by Rose George
Cold War Americans thought blood type so important that they tattooed it onto adults and children. It would come in handy after the bomb dropped, when one physician predicted a city the size of Chicago would require nearly a million pints of donated blood.27 In northern Indiana, wrote the historian Susan E. Lederer, using “a Burgess Vibratool instrument with thirty to fifty needles and an antiseptic ink, technicians tattooed the blood type and Rh factor on the chest of some 1,000 residents at the county fair.”28 Operation Tat-Type went on to tattoo children at five elementary schools, before the program was dropped because doctors didn’t trust tattoos to be a fail-safe indication of blood type.29 An editorial writer in Logan, Utah, reminisced about these “smudgy reminders” that can still be seen on middle-aged natives, though not read.30
The idea that blood is more than biology is not new. Nor is it resolved: blood is classified differently in different countries and even in the same country by different authorities. The UK exempts it from the Human Tissue Act, although it is a tissue, having cells. The United States thinks it a “biologic.” The World Health Organization (WHO) added blood to its list of essential medicines (which even poor countries are advised to stock) only in 2013. In a lab in a London hospital, a man in a white coat moves away from his microscope and lets me see. It is nothing exciting for him, but it is the first time I have seen blood cells. The blood has been stained to be visible on the slide, so I can see clearly: the red cells, those biconcave discs, dumbbells and doughnuts. So vivid, though in a human body some are always dying and being replaced. I am my sixth version of myself, if most of my cells are replaced every seven years,31 but I’m on my 143rd round of red blood cells, which live for about 115 days.32 There is a popular philosophical question about identity and self, named Theseus’s ship or Theseus’s paradox: If all the planks were replaced in his vessel, was it still his ship? If I have replaced many of the cells I was born with, and none of the red blood I had at Christmas, am I still me?
When men first started to move blood between one body and another, they thought that they transmitted spirit with it. Transfundere, to pour from one vessel into another. A Mister Acton, writing in 1668 after the early transfusionists had published experiments, thought one experiment “most remarkable” because it was the “Transfusion of the Blood of a Mangie dog into a Sound one, to try whether the mange would be communicated with the blood.” The Mangie dog was cured; “and the other who had received his blood, not become Mangie.”33 As blood was thought to cure spirit, not sickness, it was taken from suitable animals. Calves, lambs, mild and quiet creatures, were thought to transmit their sweet spirit to the frenzied and the troubled.
We can laugh at this, but we will be laughed at in turn. Our knowledge of blood is wide and unfinished.
* * *
Find yourself a blue coat first. There are plenty in the cupboard that look grubby but smell clean. Then sit on the bench provided and put your hair in a bonnet, something like a shower cap, and wrap your shoes in plastic. Follow the instructions above the basin and wash your hands thoroughly. No, more thoroughly. That’s enough: they relaxed the restrictions a few years ago so you no longer have to wrap your beard or wear a snood. The pressure chamber now: this arrangement will be familiar to anyone who has been to a bank or traveled on a submarine. You step in and wait for one door to close before the other can be opened. The higher pressure of the air beyond keeps dust and bugs out. Now you have passed from the gray zone to the white zone. Now you are safe to walk onto the processing floor of the largest blood facility in Europe.
Today’s bleed is 2706. Every day except Sunday, beginning just after lunch, one thousand gallons of blood arrive here from a several-hundred-mile radius, from many generous arms and veins. Filton is a small town in southwest England but also the name of this £60 million ($84.4 million) facility run by NHSBT, which processes a third of the blood donated in England and Wales. Getting here took months of asking. Nor I am allowed to identify or quote anyone. This is frustrating when the people I meet there are human and colorful beneath their white coats and plastic bonnets: along a corridor near the café there are photographs of staff in their leisure hours, and there is a diver, a knitter, a canicross competitor, and a newt collector. That’s just one wall. But I understand why the NHSBT guards itself so tightly: the nation’s blood is a vital and sensitive resource, and you wouldn’t want just anyone coming to visit. Between the blood leaving me and entering someone else—a process known as “vein to vein”—an awful lot is done to it.
Blood arrives by vehicle and in bags. The plastic bag that I saw my blood running into is packed along with nine others into a blue cooler like a picnic bag. In the same bag are samples, three from each donation. All is put on a conveyor, and the donations go one way and the samples another. Testing is done at the same time as processing. All donations are tested, but Colindale, one of the three processing sites, doesn’t have testing faculties, so Filton gets theirs too. Four thousand tests a day. Blood groups, obviously: ABO but also rhesus factor. Then, syphilis, HIV, hepatitis B, C, and E. First-time donors are also tested for human lymphotropic virus, which can cause leukemia. Particular donors, depending on where they have traveled or what they have done to their body with sharp implements—tattoos trigger a four-month deferral—can be tested for malaria, Trypanosoma cruzi (which causes Chagas’ disease), West Nile virus, or cytomegalovirus. Anyone who has traveled to somewhere with Zika is currently deferred for twenty-eight days. For now. Tests can change. New infections come; others die away. Zika has been known about since the 1970s, but it wasn’t expected to cause trouble. White blood cells are removed from all donations—a process called leukodepletion—because it is in white cells that many infections travel, including the prions that cause variant Creutzfeldt-Jakob disease (vCJD), a vile and violent affliction that anyone growing up in the 1980s will visualize as piles of burning cattle and skeletal humans who fall when they walk because their brains are degenerating.
Safe. A blood system that is safe. Governments repeat this as if it can be true, not aspirational. But safety is a relative concept. Blood is a biological product and can never be safe because we can’t plan for the next Zika or Ebola or HIV, until it comes.34
The processing space at Filton is vast, with a simple color scheme. The blue-coated staff and the red of the blood. There it is, hundreds of bags, hanging from hooks on what is called an overhead filtration device but what resembles a giant chicken rotisserie. It looks like a vampire’s feast, and though the blood is safely contained in its bags, the color shouts through the sterility and bonnets and lab coats: this is not an inert material. Vivid, from the Latin. To live, to be living. Leukodepletion is being done by drip and filter: as the rows of bags rotate, the larger white blood cells are filtered out and the rest collects in the bottom of the bag.
Then anything can happen. Depending on need and logistics, a donation can become several useful products. Filton produces red blood cells, fresh frozen plasma (used for burn victims and to replace lost blood volume), platelets (used for clotting and by cancer patients), cryoprecipitate (also used to aid clotting), and leukodepleted whole blood, used for infants. Everything is organized and logged on a computer system, which obviously is called Pulse.
When Filton was being designed, NHSBT consulted the car industry. It was going to be an industrial process, and they wanted to have the most efficient production lines, like any industry. Like cars. The processing room was initially divided into three long lines, like a car production line. But it didn’t work. This complicated business requires supervision, and supervisors were having to walk too far. Now the floor is set up in pods: small areas organized by a one-way flow system. A donation of leukodepleted whole blood comes in, it is processed by smart machines and dizzying technology, and it leaves at the other end of the pod as something else. If something goes wrong in a pod, a maximum of 96 units has to be quarantined, not the whole flow. All donations are centrifuged with considerable force, to se
parate plasma from the rest. Staff remember a hole in a bag—a manufacturing fault—and the power of the centrifuge throwing blood around the pod, with vigor. The humans got out of the way and off lightly: they changed their lab coats and got back to work.
The rest of the processing involves clever machinery and lots of tube connectors running between blood and bags. There is pressing and freezing and filtration and separation. It is technical and complicated and I must be starting to look the way I feel, because my guide asks kindly if he has fried my brain yet. It’s not his fault. He does his best to translate. At various points I encounter equipment described as a giant condom or a snow globe. I am warned about “lumps and clumps.” I’m invited to look for platelets in a processed bag and advised to spot “swirls,” like a sprat in an ocean shoal of fish, seen from a plane. I see the sprats—I wouldn’t from a plane, unless they were the size of a ship—and they are pretty. By the end of all this, I know that platelets look nothing like sprats, that if any donation is out of its allotted temperature for half an hour, it must be thrown away, and that anyone who complains that a unit of standard red blood cells costs £124.46 ($177.64) has no idea what a bargain they are getting. That is the price no matter what the blood group. Filton also processes blood groups so rare, they are kept frozen for ten years in an NHSBT facility in Liverpool. Plasma is cheaper, at only £28.75 ($40.39) a unit. Other products are costlier: some cryoprecipitate is £1,113.45 ($1,564.08) a unit.
In 2012, Filton flooded. Luckily, it was a Monday. No donations are taken on a Sunday, so nothing was being processed. A Friday night would have been awful. Other good times would have been during the Olympics, major football matches or sporting events, national holidays, Christmas, summer holidays, and Easter: these all badly affect blood donor numbers. The flooding could have been disastrous: all processed red blood cells must be kept in fridges at 39.2 degrees Fahrenheit until the test samples have cleared and they can be released from quarantine. Plasma is frozen from fresh—and called fresh frozen plasma—and kept that way until it is used.
That is, male plasma. Away from the pods and the processing, my guide shows me some cages. They are filled with bags of plasma that should be yellow but isn’t always. My plasma, probably, is green. I’m female and menopausal and taking hormone replacement therapy, and all those factors—along with the contraceptive pill—turn women’s plasma green. Off and odd-looking. They don’t know why, and it doesn’t really matter, as all female plasma is discarded anyway, since NHSBT introduced a policy of “male donor preference” in 2003. So many female donors take hormones of one sort or another, it’s not worth all the screening, not when NHSBT has enough plasma without it.
There are other conditions as well as being female that can turn plasma into a discard. My guide searches through the bags before he finds one with triumph. This is a nice one. I peer at it. Look, he says. Fat. I see globs of fat floating among the golden plasma. Staff are required to inform a donor if his or her blood is alarmingly fatty, even when the bag’s appearance may just be the result of a fat-laden pre-donation meal. Obesity threatens life like HIV does. Perhaps now HIV is treatable, fat is worse. None of the NHSBT videos about Filton mention the discards. I don’t mind if I become medical waste: the rest of my blood is useful. Discards used to be incinerated, but that was expensive as well as unsettlingly Old Testament. Burned blood. Now it gets “alternative treatment,” which my guide thinks is a form of fancy landfill.
The blood products that survive discard can be processed in twenty-four hours. By six p.m. each day, donations set off for their destinations. Filton serves ninety hospitals with regular deliveries but sometimes the hospitals need irregular ones. In that event blood can go by taxi, a bag on a front seat like a passenger. At even odder hours, a fleet of volunteer bikers might deliver blood. I find a captivating Pathé film from 1967 about a Volunteer Emergency Service, which involved young motorcyclists zooming around London transporting blood as a charitable enterprise. This was probably to do with Father Bill Shergold, known to his flock as Farv, and an East End priest who thought bikers—generally despised and feared by the public—could be modern knights, upholding ideals of courage, courtesy, and chivalry. When Farv was seventy, and retired, he was approached by Wrangler to star in its advertising. Shergold asked his rector if that was acceptable, and the rector replied, “Of course you must do it. Good for the Church to be seen doing ordinary, rather silly things.” Ordinary and rather silly, too, was the idea of doctors at Plymouth Hospital in the 1970s that blood samples could be delivered by carrier pigeon. The idea and the pigeons did not take off.35
I can’t discover what happened to the Volunteer Emergency Service, but blood bikers are thriving and vital. The Nationwide Association of Blood Bikes and its regional chapters deliver thousands of blood bags a year, for nothing. They also deliver breast milk, spinal fluid, surgical instruments, and fecal matter for fecal transplants. Their slogan is “Saving Lives and Money,” and, as their publicist writes on the Blood Bikes site, “despite many of us being middle aged and a bit flabby,” they are doing more and more deliveries and getting more recognition. As this is Britain, the recognition often consists of “free hot drinks in certain cafes [and] nods and waves from police and paramedics.”
Normally, blood that has been bled—Filton uses more corporeal terminology than the donor center, with its donations and gifts—arrives all day from one p.m. until eleven p.m. The quickest turnaround is blood that can be issued by one p.m. the next day. Donations from first-time donors take longer: they have to go through the testing twice, for extra safety. For this reason, blood bankers like two types of donors: young ones and ones that come back. They always sound desperate for both. A nation-state needs 1 to 3 percent of its population to give blood to maintain an adequate blood supply,36 the higher the better. The UK needs two hundred thousand new donors every year. This should be blood from voluntary non-remunerated donations because this is the type of blood supply that the WHO thinks is safest. People who aren’t paid for blood don’t generally lie about their health. But of 172 countries surveyed by the WHO, 80 reported that only 1 percent of the population was donating. That’s not enough. In Africa, the WHO judges that most countries in the region do not have enough donors for a safe or adequate blood supply.
Seventy-one countries get more than half of their blood from “family replacement” systems (where patients are encouraged to provide blood given by relatives) or paid blood sellers. I have grown up in a country with one of the best and safest blood supplies in the world. I have been spoiled. The scientific wizardry of Filton; the efficient blood donation and delivery system. That is not how much of the world gets its blood.
* * *
It is easy to wander the corridors of Delhi’s major hospitals, unmolested by staff or security. The corridors of Safdarjung Hospital, one of the city’s largest, are usually full and noisy, and even my obviously foreign face provokes no interest. People have their own troubles.
In law, India’s blood supply is rigorously monitored and a voluntary system. This fiction is as flimsy as paper. Countries that can find enough donors or sellers to meet their blood requirements are in a minority. In fact, India relies heavily on a family replacement system. Patients who require blood must supply blood from a relative or friend. Upstairs, at the hospital blood donor center, I meet a young man who is donating blood for his pregnant wife. It is his first time donating, and he says he’s not nervous, but when the needle goes in he bares his teeth. With this suffering, he will get a blood credit of one unit for his wife to use if need be. This is how the United States’ blood supply began and why we talk of blood banks. Bernard Fantus, then director of therapeutics at Chicago’s Cook County Hospital, invented the concept of blood banking. Blood storage was already being done by then, but it was Fantus who thought up debt and repayment of blood, who saw blood as a product to be transacted, not a gift. He was straightforward about this, saying in 1937 that “just as one cannot draw money fr
om a bank unless one has deposited some, so the blood preservation department cannot supply blood unless as much comes in as goes out.”37
Fantus’s reach continues today. The US system, a network of 786 blood collection centers ranging from a large Red Cross facility to a one-room community blood bank down the street, still operates according to principles familiar to bankers. Blood that Americans think they are giving for the good of their local community may then in fact be traded all over the country. There is even a spot market or clearinghouse, where purchasers requiring urgent blood resupply are obliged to take less popular blood types as part of the transaction. Your order of O negative comes with a side order of unwanted AB. Worldwide, money and blood mix more often than not.38
In India, family replacement, a benign phrase for a transaction, is impossible for migrants, the alone, the ones without networks. So other networks step in. I meet a man who tells me he has a WhatsApp group with his friends. They are all fans of a particular Tamil film star, and on that basis they have decided to give one another blood. There are now Facebook and WhatsApp groups trying to match blood givers and receivers. In the waiting area of the blood donation center at Safdarjung, I find a group of people who have formed an informal blood camp simply because they are friends, and kind.
