIV-infected hemophiliacs and

their families in the U.S., Starr highlights the emo-

tional reality of this massive tragedy. At a rally of the

National Hemophilia Foundation in 1993, there was

a demonstration by mothers who had trustingly

injected their sons with Factor VIII and thereby given

them AIDS, who with tears streaming chanted,

"They killed our sons! They killed our sons! They

killed our sons!" As I read this, my tears flowed for

Bill Pruitt and his family, and in my head echoed,

"You killed my friend!" Starr's book has brought this

stark fact home to me and allowed me to grieve my

loss. Starr's Epilogue, "Blood in a Post-AIDS

Society," provides some reassurances. "...[T]he

blood is safer now than it has ever been, even

before AIDS." (p. 345) "The statistics regarding

transmission rates of AIDS, hepatitis B and hepatitis

C indicate a reasonably safe supply, at least for the

time being." (Ibid.) He reviews the treatments to

which plasma concentrates are subjected, and notes

the changes in France, Britain, Japan and the United

States in governmental supervision and enforce-

ment. He notes that 22 countries (but not the United

States!) have established funds to compensate

infected hemophiliacs, and infection rates in newly

born hemophiliacs are virtually nil. There are

prospects for synthesized hemoglobin and other

blood products that may replace blood transfusion

eventually. Yet, hepatitis C lurks as another eventual

disaster whose transfusion-related toll may eventu-

ally exceed that of AIDS. Eternal vigilance of the

blood industry, together with a realistic understand-

ing of the residue of risk in the most controlled uses

of blood, will remain our legacy.

guished without transfusions. Massive efforts, orga-

nized by Canadian surgeon Norman Bethune, were

undertaken during the Spanish Civil War to collect

blood from donors, process and chill it, and deliver

it throughout the 56 hospitals in Madrid. In 1939,

Janet Vaughan, a young pathologist, organized a

series of blood depots throughout London in

preparation for war with Germany. In America, a

program was launched in 1940 to collect and ship

plasma to Britain. The program's medical director,

Dr. Charles Drew, was the first African-American to

earn an M.D. at Columbia. Drew used a program of

strict quality control to deal with the tendency of

plasma to become bacterially contaminated. Starr

dispels the myth that Drew's death after a car acci-

dent resulted from the hospital emergency room

doctors' refusal to give him "white" blood.

During World War II, Dr. Edwin J. Cohn devel-

oped a method for separating blood into compo-

nents: red and white cells, fibrinogen (useful in clot-

ting, especially for treating hemophiliacs), globulins

(antibiotics), other immune agents, and albumin.

Thus, a single pint of blood could be made to treat

several different patients. Cohn also was able to

freeze-dry plasma, thus augmenting Drew's quality

control by permitting it to be shipped and later

reconstituted. Cohn transformed blood from a tis-

sue into a series of pharmaceutical products. Starr

highlights this transformation in the conflicts

between various blood organizations seeking to

establish or break monopolies over the collection

and distribution of blood and its products, and in

Federal Trade Commission hearings in which ques-

tions of restriction of trade were raised about the

effort of community blood banks to discourage for-

profit blood centers. Blood was becoming a prod-

uct, an article of commerce with the potential of

carrying an implied warranty.

Part Three, "Blood Money," is the longest,

telling several interweaving stories of pioneers in the

"wildcat" days of blood's commercialization.

International corporations sprang up, buying blood

from donors in third-world countries, deriving the

various factors from it, and distributing it in Europe,

the United States and Japan. Factor VIII, a clotting

factor that was used in treating hemophiliacs,

became so lucrative that pharmaceutical houses had

an ever-increasing need for blood that created this

exploitative international trade. The practice of

pooling sera from as many as 100,000 donors in

order to make the fractionating process efficient,

combined with the careless acceptance of blood

from unscreened paid donors, set the stage for a

worldwide outbreak of AIDS in hemophiliacs.

ISSUE 19, 2000 S c I E N C E S p E C T R A 77