Book Review

Blood: An epic history of medicine and commerce

N Engl J Med 1999; 340:973-974March 25, 1999

Article

Blood: An epic history of medicine and commerce
By Douglas Starr. 441 pp. New York, Alfred A. Knopf, 1998. $27.50. ISBN: 0-679-41875-X

On February 9, 1999, Laurent Fabius, former Prime Minister of France; Georgina Dufoix, minister of social affairs under Fabius; and her subordinate, Edmond Hervé, stood before a tribunal in the Court of Justice of the Republic, where they were charged with manslaughter and criminal negligence. These former high officials of the French government were accused of delaying the introduction of a simple test, available from an American company, that enabled blood banks to detect human immunodeficiency virus (HIV) infection in blood donors. That delay, the prosecutors claim, was meant to give French scientists time to perfect their own test for HIV, which could then compete with the American test. Dufoix and Hervé were also accused of allowing the clinical use of unheated plasma, even though they knew that a process discovered by one of their own countrymen — pasteurization — destroyed HIV. Curiously, before her trial, Dufoix made the bizarre confession that she was “guilty but not responsible.”

This was not the first such trial in France. In 1992, four high-ranking officials of the French transfusion system had been convicted of similar charges in a courtroom ringing with shouts of “assassins!” directed at the defendants, three of whom were given prison terms. According to a recent article in The New York Times (Feb. 10, 1999, p. A11), about 4400 people in France were infected with HIV as a result of transfusion of infected blood during the 1980s, and about 1800 of them have died. Called as a witness before the tribunal, Agnès Cochin, the mother of a boy who died after receiving infected blood, angrily asked the defendants, “Have you no shame, Sirs, Madame?”

The shame for delaying the implementation of simple measures that could have prevented thousands of HIV infections and deaths from AIDS will haunt not just the French bureaucrats but many others. In his excellent book, Blood, Douglas Starr tells of similar delays in virtually all industrialized countries. From Japan to Switzerland, blood transfusions spread HIV to thousands of persons because of incompetence, greed, bribery, denial, and conflict of interest. In Japan, Green Cross, a company dealing in plasma and plasma products, was secretly selling unheated plasma as late as 1987, and as Starr notes, “In Switzerland, an unsurpassed complacency held sway.” In Britain, the director of the National Haemophilia Society scoffed, “whatever happened in America won't happen here. After all, we don't have gay bathhouses.” Here in America, the same deadly sins enchained the knowledge that could have made transfusions safe, while ignorance unleashed fear. William F. Buckley, the right-wing commentator, proposed not only universal testing for HIV but also the tattooing of all persons with positive tests. Others of Buckley's persuasion demanded prison sentences for the infected.

According to Starr, when it became clear in the United States that treatment of hemophilia with plasma carried a risk of transmitting HIV, Hyland, a division of Baxter Laboratories, started to dump lots of factor VIII concentrates they considered unsafe, yet the National Hemophilia Foundation minimized the problem and continued to urge the liberal use of factor VIII concentrates for the treatment of hemophilia. A prominent hematologist reassured the hemophilia community by announcing, “My position is business as usual. . . . There is no evidence that treatment per se is the cause of AIDS.” The policy of Cutter Laboratories was to clear the pipeline of unscreened inventory through normal sales without separating plasma screened for HIV from unscreened lots. Meanwhile, in Kokomo, Indiana, Ryan White, a 14-year-old boy with hemophilia who was infected with HIV, was denied admission to school, as were three HIV-positive brothers with hemophilia in Florida. These tragedies, and thousands more (in Japan, 1800 persons with hemophilia were infected in just two years), are the heart of Blood, a book that will teach readers not just about transfusion but also about human folly.

Starr begins his book by recounting the early history of transfusion: the attempts to transfuse animal blood; the arm-to-arm transfusions required because there was no known way of preventing collected blood from clotting; the discovery of the anticoagulant properties of sodium citrate by Lewisohn; the organization of blood banks, spurred by war — first the Great War, then World War II; the life-saving use of plasma in shock; and the fractionation of plasma into albumin and other constituents by Cohn and his associates. The stories of these remarkable events are worth reading, if for no other reason than the tendency we all have to accept medical miracles without any knowledge of how they evolved, who was responsible for them, and how they became woven into the fabric of modern medical practice. Without transfusions, medicine and surgery as we know it would not exist.

Starr's main theme is blood as a commodity, hence his book's subtitle, An Epic History of Medicine and Commerce. He has little to say about other aspects of transfusion medicine. Starr does not adequately explain why animal blood is unsuitable for transfusion into humans. He skims over the exceptionally interesting history of the discovery of blood groups (an excellent source is Species and Specificity: An Interpretation of the History of Immunology, by Pauline M.H. Mazumdar. New York: Cambridge University Press, 1995), and what little he does say about immunohematology is flawed. Levine and Weiner cannot be credited with showing that injection of Rh antibodies into an Rh-negative woman immediately after the birth of her first Rh-positive child prevents erythroblastosis fetalis in subsequent pregnancies, and the enormous contribution of Coombs is not mentioned. But these are mere quibbles, especially because the immunologic and genetic aspects of blood transfusion are only sidelights in Starr's book.

The main story Starr tells, and tells well, is the development of blood and plasma as commodities: the international trade in plasma from paid donors, whether from Haight-Ashbury in San Francisco, Port-au-Prince in Haiti (where one of the owners of Hemo Caribbean was the minister of the interior and of national defense), Lesotho in southern Africa, or Managua, the capital of Nicaragua, where the Nicaraguan dictator, Anastasio Somoza, collaborated in an infamous plasmapheresis operation. According to Starr, the assassination of Pedro Joaquín Chamorro Cardenal, editor of La Prensa, for relentlessly exposing the sordid plasmaféresis business in Managua was the beginning of the end of the Somoza regime. There is no doubt that sleazy operations like these promoted the worldwide spread of HIV and the hepatitis B and C viruses. A notable example is the case of Edwin O. Reischauer, American ambassador to Japan in the 1960s. After an attempt on his life by an assassin, Reischauer underwent surgery and received purchased blood. Some weeks later, all the signs of hepatitis developed in the ambassador. The mortified Japanese, who revered Reischauer, outlawed the sale of whole blood but, strangely, not plasma.

When it was at last evident that commercial suppliers of plasma and plasma fractions could be sued, an avalanche of litigation began. But so many of the physicians who cared for patients with hemophilia had financial arrangements with the suppliers that expert witnesses for the plaintiffs were hard to find. As Starr puts it, “these doctors were testifying for the drug companies and against their own patients.”

Starr tells a fascinating story. Blood is a story of human frailty and courage, a book from which any reader could learn. It is highly recommended.

Robert S. Schwartz, M.D.