Pint for Pint

Thomas Laqueur

  • Blood: An Epic History of Medicine and Commerce by Douglas Starr
    Little, Brown, 429 pp, £20.00, February 1999, ISBN 0 316 91146 1

Aids – or, more specifically, the lawsuits, criminal prosecutions and political recriminations that followed the transfusion of whole blood or blood products wittingly or unwittingly tainted with HIV – has renewed our interest in the sanguinary, and Douglas Starr has now set this interest in context. He describes his book as ‘the story of blood – the chronicle of a resource, the researchers who have studied it, the businessmen who have traded it, the doctors who have prescribed it, and the lay people whose lives it has so dramatically affected’. The ‘scandals that killed thousands of haemophiliacs and recipients of transfusions’ form the story’s dénouement. The moral, according to Starr, is that the safe use of this ‘precious, mysterious and hazardous material’ depends on a successful resolution of two sets of questions.

The first seems to be formulated by Richard Titmuss in The Gift Relationship: From Human Blood to Social Policy. Titmuss draws a distinction between Britain, where all fresh blood donation was voluntary, a gift to the community and hence an expression of concern with the general good; and the United States, where a high proportion of blood was procured from paid donors – a commodity and hence emblematic of an excessively individualistic culture. So is blood, ‘this most human of commodities’, ‘a gift of charity or simply a pharmaceutical’? And if it’s both, ‘what are the safest and most ethical ways to manage it’? It is not clear from what Starr writes how an answer to the first question will help to resolve the second. (There are no ambiguities in Titmuss.) Sometimes he seems to be suggesting that the commercialisation of blood, its being something to be bought like oil or golf-clubs, leads to a callous disregard of both donors and recipients – Japan is the case in point here. At others he appears to be saying that the more blood becomes an item of commerce, the greater the likelihood of its being safely processed: the collecting agency can make more stringent demands on those whom it pays. Tort liability maintains a certain standard of care.

The gift v. commodity question seems to map – I’m not clear how – onto a distinction between the ‘mythic and moral symbolism’ of blood, on the one hand, and what Max Weber might have called ‘disenchanted blood’, on the other. Some of the time Starr seems to think that the more disenchanted blood is, the more it is purged of its cultural baggage, the better. To take one example, ‘mythic and moral symbolism’ clouded ‘professional judgments and public perceptions of the Aids scandals’ and made officials, ‘faced with the necessity of refusing blood from certain people’ – homosexuals, prisoners – in order ‘to minimise the spread of disease’, unwilling to do so for fear of offending their ‘cherished donors’. On the other hand, it was disenchantment which led to the monumentally exploitative blood market of the Seventies and to the depredations of the drug companies in the Eighties as they dumped their outdated, unsafe blood products on unsuspecting consumers – Starr is rightly indignant about this.

Starr’s is a tightly circumscribed history, but perhaps it had to be. There are more than five hundred separate subheadings under blood in the University of California Library Catalogue and the word finds its way into 10,250 quotations in the OED, where two full pages map out its literal and figurative linguistic field even before we get to its adjectival and compound forms: blooded, blood-guilty, blood money, bloodshed, bloodhound, life blood etc. And then, on the shelves of my office, sit Blood Magic – an anthropological study of menstruation, which reminds us that there exists a quite other and relatively new blood market, that sells products which absorb, hide and dispose of a substance whose freight of meaning generally interests us only in other tribes; Bad Blood, the term the United States Public Health Service appropriated to represent syphilis to the largely illiterate black men who were about to become the unwitting subjects of medical observation in the notorious Tuskegee experiment; Paul Goodman’s Of One Blood (the phrase is from Acts 17.26), about the abolitionist response to St Paul’s pronouncement that the whole human race has a common origin; Barbara Ehrenreich’s Blood Rites, about the origins of warfare – and more.

And this is to say nothing of the medical and more general biological history of blood that does not directly affect its life as a product. Blood had moved from ‘the magical to the biological’ long before it became recognised in the early 20th century as ‘a therapeutic liquid transferable from one creature to another’. Lamery discovered in the late 17th century that it contained iron, the first episode in a long story of blood chemistry; Hewson’s An Inquiry into the Properties of the Blood in the late 18th century established among other things its coagulative properties; the absorption and release of oxygen and carbon dioxide in respiration was firmly established early the next century.

The field is vast but Starr focuses on that strand of blood’s history which winds most directly to the beginnings, in 1982, of the Aids crisis. His Part I, ‘Blood Magic’, thus takes the story quickly from magic and mystery to the early 20th-century achievements of Karl Landsteiner, who identified the ABO blood groups; Richard Lewisohn, who discovered that sodium citrate would keep blood from coagulating; and Alexis Carrel, whose brilliant suturing of a father’s artery to the tiny, delicate vein of his infant daughter’s leg saved her life. Together, these pioneers laid the foundations for the widespread use of whole blood and for much else besides. Blood groups, for example, were almost immediately used for forensic purposes – for sorting out mixed-up babies in hospitals, or bloodstains on the clothes of an accused murderer.

The second part of the book, ‘Blood Wars’, begins with the early days of transfusion, when it was done ‘on the hoof’ – i.e. when donors were hooked up to recipients as needed – because there was no institutional structure for storing blood. It goes on through the founding, in the Twenties, of transfusion centres and of the world’s first centre for transfusion research by Alexander Bogdanov in the Soviet Union, which inspired a Chicago doctor to establish the first ‘blood bank’ in the US in 1937, and ends with the remarkable mobilisation of blood resources, largely by the US and its allies, during World War Two. Bogdanov’s story is remarkable. He got into blood only when Lenin got the better of him in the pre-Revolutionary rivalry between the two men. A committed collectivist he pooled his own blood regularly with that of his students – shades of the end of Stoker’s Dracula – and apparently felt revitalised by each exchange. On the 12th such occasion, however, he developed an incompatibility reaction and died, though not before carefully narrating his own death. His colleague Serge Yudin, meanwhile, began large-scale experiments with blood from corpses, draining healthy accident victims for the use of the living. (Shades here of the post-colonial African belief that fire-engines were driven by vampires.) All this was part of a much larger project which imagined that, at the dawn of the new Communist era, the body and medical science generally could be remade to fit them for socialism. People were injecting all manner of hormones to stop ageing and extend life; a Stalinist endocrinology went side by side with Stalinist blood-collecting.

War was the mother of invention for blood as for so much else, and the heroes of ‘Blood Wars’ are the men and women who figured out how to collect, store, process and ship blood or its derivatives to the battlefronts of Europe and the Pacific. One of them, Janet Vaughan, a British doctor (in later life Principal of Somerville College, Oxford), warned blood banks to prepare for injury on a massive scale and gave her name to the modified milk bottle in which donated blood was stored. Another, Charles Drew, Columbia’s first African American medical graduate, built the infrastructure for plasma collection in the US for shipment to the various theatres of war. At a time when black blood was acceptable only when specifically labelled pint by pint, and was excluded altogether from plasma pools because there segregation was impossible, Drew developed procedures which made it possible to get the product from the arm of a donor into a can and out again without contamination. Established procedures – doing things carefully, methodically, predictably – would become the heart of a safe system of blood use and exchange in the postwar world.

Drew died in his prime at a North Carolina hospital after a car accident and it is a sign of the state of American race relations that the story – untrue, it turns out – of how he was refused what might have been life-saving Caucasian blood, persists today. In fact, not since the 18th century has anyone argued that blackness resides somehow in the blood; the American Red Cross acknowledged that ‘black blood’ was indistinguishable from any other sort but in deference to Southern sensibilities continued up into the Seventies to identify it in its blood banks, on grounds – it argued – of consumer choice. Louisiana and Alabama passed blood segregation laws in the late Fifties: I wonder how they were justified in a public forum.

The major advance in Part 2 of Starr’s book is the ‘fractionation’ of blood. The hero this time – and a looming presence for the rest of the book – is Edwin Cohn, a brilliant, obsessive Harvard protein chemist, who worked out how plasma, much more stable than whole blood, could be freeze-dried and reconstituted on the battlefield; albumin – so-called Fraction V – could be shipped to front-line operating theatres in tiny vials, dissolved in saline, and dripped into the wounded to restore blood volume and prevent shock. Eventually, other researchers trained by Cohn learnt how to further process his Fraction I so as to yield the clotting factors which, after the war, would improve and extend the lives of haemophiliacs. Gamma globulin, the antibody-bearing protein in blood, was isolated from donors who had had certain diseases – hepatitis, for example, or polio before the vaccine – and sold to those who needed protection. The world blood industry was built on Cohn’s insights and energy.

The postwar story follows two, occasionally intersecting tracks, one technical, the other institutional. The technical track concerns the ways this remarkable product is extracted. Plastic bags replace bottles and make possible a closed system, from collection to use; silicone is used to coat surfaces and prevent cell damage; resins replace citrate to keep blood from clotting; new techniques of plasmapheresis increase the efficiency of production to undreamt of levels: one pint went 600 per cent further by the Fifties than it had a decade earlier. Freezing blood allows relatively easy extraction of clotting factors.

All this technology subsists in a variety of social contexts. Between the Twenties and the end of World War Two each country got the ‘level of allegory’ it deserved: blood as an expression of the collective in the Soviet Union; as a ‘covenant between the people and their cause’ in Spain during the Civil War; as the sign of racial purity for the Nazis. And, more dubiously, for the Americans, a ‘typically practical symbology – not the lofty social contract of the French, but a pride in their competence to develop and use a resource’. My sense is that there was considerably more mix-and-match than Starr allows. There were differences between national traditions, and these differences suggest deeper differences in attitudes to the individual, society and the state. But the symbolism of blood and the politics of its use were much more complex than the one nation/one blood allegory. By the Sixties, no country, whatever the system, was an island.

Even though France and Britain were self-sufficient in whole blood and committed to voluntary, unpaid donation, both countries bought blood products in an international market dominated by multinational, mostly US-based companies. Whole blood was banked and credits were traded within countries, more like wheat futures than real wheat. And while free blood, freely given, might have been the ideal, not enough was available to meet a growing world demand for plasma and various fractions – particularly Factor VIII, which haemophiliacs came to use in ever greater amounts. How much they took depended less on the disease than on national medical traditions and, on occasion, on kickback schemes. The Germans believed in giving clotting factor regularly, not just when there was a danger of a bleed, but some of the money that flowed from the welfare state to the drug companies made its way back into the pockets of haemophilia clinic doctors. Blood, in short, became part of an elaborate, global biofiscal infrastructure with a life – many lives – of its own.

Part 3, ‘Blood Money’, charts the history of this economy. There were of course national variations within the global market. In Japan, collections were a huge failure: there was no tradition of giving blood, blood represented family and was not to be shared. (Japan also has the lowest rate of organ donation in the industrial world; more than blood is at stake in a culture with so highly elaborated a sense of corporeal integrity.) Ryoichi Naito, who had been involved in the notorious wartime programme of human experimentation, was able, one way or another, to gain the confidence of the American authorities and, later, the Japanese, eventually setting up a private corporation (with the help of the Kobe Bank) which paid for poor people’s plasma and exported it raw. The company eventually became a huge multinational – Green Cross – and by 1980 Japan was importing 98 per cent of its blood products. Starr does not make clear where Japan got its fresh blood from once a growing economy offered the poor other sources of income and after the sale of blood was outlawed – Edwin Reischauer, the American Ambassador, had contracted hepatitis from the free-market transfusion that saved his life after an assassination attempt. But there’s no question that blood and blood products were – like so much in Japan – imbricated in a tight nexus of state, bureaucracy and big business.

In France, by contrast, giving blood became almost a national duty. ‘Days of Blood’ joined members of a community together, prisoners gave regularly to expiate their sins and to maintain their links to society. But the state managed the system. Blood distribution was organised from the centre: from the minister of health through various sub-ministers to the regional directors, who supervised collection and distribution of whole blood. Paris took care of producing and distributing blood products.

There were two critical developments in the United States. First, blood banks were organised into two loose configurations. The American Red Cross, run by laymen, maintained a voluntary donor system and held that each community was responsible for its own blood supply, while the American Association of Blood Banks, run by physicians, argued for individual responsibility, so that every recipient of a transfusion had to find a replacement for the blood received, pint for pint. Both organisations eschewed paid donation and the squabbles between them were largely to do with territoriality and personal jealousy. There was sporadic government regulation, but no one was in charge of fresh blood supplies. On the other hand – and Starr ignores this point – even physician-managed local blood banks depended on community support. For better or for worse, the Irwin Memorial Blood Bank in San Francisco, flagship of the AABB and at the very centre of the tainted blood controversy once Aids became an issue, was part of civil society.

The second critical aspect of the US story is that its pharmaceutical industry became the world leader, buying ever greater quantities of plasma from the poor and converting it into ever greater quantities of blood products. (Extracting plasma takes very much longer than taking whole blood, so that people are less likely to do it for free – and giving blood that is destined to be a raw material is psychologically less attractive than giving it to save a life more directly.) By the late Seventies, US drug companies owned one-third of all collection centres, and national plasma chains owned the rest. There were also wild-cat operations. Dorothy Garber in Florida earned tens of thousands of dollars from selling her rare antibody-rich blood; Austin Stough, an Oklahoma physician, injected volunteers with antigens and then harvested the antibodies; a former used-car salesman, Francis H. Bass and his wife – a mail-order-credentialled nurse – all but cornered the blood market in Kansas City. Efforts to regulate the Basses led finally to Federal court rulings that blood was not a commodity, so that doctors and the Red Cross, which also opposed the Basses, were not violating anti-trust laws when they tried to keep them out of the booze-for-blood business. In fact state legislatures were already working on changing the legal status of blood from a product to a service. Manufacturers have to be in a position to know whether there are impurities in their products – a successful suit by someone who discovered a snail in his soda is the founding case of strict product liability law, but how could you know whether there was a virus in the blood you sold before tests were available to detect it? Legislatures held, rightly, that strict liability be abandoned and that purveyors of blood, like providers of services, should only be required to exercise certain standards of care.

This was the state of things when, in January 1982, Dr Bruce Evatt of the Centers for Disease Control and Prevention (CDC) in Atlanta learned of a case of Aids in a 62-year-old, white, married haemophiliac. Aids had only just been recognised as some sort of, as yet mysterious, immune deficiency syndrome and until this case it seemed to have infected exclusively sexually promiscuous gays and Haitians. Six months later, there were two more cases in haemophiliacs. In May 1983, a heterosexual woman got Aids from a transfusion of whole blood whose donor turned out to be a gay man (although not one who was ‘homosexually active with numerous contacts’) who later developed Aids.

As I said earlier, Starr suggests that, as Aids developed, the way in which various countries, and agencies within countries, responded to these discoveries and the many subsequent cases depended on an auspicious resolution of the blood as gift v. blood as commodity question, while also claiming that, in specific instances, the judgment of decision-makers was clouded by ‘the mythic and moral symbolism of blood’ – and that the French and Japanese scandals were somehow the result of a national belief in pure blood. I do not think this is the case, however. In the first place, Starr gets the cultural history of blood wrong. More important, political and organisational cultures – differences in civil society, in how bureaucracy functions and how responsibility is assigned, in how error is perceived and made known, in how advocacy groups work and what they had come to expect from government, industry or the medical profession, not to speak of what was, or could have been known, at any given stage – determined how the various actors responded to the sudden advent of a novel, terrifying and, at first, deeply mysterious collapse of the human immune system.

‘Disenchantment’ is not the issue here. We care about the story of blood so much more than about other stories of commercial malpractice or scandal because blood, like food, has been, right from the start so relentlessly material, so present in the Western tradition, and not primarily either mythic or symbolic. At the same time, it is peculiarly freighted with meaning. People died in battle or at the stake for the proposition that the wine and bread of the eucharistic feast were really, and not symbolically, the blood and flesh of Christ. How the transformation happens is a mystery –‘magic’ in Starr’s terms – but its concreteness is not in question. When William Cowper wrote, in support of the anti-slavery sugar boycott of the late 18th century, ‘No nostrum, planters say, is half so good/To make fine sugar, as a Negro’s blood,’ he was being materially specific. The blood of enslaved blacks becomes, literally, part of the sugar.

Despite Starr’s claims, there was nothing ‘spiritual’ about the Galenic theory of blood and blood-letting. Certainly it was not based on the view that blood ‘flowing from the liver to the heart and brain ... acquired a trinity of spiritual characteristics from the combination of organs through which it passed’. Nor did the early Christians ‘dogmatically’ support the spiritual implications of the theory. ‘Spiritual’ would be an anachronistic term in any case, but the important point is that although Galenic medicine was wrong about the role of blood and the therapeutic efficacy of blood-letting, its position was thoroughly naturalistic. A patient was bled so as to be rid of something universally regarded as real and of this world.

Belief in its therapeutic powers did not depend on blood’s supposedly magic or symbolic qualities but on its real life-giving force. When, in the 1750s, the people of Paris rioted because Louis XV’s henchmen were supposedly kidnapping children in order to cure his morally corrupt, and hence leprous, body by bathing it in the children’s blood, they weren’t driven into the streets by rumours of black magic, but by outrage that the people were being secretly bled for the King’s benefit. It is this hyper-material quality which makes the rapacious capitalism of blood procurement in Nicaragua – a story Starr tells well – so scandalous. In the early Seventies the Somoza dictatorship was translating the blood of Nicaraguans into money – body into commodity – with breathtaking literalness.

This is not to say that blood is, or ever was, purely natural, or purely material, in the sense of ‘devoid of meaning’. Few objects of any kind are without meaning – that’s the point of consumer culture – and fewer still among those intimately connected to the body and its primal needs. Food once seemed too sacred, too important to the body politic, to be traded in a free market – Adam Smith argued against this position in his famous addendum on the grain trade. Today soy, grain and pork belly futures seem to be facts of nature. Four decades before I was born one could still buy people in the state where I grew up; labour, alienated from bodies, had long been for sale. Now we can’t buy bodies but we can discuss whether we should be allowed to pay for surrogate child-bearing. (Are we buying babies or the surrogate’s body in violation of the prohibition against slavery; or are we simply paying for a surrogate’s labour?) We can sell renewable parts of our bodies – semen, eggs – but, in the United States, not non-renewable ones, even if we have a spare. No one thinks that selling the parts of executed prisoners – as China did – is acceptable; though there are some who would argue for allowing people to sell one of their kidneys. Where components of blood are concerned, the only question now is who owns what: the California Supreme Court recently held that a cell line grown from a rare cancer removed from a patient at a University of California hospital belonged to the system, not to its former owner.

The figurative meanings of blood are intimately tied to its material specificity, however. The notion of ‘blue blood’ or ‘sangre azul’, as a synonym for ‘aristocratic’, is not symbolic although it may be emblematic; it refers to the supposed visibility of blood in the veins of high-born, white-skinned Spaniards with no trace of Moorish blood; hence, perhaps, the prominent blue blood-vessels in Sánchez Coello’s portraits of Philip II’s family.

These metonymic transfers of meaning persist well into the supposed age of blood as pure biology. There is nothing mystical or symbolic about Starr’s story of a Jewish doctor imprisoned in Nazi Germany for giving his own blood to save an Aryan patient, and there is something insanely literal about the so-called ‘one drop rule’ – whereby a tiny quantity of black blood was enough to make you a ‘Negro’. As recently as 1970, the Louisiana legislature held that no public official of the state shall designate anyone as ‘coloured, African American, Negro, mestizo’ and so on who had ‘one 32nd or less of Negro blood’. With mathematical precision race could thus be read in blood known for 150 years to be the same for all races. It was not the symbolic or mythic blood which seemed to some whites so powerfully polluting, but blood as it came from the veins, or after it was centrifuged. Blood remains emblematic even now but only in quite peripheral areas does that determine public policy. De Gaulle refused to allow red blood cells to be exported to the US. He also brought French blood with him to Britain when he visited Harold Macmillan.

When Aids struck, national conceptions of the meaning of blood or blood donation played a small but scarcely decisive part in determining how widely and quickly the virus would spread. The French, for example, were resistant to stopping the collection of whole blood from prisons despite evidence that inmates’ blood was much more likely to be tainted than blood collected elsewhere. This pales in significance, however, beside the fact that the French Health Ministry delayed for five months approval of the ELISA sero-conversion test which revealed the presence of the HIV antibody, if not of the virus itself, and thus made real screening possible for the first time. (In fact, dangerous blood could still sneak through if the test took place after a donor had become infected but before the antibody was produced.) Why? When Abbott Laboratories, the US pharmaceuticals firm which developed the test, applied to the French Government for a licence in February 1985 the Minister of Health ordered the relevant officials to stall so that a French test that was being developed could be approved instead. National economic self-interest? Yes. National attitudes to blood? Hardly. Canada took six months to license the American test because of various snafus and Britain dilly-dallied from March to November in order to give the business to Burroughs-Wellcome rather than Abbott. (Why the British Government also approved Organon, a Dutch firm, when they had denied Abbott’s application six months earlier is unclear.)

Nothing can excuse these delays, but even taking them into account, it is remarkable how quickly even the most foot-dragging of European countries adopted the test, and how soon after the discovery of HIV it was developed. On 23 April 1984 Robert Gallo announced that he had found the viral agent that caused Aids: by March 1985 a test was in place. It’s worth pointing out once again that the delays had nothing to do with the cultural meaning of blood and everything to do with pushes and pulls on licensing agencies.

Two other steps might have been taken to prevent the spread of Aids through transfusions: excluding homosexuals from the blood pool, and using surrogate tests before the ELISA test became available – i.e. using hints found in the blood instead of the sexual orientation of the donor to make an educated guess at its safety. For example, testing for Hepatitis B antibodies earlier, and on a larger scale, would have saved some lives. This disease and Aids were known to follow similar patterns of transmission so that someone who had been exposed to hepatitis and developed antibodies against it was, presumably, more likely to develop Aids than someone who had not. Unfortunately, this is much clearer now than it was at the time. Nowhere does error look more nakedly wrong than in science; no intuition or argument is more dazzling than the spurned hypothesis proven right. The CDC was gloriously right in calling for what, at the time, seemed precipitate action; but from the blood bank’s point of view the most dangerous pint might be the one that was not on the shelf. When the Aids and transfusion story finally got out, a sizable minority of Americans believed one could actually get Aids from giving blood. Furthermore, the CDC had been wrong, only months before the Aids crisis, in calling for a national swine flu vaccination programme which had killed more people than it helped. There was also what looked like contradictory evidence. Studies showed that lots of people besides those with Aids had Hepatitis B antibodies – Chinatown in San Francisco had a much higher incidence than the Castro, where the gay community, and Aids, were concentrated. Fifteen per cent of the general population had anti-Hepatitis B antibodies, which meant that millions of people would be falsely labelled as potential carriers of Aids.

Only in retrospect does the case become medically clear, and the social dimensions of the problem are still worth debating. As I write, the Food and Drug Administration, reacting to the mad cow scare, has prohibited blood donation by anyone who has spent, cumulatively, more than six months in Britain since 1980, despite the fact that no one is known to have contracted CJD as a result of a transfusion. I don’t mind this a lot, although I used to give blood regularly, but if I thought that having spent time in the UK meant that I had more than an infinitesimally small chance of going spongy in the brain I would be extremely upset.

Which leaves the question of excluding gays from the blood pool. Starr writes as if this were both easy and transparently desirable. Again, in retrospect, it is clear that the spread of Aids through blood transfusions would have been much slower than it was had it been possible to exclude all blood from all gay men. But some things need to be kept in mind. First, Aids struck within less than a generation of Jewish blood being excluded from the German blood supply, and black blood from the American. Gays had been stigmatised and prosecuted in this and other countries for time out of mind. In the absence of any positive evidence that it was sexual orientation which somehow caused Aids – an idea beloved of the Right in America – excluding gays, whether of their own volition or by grilling them, was not on. In small towns they would have lied; in San Francisco, Paris and other places where there were organised gay communities, the idea was repugnant.

Nor was it clear before 1984 what the connection was between being gay and Aids. Haitians also had a high rate of infection and only later did it turn out that they got the disease, not from voodoo practices, but from selling sex to American homosexual tourists. They did not identify themselves as gay. In the early Eighties it seemed that Aids wasn’t the result of being homosexual but of something else: of having too many sex partners; or of drug use, thought to be associated with certain sorts of gay sex. This made the transmission of the disease by monogamous gays living quiet lives difficult to explain.

The Irwin Blood Bank in San Francisco, which Starr criticises for its slowness in this as in other matters, in fact contacted Physicians for Human Rights, a gay human rights group, almost immediately after a baby caught Aids from a transfusion late in 1982: before the CDC called its first national meeting on the subject in January 1983, and before the case was reported in the scientific literature. It seemed as if a healthy homosexual carried something which caused immune deficiency via the blood. Irwin worked with Physicians for Human Rights to screen out those homosexuals who had had multiple sexual partners; it was suggested at the time that the sheer antigen load that promiscuity entailed might be what caused the immune system to collapse. But screening for this group was not so easy: what counts as many partners, over what period of time? And as questionnaires were refined, new questions arose: if a man was monogamous how about his partner? How could the blood bank get at his history? It is difficult to see how exactly a decent society could have responded better to the crisis of 1982-83.

The question of blood products, and especially of Factor VIII, which keeps haemophiliacs alive, is somewhat different. In the first place, no country with the exception of Belgium came out well from the crisis of the early Eighties and Belgium’s haemophiliacs survived because they were a small community in a small country which could produce enough clotting factor from local blood by the relatively safe technique of cryoprecipitation. Everywhere else in the world, from 40 to 70 per cent of haemophiliacs sero-converted. Even the most sympathetic doctors felt themselves in a quandary. ‘One of the most difficult years I have ever spent,’ said Shelby Dietrich, an experienced physician who had an extensive haemophiliac practice, of 1983. She recommended that her patients not change their regime; she was wrong. But it isn’t clear that there was much they could have done instead. Cryoprecipitation, an alternative way of fractionating blood to derive Factor VIII, was expensive, in short supply, and not certainly safe either. Advising haemophiliacs to stop taking their life-sustaining medicine for fear of Aids might have doomed them to an ugly and more immediate death or, at the very least, to debilitating pain.

Remarkably, by March 1983, months after it became known that Aids was borne in the blood, the Baxter pharmaceutical firm patented a heat treatment for Factor VIII. It was not clear at first, however, whether this worked or whether indeed the treatment might not lessen the effectiveness of the product and make it dangerous in some other way. There had been no clinical trials. Nevertheless, by early 1984 every US manufacturer had adopted the method, even though organised haemophilia groups did not wholeheartedly support them. This was not, as Starr suggests, because they were in bed with the drug companies, who provided some, though by no means a majority, of their funds, but because that generation had been the first haemophiliacs in history to lead normal lives. Raised in a world of plentiful clotting factor they did not want to risk going back to the bad old days.

The so-called Aids ‘scandals’ were the consequence of the actions various national authorities took – or did not take – once it became clear, in late 1984, that heating blood products did kill the pathogen that caused Aids without apparently affecting the product’s potency. There was horrible negligence – or worse – in almost every instance and yet there is no general explanation why so much tainted Factor VIII was delivered to haemophiliacs. The behaviour of drug companies was alternately responsible and mendacious. Cutter Laboratories, for example, withdrew vast amounts of impure Factor VIII – 2 to 3 per cent of the nation’s supply – when it learned that one man who had died of Aids had contributed to its plasma pool. On the other hand, Cutter and other companies dumped unheated product in countries which did not insist on having the good stuff.

The sheer inertia of social systems played its part. Delays in providing new British blood-processing plants probably had more to do with the sort of screw-ups that held up the British Library for twenty years than with the politics or ideology of blood – and meanwhile, American companies with their safe products made a fortune in the UK. Japan simply denied the existence of Aids for several years after the first cases appeared and prohibited the importation of heat-treated, safe Factor VIII for haemophiliacs longer than any other industrialised nation. Drug companies had no choice but to sell the Japanese untreated products. This failure had nothing to do with the fact that Japan opted early on for an entirely commercial system of blood distribution. Before Aids its government, bureaucracy and industry had denied that mercury pollution caused the horrible birth defects of Minimata disease. Only Eugene Smith’s heart-breaking pictures, blazoned around the world, of mothers cradling their deformed children, finally shamed the Government and the polluters into an apology and into paying minimal compensation. Survivors of Hiroshima and Nagasaki had had to wait decades before anyone accepted responsibility for their plight. Here is a society in which the seemingly limitless responsibility of a bureaucracy or a giant company results in no one being held responsible at all. The stakes become too large, the costs of admitting error catastrophic, and the most outrageous abuses persist until it seems that only suicide or some similarly dramatic act of contrition suffices to right the wrongs done.

In France, the first big failure was not the result of a failed ideology but of a blustery, perhaps overweening, male ego: the head of the blood service, Michel Garretta, walked out of a negotiation with a Swiss firm to buy heat-treating technology because it would not take some piece of French technology in equal exchange. When, some months later, he realised his mistake, he could not get enough safe Factor VIII and decided to reserve the heat-treated product for ‘virgin’ haemophiliacs, who had not taken the old, tainted stuff. (It was thought, wrongly, that once a patient had been exposed, further exposures could do no harm.) He did not alert the haemophiliac community to this decision. His subordinate, Jean-Pierre Allain, a man who had spent his life treating haemophiliacs, did not go public with his complaints against his boss and neither was willing to take responsibility for the financial consequences of tossing the old product. They asked the minister to mandate their course of action; no such order came. Nothing of a mystical or ideological nature here, but simple bureaucratic pusillanimity. If one relies on the bravery of functionaries one is usually disappointed.

Conversely, the United States came out of the blood crisis relatively well, not because it got the gift-to-commodity relationship right, or because its blood providers were quicker than others to see through the symbolism, but because a tort system kept manufacturers on their toes, haemophiliac pressure groups lobbied for the new product after their initial hesitation, and an independent CDC, which had no front-line responsibility to keep the blood flowing but a huge professional commitment to getting the epidemiology right, nudged the more sluggish blood banks and drug companies along. If there is a lesson to be learned, it is that civil society can work pretty well. The same political processes which made it difficult to exclude the blood of gay men made the system ultimately responsible. True, the Irwin Blood Bank had to contend with various local organisations and the policies they negotiated were not optimal. But the situation in which haemophilia spokespeople were in the thick of the struggle for safe blood – and not, as in France, on the outside looking in – in this area at least produced an informed and relatively successful policy.