This article examines the reasons for, and likely impact of, the decision by the US and other countries to permanently defer blood donors who have spent time in Britain or Europe, for fear they may transmit new variant Creutzfeldt–Jakob disease (vCJD), the human form of “mad cow disease.” It begins by discussing how vCJD and blood transfusion are linked, and how these have been translated into policy. First, maintaining a safe and stable supply of blood entails not only maintaining the trust of recipients in the system, but also that of donors, who need to be assured that their blood will be welcomed and used. Often, the balance, once upset, is regained by sacrificing donors, but accompanying costs might also be high. Second, the article highlights the impact of various forms of globalization—of commerce, disease and travel, and immigration—on blood policies and public and policy attitudes. Third, it assesses the decision by the US to restrict blood donations from Europeans and travelers to combat such a pervasive risk. The conclusion discusses how donor deferral policies may be interpreted by the public in the light of earlier discussions, and raises issues for future research.
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References
1.
1 Scott Gottlieb, “FDA bans blood donation by people who have lived in UK,” British Medical Journal319, no. 7209 (1999): 535-535 .
2.
2 US FDA Center for Biologics Evaluation and Research (CBER), “Guidance for industry: revised preventive measures to reduce the possible risk of transmission of Creutzfeld–Jakob Disease (CJD) and Variant Creutzfeld–Jakob disease (vCJD) by blood and blood products,” (2002) (http://www.fda.gov/cber/bse/bse.htm, accessed 10 March 2003). All but one of the 74 America’s Blood Centers members have implemented these recommendations, and the American Red Cross has gone the furthest: anyone who has spent three months or more in Britain, or six months or more in any European country from 1980 to the present. See Deborah Josefson, “US worried as restrictions on blood donors tighten,” British Medical Journal 323 (1 September 2001): 469-469.
3.
3 Sheila Jasanoff, “Civilization and madness: the great BSE scare of 1996,” Public Understanding of Science6, no. 3 (1997): 221–232 , and Douglas Powell, and William Leiss, Mad Cows and Mother’s Milk: the Perils of Poor Risk Communication (Montreal: McGill–Queen’s University Press, 1997). The Guardian (London) maintains a page of BSE/CJD related links and stories, (http://www.guardianunlimited.co.uk/food), as does the British Medical Journal (http://www.bmj.com/cgi/collection/mad_cow; both accessed 10 March 2003).
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4 Blood Safety … for Too Few, WHO Press Release, WHO/25 (7 April 2000).
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5 Jessie Saul, “Tainted blood: risk, safety, and civic dislocation in the case of the contamination of the blood supplies of France and the United States with AIDS,” paper presented at the 2001 Meeting of the Society for the Social Studies of Science, Boston, MA.
6.
6 Richard M. Titmuss et al., The Gift Relationship: From Human Blood to Social Policy, Expanded and Updated Edition ( New York: The New Press , 1997); Gilbert Gaul and Mary Pat Flaherty, “Red Cross accused of letting blood go to waste,” Sydney Morning Herald and Washington Post (13 November 2001)
7.
7 Sherry Sheethaler, “In the face of uncertainty: batty bovines and empty blood banks,” Berkeley Science Review3, no. 1 (2003): 44–44 .
8.
8 There is a large literature on risk and trust in modern society. Directly on this topic, see Paul Slovic, “Perceived risk, trust and democracy,” Risk Analysis13, no. 6 (1993): 675–682 , and the introduction to Ragnar Löfstedt and Lynn Frewer, (eds), The Earthscan Reader in Risk and Modern Society (London: Earthscan, 1998).
9.
9 For example, many major newspapers and radio programs have carried stories on the issue. Popular science journals have also provided a bridge between the expert community and the general public on both vCJD and blood supply issues. Finally, private citizens have set up their own news sites on this subject. See, for example, http://hometown.aol.com/debbieoney/blood.htm (a support network for people who may have received “classic” CJD-tainted blood; accessed 10 March 2003).
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10 Richard Rhodes, Deadly Feasts: The “Prion” Controversy and the Public’s Health ( New York: Touchstone Books , 1997).
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11 “No sign people get brain disease from blood – experts,” Reuters (October 7, 1997).
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12 Report of a WHO Consultation on Medicinal and other Products in Relation to Human and Animal Transmissible Spongiform Encephalopathies, WHO (March 1997).
16 On the prion-virus controversy, see Rhodes, Deadly Feasts (afterword), and Gretchen Vogel, “Prusiner recognized for once-heretical prion theory,” Science 278, no. 5336 (10 October 1997).
18 Jasanoff, “Civilization and Madness” (cit. no. 3).
19.
19 David Brown, “Human version of ‘mad cow’ on rise; increase reflects delay of symptoms, not new cases, British expert says,” The Washington Post (28 March 2002).
20.
20 See: Ghani et al., “Predicted vCJD mortality in Great Britain,” Nature406 (10 August 2000): 583–584 ; Valleron et al., “Estimation of epidemic size and incubation time based on age characteristics of vCJD in the United Kingdom,” Science 294 (23 November 2001): 1726–1728; Huillard d’Aignaux et al., “Predictability of the UK variant Creutzfeld–Jakob disease epidemic,” Science 294 (November 2001): 1729–1731; and Tim Radford, “Victims of CJD fewer than feared,” The Guardian (10 August 2000).
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21 Ferguson et al., “Estimating the human health risk from possible BSE infection of the British sheep flock,” Nature415 (24 January 2002): 420–424 .
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22 “Mad cow concern shifts to blood supply – scientist,” Reuters (11 March 1998).
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23 James Meikle, “vCJD may have been passed on in blood,” The Guardian (29 January 2002).
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24 F. Houston et al., “Transmission of BSE by blood transfusion in sheep,” The Lancet356, no. 9234 (16 September 2000): 999–1000 .
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25 As the study has continued, four more sheep are, or appear to be, infected. According to the research team in 2002, if this trend continues, the study indicates an infection rate through transfusion of up to 17%. See Emma Young, “vCJD risk from blood transfusion ‘appreciable’,” New Scientist (5 August 2002), a discussion of Nora Hunter et al., “Transmission of prion diseases by blood transfusion,” Journal of General Virology 83 (2002): 2897–2905. In Britain, the publication of this report significantly upgraded the blood transfusion risk, according to the scientific establishment (James Meikle, “Tests Reveal CJD Blood Risk,” The Guardian (3 August 2002)).
26.
26 “Britain to purify blood to remove CJD risk,” Reuters (17 July 1998).
27.
27 “CJD link to blood Britain sold abroad,” The Guardian (5 February 2001).
28.
28 “Making blood safer,” British Medical Journal (24 August 2002): 400–401 ; Staff and Agencies, “NHS pays £50m for US Blood Plasma Firm,” The Guardian (17 December 2002). The same article reports that the Department of Health is considering banning people who had previously had transfusions from giving blood.
29.
29 Oliver Wright, “Hemophiliac refuses surgery in vCJD protest” The Times ( London ) (15 February 2001).
30.
30 James Meikle, “Blood supplies ‘could be halved’ as donors fear results of vCJD tests,” The Guardian (2 October 2001).
31.
31 The most common form of blood donation in the US is allogeneic donation, i.e. for the use of others. Other forms include autologous (self-donation for one’s own need), and directed (for the use of a friend or family member). These sorts of donations have declined after a brief peak in the US in the 1980s, due to fear of contamination of HIV, following the development of better screening techniques. However, they remain common in poorer countries. See WHO, Blood Transfusion Safety, Global Database on Blood Safety, Summary Report, 1998–1999.
32.
32 Comprehensive Report on Blood Collection and Transfusion in the United States in 1999, NBDRC, released 2001. A similar report issued by the General Accounting Office is more optimistic in its assessment of future trends but also notes the decline in supply. See Blood Supply: Ability of Blood to Meet the Nation’s Requirements, US GAO report released 20 September 1999.
34 Gottlieb, “FDA Bans Blood Transfusion,” and Wayne Kondro, “Canada blood-donation prohibition for UK visitors,” The Lancet353, no. 9166 (22 May 1999).
35.
35 Sarah Ramsey et al., “Variant CJD fears prompt growing number of countries to ban British blood donations,” The Lancet354 no. 9180 (28 August 1999): 754-754 . This represents a loss of about 15,000 pints, or units, of blood each year.
36.
36 Josefson, “US worried as restrictions on blood donors tighten,” (cit. no. 2).
37.
37 Questions and Answers on FDA Guidance Entitled ‘Revised Preventive Measures to Reduce the possible risk of Transmission of Creutzfeldt–Jakob Disease and Variant Creutzfeldt–Jakob Disease by Blood and Blood Products’ (http://www.fda.gov/cber/gdlns/cjdvcjdq&a.htm, accessed 10 March 2003). So far, there have been seven reported cases of cattle with BSE in Japan (New York Times, 24 January 2003).
38.
38 Staff, “Bay Area blood banks need donors: ‘Mad Cow’ risk creates shortage,” The San Francisco Chronicle (15 January 2003); Additional blood donor guidelines going into effect October 31; America’s Blood Centers Could Lose Thousands More Donations, press release from America’s Blood Centers (31 October 2002) (http://www.americasblood.org, accessed 10 March 2003); “US blood supply unusually low,” Morning Edition, National Public Radio (27 August 2002) (interview with J.B. Gaskins, president of Florida Blood Services).
39.
39 Keith Parsons, “Ga. Red Cross Issues Blood Quarantine,” Associated Press (31 January 2003) (on the occasion of “white particulate matter” being found in blood products); news item on Public Radio International’s The World, 5 March 2003, on the US military’s blood supplies going into Iraq, and “US blood supply unusually low,” NPR transcript.
40.
40 Lisa Bloch, spokeswoman for Blood Centers of the Pacific, quoted in “Bay Area Blood Banks,” San Francisco Chronicle (15 January 2003).
42 “Red Cross denies ‘mad cow’ blood ban,” The Age ( Melbourne ) (18 July 2000); ‘“Mad Cow’ fear raises blood ban,” The Age (19 July 2000).
43.
43 Judith Whelan, “High Blood Pressure as Mad Cow Takes a Toll,” The Sydney Morning Herald (25 May 2001).
44.
44 Doug Payne, “Ireland fears blood shortage with new ban on donors,” British Medical Journal (1 September 2001): 469-469 .
45.
45 Saul, “Tainted Blood” (cit. no. 5).
46.
46 For example, in February 2003, surgeons in North Carolina accidentally gave a young girl heart and lungs of the wrong blood type, and the girl subsequently died. It is not clear where in the chain of communication this mistake was made.
47.
47 BSE is, in the eyes of some, only one of the problems affecting the US meat supply. See Eric Schlosser, Fast Food Nation: the Dark Side of the American Meal (Boston: Houghton-Mifflin, 2001).
48.
48 There is a large literature on the role of HIV and AIDS in transfusion medicine. See, for instance, Eric A. Feldman and Ronald Bayer (eds), Blood Feuds: AIDS, Blood and the Politics of Medical Disaster ( Oxford: Oxford University Press , 1999), Saul, “Tainted Blood” (cit. no. 5), and Penny Chan, “Blood, risk, and stigma” in Risk, Media, and Stigma: Understanding Public Challenges to Modern Science and Technology, eds J. Flynn, et al. (London: Earthscan, 2001): 229–240 for overviews.
49.
49 Paul Farmer, AIDS and Accusation: Haiti and the Geography of Blame ( Berkeley: University of California Press , 1992).
50.
50 Meikle, “Blood supplies ‘could be halved’ as donors fear results of vCJD tests” (cit. no. 30).
51.
51 Most recently, West Nile virus has been transmitted through infected blood (Fred Charlatan, “Organ transplants and blood transfusions may transmit West Nile virus,” British Medical Journal (14 September 2002): 566-566 ).
52.
52 Douglas Starr, Blood: an Epic History of Medicine and Commerce ( New York: Alfred A. Knopf , 1999).
53.
53 Ibid., chapter 14.
54.
54 Ibid., pp. 258–259, 351; although the configuration of major players changed after the AIDS/HIV blood scandals broke.
56 Starr, Blood; Andrew Kimbrell, “Biocolonization: the patenting of life and the global market in body parts,” in The Case Against the Global Economy and For a Turn Toward the Local, eds. J. Mander and E. Goldsmith ( San Francisco: Sierra Club Books , 1996).
57.
57 Nancy Scheper-Hughes, “The ends of the body: commodity fetishism and the global traffic in organs,” SAIS Review22, no. 1 (2002): 61–80 .
58.
58 Josefson, “US worried as restrictions on blood donors tighten,” (cit. no. 2).
59.
59 Feldman and Bayer, Blood Feuds (cit. no. 48).
60.
60 John Warden, “UK blood products are banned,” British Medical Journal (7 March 1998). On the blow to Britain’s hard-earned self-sufficiency, see Starr, Blood, p. 354-354 .
61.
61 For recent work on the history and emergence of new international diseases, including CJD, see Rhodes, Deadly Feasts (cit. no. 10) and Laurie Garrett, The Coming Plague: Newly Emerging Diseases in a World Out of Balance (New York: Farrar, Strauss and Giroux, 1994). In the arena of popular culture, see Richard Preston, The Hot Zone (New York: Random House, 1994) and, for instance, “More Buzz than Bite,” People Magazine (21 August 2000): 113–114.
62.
62 Garrett, The Coming Plague.
63.
63 Andrew T. Price-Smith, The Health of Nations: Infectious Disease, Environmental Change and Their Effects on National Security And Development ( Cambridge: MIT Press , 2002); Laurie Garrett, Betrayal of Trust: The Collapse of Global Public Health (New York: Hyperion, 2000).
64.
64 For data on this epidemic, see the Joint UN Programme on HIV/AIDS (http://www.unaids.org, accessed 10 March 2003)
65.
65 For an overview of blood’s symbolism as represented in the art world, see James M. Bradburne, ed., Blood: Art, Power, Politics and Pathology ( Munich: Prestel , 2001).
67 According to the American Red Cross, you are ineligible to give blood if “you were born or lived in Cameroon, Central African Republic, Chad, Congo, Equatorial guinea, Gabon, Niger or Nigeria since 1977”(http://www.redcross.org/services/biomed/0,1082,0_557_,00.html, accessed 10 March 2003).
68.
68 Mary Curtis, “Protestors attack blood policy; angry Ethiopian Jews see racism in Israel’s fear of HIV,” Los Angeles Times (29 January 1996).
69.
69 Edward H. Kaplan, “Israel’s ban on use of Ethiopians’ blood: how many infectious diseases were prevented?,” The Lancet351, no. 9109 (11 April 1998): 1127–1128 .
71 Ulrich Beck, World Risk Society ( Cambridge: Polity Press , 1999), 48-48.
72.
72 Ibid., p. 19.
73.
73 Robin Gregory et al., “Technological stigma,” in Risk, Media, and Stigma, eds Flynn et al. ( London: Earthscan , 2001): 3–8.
74.
74 Starr, Blood (cit. no. 52).
75.
75 America’s Blood Centers cites accidents, burns, bone marrow transplants, organ transplants, burns, and heart surgery as examples of when blood transfusion is commonly used.
76.
76 See Feldman and Bayer, Blood Feuds (cit. no. 48), for this argument. For other works on comparative blood donation politics, see Starr, Blood, and Piet J. Hagen, Blood Transfusion in Europe: a “White” Paper (Strasbourg: Council of Europe Press, 1993).
77.
77 See W.N. Gibbs and A.F.H. Britten, eds, Guidelines for the Organization of a Blood Transfusion System (Geneva: WHO, 1992).
78.
78 Christine Gorman, “Post-traumatic infection: some who donated blood on September 11 are discovering they have hepatitis,” Time Magazine158, no. 17 (15 October 2001): 106-106 .
80 See Robert G. Westphal, “International perspectives on blood availability,” in Blood Donors and the Supply of Blood and Blood Products, pp. 25–30, eds Frederick J. Manning and Linette Sparacino (Forum on Blood Safety and Blood Availability, Division of Health Sciences Policy, Institute of Medicine, Washington: National Academy Press, 1996) and Sean French, “Only those with pitifully dull lives can give blood these days,” The New Statesman 127, no. 4389 (June 1998).
81.
81 Vanessa Martlew, “Transfusion medicine towards the millennium,” in Titmuss et al., Gift Relationship ( New York: The New Press , 1997), 49-49.
82.
82 Although essentially a wider treatise about social policy, in The Gift Relationship, Titmuss demonstrated that the US system, at that time run on a commercial, paid basis, was far less efficient—more costly, more blood wasted—than the British system, based entirely on altruistic donation by anonymous donors. Titmuss also highlighted the adverse selection problems of a paid donor system: the pool of donors tended to be the people most likely to transmit infectious diseases, and most likely to be destitute and/or addicted to drugs or alcohol. This book, and the publicity it received, was instrumental in the US move to a more voluntary system.
83.
83 The term “Blood Establishment” is used by the FDA in its guidelines about blood donation, deferral, and screening to refer to the agencies (private and non-profit) who collect and distribute blood.
84.
84 Löfstedt and Frewer, Risk and Modern Society (cit. no. 8).
85.
85 See Westphal, “International perspectives on blood availability” (cit. no. 80).
86.
86 “Donated blood wasted in Sept. 11 aftermath,” Reuters (20 February 2002).
87.
87 “Blood and Money,” interview with Jim McPherson, Executive Director of America’s Blood Centers, on PBS’ News Hour with Jim Lehrer, 19 December 2001.
88.
88 Russ Buettner, “Red Cross may trash 20% of donated blood,” New York Daily News (12 November 2001), quoting blood donor Helene Pincus.
91 For instance, Mad Cow Disease: Improvements in the Animal Feed Ban and Other Regulatory Areas would Strengthen US Preventive Measures. United States General Accounting Office Report to Congressional Requesters, GAO-02–183 (January 2002), and Evaluation of the Potential for Bovine Spongiform Encephalopathy in the United States. Harvard Center for Risk Analysis, Harvard University and the Center for Computational Epidemiology, College of Veterinary Medicine, Tuskegee University (26 November 2001).
92.
92 Evaluation of the Potential for Bovine Spongiform Encephalopathy in the United States. Executive Summary, Harvard Center for Risk Analysis, 1.
93.
93 For critics of the official US stance, see Sheldon Rampton and John Stauber, Mad Cow U.S.A.: Could the Nightmare Happen Here? (Monroe, Maine: Common Courage Press, 1997). Opposition reports are collected on the Organic Consumer’s Association website (http://OrganicConsumers.org/madcow.htm, accessed 10 March 2003).
94.
94 See Ronald Brickman et al. (eds), Controlling Chemicals: the Politics of Regulation in Europe and the United States ( Ithaca: Cornell University Press , 1985), and, more recently, David Vogel, “The Hare and the Tortoise Revisited: the New Politics of Consumer and Environmental Regulation in Europe,” British Journal of Political Science 33 (2003), 557–580, and Robert A. Kagan and Lee Axelrad (eds) Regulatory Encounters: Multinational Corporations and American Adversarial Legalism (Berkeley: University of California Press, 2000).
95.
95 On the precautionary principle, see Carolyn Raffensperger and Joel Tickner (eds) Protecting Public Health and the Environment: Implementing the Precautionary Principle ( Washington, DC: Island Press , 1999) and Ronnie Harding and Elizabeth Fisher (eds) Perspectives on the Precautionary Principle (Sydney: Federation Press, 1999). The US opposition to use of the precautionary principle as a principle of international law, as opposed to “sound science,” has been at the center of many international environmental negotiations, for example over climate change and biosafety.
96.
96 Streamlining the Donor Interview Process: Recommendations for Self-Administered Questionnaires, Draft Guidance for Industry, US FDA Center for Biologics Evaluation and Research (April 2002).
97.
97 Sheethaler, “In the face of uncertainty” (cit. no. 7).
98.
98 Liam Callanan, “New FDA guidelines prevent more people from giving blood,” commentary on the Morning Edition, National Public Radio (5 June 2002).
99.
99 On the capacities of the WHO, see Garrett, Betrayal of Trust (cit. no. 63).
