Nine Pints

by Rose George

  The brain is aerobic and fueled by blood like every other part of us, and this fact may be why humans conquered the planet. A recent study of skulls throughout evolution concluded that brains have increased in size by 350 percent, but the volume of blood passing into the brain has increased by 600 percent. You can judge this from the holes in your head. The brain gets blood from carotid arteries, whose different sections—including cavernous, ophthalmic, and communicating—can be remembered with a helpful mnemonic of Please Let Children Consume Our Candy. The skull researchers noticed that the holes that the carotid arteries pass through increased in size too, to enable more blood to be delivered. “We believe,” said project leader Professor Emeritus Roger Seymour, “this is possibly related to the brain’s need to satisfy increasingly energetic connections between nerve cells that allowed the evolution of complex thinking and learning.”25 Intelligence is as bloodthirsty as everything else.

  Is GDF11 the elixir of youth? Is the fountain of youth actually red and consisting of nine to twelve pints? Subsequent studies found that too much GDF11 caused damage not growth, impediment not immortality.26 The debate is dynamic enough that the most common trait of scientists working in this field should be caution. Jesse Karmazin is different. He needs to be: although he claims he wanted to set up a trial in the usual way, funded by investors, he couldn’t find funding. “You can’t patent this, using young blood for aging. If you can’t patent something, that scares off investors.” Instead, he set up two clinics, employed two doctors to administer transfusions, and charged clients $8,000 to participate. In return, they had one hundred biomarkers in their blood analyzed before and after, and they were given plasma from a donor aged under thirty-five. A hundred people signed up. The results, says Karmazin, were so staggering, he cut short the trial. What results? “I have to preface this by saying that this has not yet been peer reviewed.” Some patients report feeling younger. One of his patients, who had Alzheimer’s, has now been assessed by a neurology team and can live independently again. “They no longer have Alzheimer’s.”

  Sorry, are you saying the treatment eradicated dementia?

  “Oh yes. This is the part where it breaks apart and you think, it can’t be true.”

  But he continues. Two liters of plasma can cure cancer, heart disease, and diabetes. My skeptical alarm is sounding, and it gets louder when Karmazin says these results were found after only one infusion. Ambrosia has had plenty of criticism: a true scientific trial cannot be a cash cow. There is no control group (Karmazin says taking blood biomarkers before and after treatment means his cohort acts as its own control group). There are things to be concerned about, not least the grandiose claims. He wouldn’t dare make them, he says, on TV or in print. “With the FDA, there’s a very long process we have to go through to be able to say things like that and that happens. I can tell you because this is for a book.” Still, Karmazin plans to publish his research, but in a “mid-tier journal.”

  For now, it is safest to say that the field of blood rejuvenation is in flux, an appropriate word meaning a discharge of blood. And I salute the mice and rats who continue to be stitched together, although now they are shaved not soap-chipped, and joined at knee and elbow not torso, and they are female usually, as female mice are less likely to chew each other’s heads off. Thank you, mice, for perhaps enabling us to live a bit longer to experiment on more mice.

  I know this sounds churlish. My dismay is directed at the vanity, at the rumors of the insultingly rich, people such as PayPal billionaire Peter Thiel, perhaps paying to have themselves injected with young blood or plasma. Though I do admire a satirical show named Silicon Valley that portrayed a mogul who employed a Blood Boy for regular rejuvenating transfusions. On The Late Show, wrote Tad Friend in a New Yorker exploration of the longevity industry, Stephen Colbert told young people that President Trump was going to replace Obamacare with mandatory parabiosis. “He’s going to stick a straw in you like a Capri Sun.”27 I would prefer an antiaging emphasis that is not about extension but betterment, that can alleviate Alzheimer’s, Parkinson’s, and the other diseases that have stepped into our longer life spans to end them. I have seen how someone dies of dementia, and if that can be cured with blood, fetch me a straw.

  * * *

  The trouble started on the gurney. As she lay there prepped and ready for surgery, Hazel Jenkins was as nervous as any patient before a significant operation, but not unduly. She had been diagnosed with bowel cancer the year before and had an operation to cut out her bowel. Then the cancer had spread to her stomach and duodenum, so they had to be removed. There was no question of her refusing consent: she had faith that modern medicine could cure her. But she had a handicap. She was a Jehovah’s Witness. This millenarian Christian sect with nine million members worldwide believes there will be a Second Coming, that birthdays are pagan and wrongful, and that they should never accept whole blood. This decision is based on a few Bible passages. Don’t consume blood, it is written in Deuteronomy, because blood is life. “You must not eat the life along with the meat.” The book of the Acts of the Apostles forbids food offered to idols, blood and the meat from strangled animals. Leviticus is the most severe: anyone who eats blood will bring severe opposition from God, and “must be cut off from their people.”28

  To me, all this reads as divine instructions for vegetarianism. But after the Second World War, after transfusion had been accepted as a powerful medical good, the church elders interpreted “eating” as “transfusion” and they judged it sinful.

  “It’s the life blood,” Hazel tells me in a quiet hotel lounge in Leeds, where she has come after getting her latest scan at a nearby hospital. It should not be squandered. Witnesses are often confused with Christian Scientists (who consider medicine quackery), but actually they accept most that modern medicine can give them, with gratitude. “We believe in a loving God who wants us to live.” But they will not have blood. Hazel’s husband, Bob, is on the other side of the table: he accompanied her to the scan, and he also has cancer. They are both very Yorkshire, by which I mean plain speaking, no flummery. When Hazel describes how her bowel cancer was discovered, she says she got to the emergency department and had her temperature taken “to see if I was about to peg out or whether we could wait the four hours [to be seen by a doctor].” She and Bob became Witnesses in the 1960s. They researched the scriptures and at the same time read up on blood scripturally and medically. “Well, it’s a core belief.” They wanted to understand it properly.

  Although they have five children and four grandchildren and though blood transfusions are often given in childbirth, the Jenkinses had no cause to test their belief until recently. First, Bob was diagnosed with myeloma, a cancer of certain white blood cells. Severe cases are often treated with a stem cell transplant, whereby the bone marrow is killed off, new stem cells are injected, and, if all goes to plan, new and undamaged blood cells begin to reproduce within weeks. Although the removed and replanted stem cells are hematopoietic—they produce blood—Witnesses will accept stem cell transfusions. But the weeks of having reduced immunity are perilous, and blood transfusions would normally be given. A patient with leukemia, a cancer of white blood cells that can also be treated with bone marrow transplants, might receive 30 units a year. In fact, although transfusions may be associated with severe bleeding and trauma, this is not their main use in the developed world. A recent report on red cell use in the UK found that only a quarter of transfusions were used in surgery. Most red cells were used for nonsurgical purposes such as hematology or oncology.29 In developing countries, the typical recipient of a blood transfusion is an accident victim or woman in childbirth. Here, the typical recipient is an elderly person with a chronic disease. Someone like Bob, if he weren’t a Witness.

  The trouble on the gurney arose because science has raced ahead of biblical prohibitions. Richard Carter, a Witness, serves on the Hospital Liaison Committee, which acts as an information resource for Jehovah’s Witnesses and clinician
s. He speaks in measured tones and in a fluent medicalese learned from twenty-seven years of committee work and attending many meetings with hematologists and blood specialists. These hospital liaison committees began to be formed in the 1990s, after many years of trouble. For decades, Jehovah’s Witnesses were a severe problem for medicine and medics. How could they have surgery without blood? How could anyone have surgery without blood? It was believed to be unassailable as a force for clinical good. Yet the widespread adoption of blood as medicine after the Second World War had not been accompanied by any of the rigorous clinical trials that new drugs or therapeutics usually undergo. Countless transfused and resuscitated soldiers were judged evidence enough. “Before,” says Dr. Dana Devine, editor of the blood journal Vox Sanguinis, “it was, any kind of blood is good for you. We topped it up like you top up oil in your car. Now we’re understanding better how to do effective transfusion.” Even by 1956 some blood specialists were wondering whether such liberal blood use was wise or safe. Dr. Theodore Zeltin, director of the South London Blood Transfusion Centre, wrote an editorial in the Manchester Guardian that warned of the “over-free use of blood transfusions.” Transfusion had become so common “that nowadays in some hospitals pints of blood are dispensed more liberally than pints of beer.”30 Blood was so trusted, remembers Dr. Harvey Klein, chief of the Department of Transfusion Medicine at the National Institutes of Health, people were given a dose as a tonic. Half a liter of vim and zing.

  Yet here were these strange religious people who were emphatic about not wanting blood but did not want to die because of it. They did die. Often, there were court cases, particularly when children were involved. There were angry clinicians, who must have found it hard to stomach such obstinacy when their job was to preserve life. Witnesses’ views, wrote the BBC, “can spark immense upset, [and be] blamed for unnecessary deaths, as can their demands for special bloodless treatment, which can be both costly and ineffective.”31 They still die: just before Christmas 2016 in Canada, Éloise Dupuis, a young Witness, died of hemorrhagic shock after a cesarean section, having refused blood ten times. Her aunt accused members of the local hospital liaison committee, who were present in the hospital room, of putting her under duress, but a coroner found she had made her choice freely.32 Several prominent doctors wondered publicly whether autonomy and patient choice had gone too far.33

  For Richard Carter, committees like his are nothing more sinister than a resource, set up to link Witnesses—he has thirteen thousand in his catchment area—and the medical profession. They are meant to inform each about the other. There is no pressure exerted (though plenty of former Jehovah’s Witnesses write copious blog posts suggesting otherwise). Carter is keen to inform me too, and does so thoroughly and carefully.

  He gives me a copy of the medical directive that Witnesses carry around. It is simply a paper form that includes a cutout card that reads NO BLOOD next to an image of a blood bag crossed out. Witnesses carry these in their wallets or handbags, and it usually works, though not always. In an emergency, urgency can supersede going through a wallet. And emergency staff, says Carter, don’t like to go through handbags. Maybe a bracelet would be better? Maybe. They’re thinking of an app or digital alert.

  The rest of the form is for details. A section lists what is forbidden. These are the “big fractions”: red blood cells, white blood cells, plasma, and platelets. Below that, Carter says, “it is up to your conscience.” Things are more fluid. Witnesses can make their minds up about whether they accept autologous blood transfusions, where their own blood is removed and re-transfused; cell salvage, where red blood cells are removed during an operation, filtered, and re-transfused; glues and sealants; recombinant erythropoietin (EPO), which can raise the level of oxygen in the blood to counter any possible anemia; and many other possibilities. They are happy to give blood samples, although studies have shown that patients in intensive care, for example, can be asked for 40 ml of blood a day. Some doctors call this “ICU vampirism” and wonder at the wisdom of taking all the blood from patients who are probably anemic and testing blood so often to see if someone needs a transfusion that they need a transfusion.34

  These three Witnesses seem like kind and polite people, and we are having a nice cup of tea together, but I have to inquire about the lack of logic. Why refuse blood but not sizeable fractions of blood? Why refuse platelets—which are only 1 percent of blood—but accept albumin? Why reject blood but give it away for samples to be consumed in a pathology lab? Why stem cell transplants? You draw your line, says Hazel. She resorts to Noah to explain. “In the scriptures after the flood, Noah was given permission to start eating the animals. Of course they had to be bled. But when you buy your steak from the butcher’s, there is a residue. If you ran it under the tap there would be a minute amount of blood. I don’t think it’s possible to remove every tiny amount. So it’s a similar sort of thing, that’s what it makes me think of.” I think the essence of this is that you choose your limits. Some Witnesses won’t accept even a “taint,” she says. Some have, in extremis, accepted blood transfusions. Until 2000, when the church changed its policy, this transgression would mean Witnesses were “disfellowshipped” and expelled from their congregations.35 In the all-encompassing culture of a cult, this meant losing friends, family, and church, all at once. Hazel answers carefully when I ask her what would happen now if anyone accepted blood. “It would be an indicator of whether you were actually a Witness. If you’re going to pick and choose which laws you obey, you’re not really a practicing Witness.” You disqualify yourself by default.

  Witnesses who have had accidents and been in a critical state have been given blood. That, says Carter, is forgivable. Sometimes the card isn’t looked for. There is no family present to alert medics. It happens. Hazel carries her card and her form. She knew about fractions, and unlike with her urgent bowel surgery, this operation had been planned for and discussed. The chief surgeon had operated on her the first time, and on many other Witnesses. He was, says Hazel, “relaxed.” But the anesthetist was the one who would administer drugs and products, and here was the anesthetist, who had not been present in the presurgical discussions, asking her if she consented to a blood fraction she had never heard of. Hazel was stumped. Bob had already left to get breakfast in the cafeteria and couldn’t help. She said to the medical staff, I trust you, and she had reason: she was being cared for in a hospital that had performed a pioneering liver transplant without blood.

  But the anesthetist needed her express consent. So there she was, horizontal and phoning Bob, then Carter. It was all a bit frantic. “My wife will tell you,” says Carter, “that if the phone rings early on a Monday morning, it’s an anesthetist who’s got somebody already scrubbed up and waiting.” Hazel asked her questions. Did they think she could have it? Was it allowed? Was it a small fraction or a big one? In the end, the surgeon came out of the operating theater to ask what the holdup was, and said, “Oh, then we’ll just use something else,” and that was that. Like she said, relaxed. “They obviously have so much in the armory.”

  This armory grew fastest after HIV infected the blood supply. Suddenly blood could be tainted and poisonous. Suddenly there was more scrutiny and there were more questions. At the same time, the concept of patient choice was beginning to percolate into paternalistic medicine. “We probably fit right into that,” says Carter. “If you went back before that, you didn’t ask a surgeon what he was going to do. Now things are very different.” Questions began to be asked about blood in all sorts of ways. How much, what type, and, although it clearly did good, whether it also did bad. The Canadian doctor Paul Hébert caused a stir with a 1999 study of 823 critically ill patients. Critical care transfusions were given according to the transfusion trigger, a precise hemoglobin level in a patient’s blood. When there is too little hemoglobin, the blood struggles to deliver enough oxygen to where it needs to go, and the patient is considered to be unsafely anemic. Since after the war, the trigger was 10 grams of
hemoglobin per deciliter. Hébert’s study split the patients into two groups. One set was transfused according to the regular trigger. This was the liberal transfusion group. The others were given restrictive transfusion: blood wasn’t given until their hemoglobin had dropped to 7 grams per deciliter. The shocking result found that outcomes were no different in either group.36 Patients younger than fifty-five actually did better on the restrictive regime. A big study called Transfusion Requirements in Critical Care (TRICC) backed this up.

  The trigger dropped to 7 grams, although many doctors think any one-size-fits-all trigger is too restricting. And other innovations began, stimulated by this extraordinary new thought: What if blood wasn’t an unquestioned good? What if there were alternatives? If they were going to use less blood or cut it out altogether, then they needed to prevent patients from bleeding. Early on, autologous blood transfusions were used. Blood could be removed from a patient before surgery, then reinfused into them if needed. These weren’t popular with Witnesses, who thought storage was the same as pouring blood out on the ground. Once blood is mixed with a storage medium, says Carter, who says that their stance is spiritual, not clinical, but seems to prefer medical definitions over spiritual, then it is unacceptable. Also, perhaps you don’t want to remove blood from an ill patient who is already at risk of anemia, even if you’re going to put it back.

  Carter hands me a booklet produced by the Royal College of Surgeons, meant as a guide for clinicians faced with people who refuse blood. It lists many possibilities.37 Preoperatively: treating someone with EPO for several weeks can increase red cell blood production in the bone marrow sevenfold. More blood means more can be safely spilled. It also means muscles get more oxygen and effort is easier. That’s why EPO will be forever associated with professional sporting cheats, and why if Witnesses weren’t very sick patients awaiting treatment they could probably win marathons. Apart from their obvious surgical handicap, Witnesses are actually good patients. “We’re quite a good clinical risk,” says Carter. “We don’t smoke. We’ve got good lungs, we can cope with low [blood] counts. We drink in moderation. We’re not perfect but the nature of the Witness, being principled and disciplined is part of our culture. We’ll take the drugs you give us, we’ll take your dietary advice.”