The Battle Over BLOOD
A handful of big city hospitals and the Red Cross are deadlocked over the supplying of human blood. Their disagreement jeopardizes a national program to boost production of the new weapon against polio — gamma globulin
THIS YEAR, as every year, poliomyelitis played a grim game of tick-tack-toe on the map of Canada. The disease struck more than six thousand, mostly young people; it killed about’ two hundred and fifty and crippled considerably more than that number; it terrified the population of every city, town and crossroads from May, when an epidemic attacked Whitehorse, Yukon, until September, when Winnipeg’s worst outbreak began to taper off.
There were actually more cases of polio in Canada during 1953 than in any other year on record, but it might have been worse if the spread of the disease had not been retarded for the first time by a new and hard-won medical weapon known as gamma globulin. This is not a cure and it is not a vaccine, but an injection of gamma globulin can give a child or adult virtual immunity from the crippling effects of polio for several weeks.
The source of this long-sought agent is human blood. It is the best known of several “blood fractions,” microscopic protein particles in the liquid portion of the blood which have diseasekilling qualities. This year there was only a limited quantity of gamma globulin, not a twentieth of what could have been used to good advantage had it been available for the epidemics in Whitehorse and Winnipeg, and in other cities like Toronto which were less seriously affected.
The goal of providing enough globulin for use in epidemic areas in 1954 is now being attacked from several directions. However, because the Red Cross and thirty-two big city hospitals in Toronto and Montreal can’t get together on the collection and distribution of blood, the gamma globulin program may fail to supply minimum requirements and children may needlessly die of polio in Canada next year.
Up to now their disagreement has been no more serious than an honest difference of opinion between two factions equally devoted to the nation’s health. Next year it may have a direct influence on the fight against disease.
This is what is being done:
A new laboratory for the production of gamma globulin is being built by the University of Toronto with the help of the federal and provincial governments.
The federal government has enlisted the Red Cross to supply
the required blood through its nationally-organized Blood Transfusion Service, organized in 1947 to provide blood and blood products from coast to coast for hospitals, the armed forces and civil defense. The federal government granted the Red Cross one hundred and fifty-seven thousand dollars to help collect blood for gamma globulin.
The Red Cross, which last year collected from Canadians 321,930 bottles of blood, will attempt to increase that total by one hundred and fifty thousand donations. On that attempt rests the degree of success the gamma globulin program will attain.
The production of gamma globulin is, however, only the newest and most spectacular front in the battle for blood. The Red Cross in the past six years has become Canada’s major supplier of transfusion blood for the sick and injured, and the stalemate with the Toronto hospitals is the only large obstacle to the society becoming a national blood service, the collector and distributor in peace and war of what has become one of medicine’s most important weapons.
“If we go to war again,” declares Dr. J. E. Pritchard, former head of the blood service of Montreal General Hospital, now a member of the Red Cross blood pool, “we will need an agency to collect blood in large quantities. The same type of agency would be necessary in case of civilian disaster. No other group has the experience of the Red Cross in handling and transporting blood.”
When the Red Cross blood service was initiated in 1947 to provide blood and blood products from coast to coast for hospitals, the armed forces and civil defense, some hospitals refused to join in, on the grounds that the terms laid down by the Red Cross would mean that the hospital would lose full direct control over one of its most vital functions. It would also mean that blood transfusions would have to be given free, instead of at the usual rate of up to twenty-five dollars a pint, or a return of two pints donated by friends or relatives for every pint used on the patient. For the Red Cross agreement with the hospitals provided that in return for free blood and blood-transfusion equipment no charge was to be made to the patients.
Some hospitals accepted immediately; others have come in since. But today all hospitals in Toronto Continued on page 40
Continued on page 40
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and two in Montreal still refuse to participate, and collect and distribute blood on their own. Whoever—if, indeed, anyone—is at fault, the silent battle for blood between the thirty-two eastern hospitals and the Red Cross threatens serious harm to the nation’s blood program and to next year’s blueprint for fighting polio with gamma globulin.
Particularly in regard to the Toronto area, where the hospitals’ attitude controls the over-all blood-collection program, the Red Cross puts forward two serious contentions:
Donated blood is only a trickle of what it might be.
What blood is collected is inefficiently used.
Dr. W. Stuart Stanbury, forty-eightyear-old National Commissioner of the Red Cross and the most militant figure in the battle for blood, points out that the Society set up a fully-equipped blood-donor depot in Toronto in 1949, but because of the refusal of the hospitals to participate, blood has been solicited only for military and veterans’ hospitals and the armed forces. Last year in Toronto the Red Cross collected seventeen bottles of blood per thousand population, compared with sixty-five bottles in Hamilton, fifty-four in Winnipeg and thirty-nine in Vancouver.
Of course this is not a true comparison of the amounts of blood actually given. Many Torontonians give blood to individual hospitals; how much isn’t known. But this blood and its byproducts are not available to the Red Cross’ national pool.
“We don’t expect to get a great amount of blood for gamma globulin in Toronto,” says Dr. Stanbury. “We haven’t been able to collect a large amount there since we started the service because the people know they wouldn’t get blood free themselves. And where we cannot provide free blood service, we have found our appeals for blood donations have met with poor response.”
The Red Cross argues that individual donors give proportionately less blood than they would to the national pool. Most hospitals which handle their own blood procurement have arrangements with industries and societies to supply blood transfusions to employees, and members or their families as long as these groups maintain a blood credit in the hospitals’ banks. When a group’s credit gets low it is asked for blood donations. People in such groups are reluctant to answer Red Cross appeals for blood because they don’t know when they might be called on to contribute to their own hospital bank. In practice such people may give blood once a year or even less often.
There is a further loss of potential blood collections, according to Dr. Stanbury, in the fact that “replacement donors are one-shot donors.” Most who give blood to private blood banks to replace blood used by a friend or relative never give blood again. The same people, embraced by the Red Cross system, might join those who give regularly three or four times a year.
Moreover, the Society claims that because it can’t set up an all-purpose service in Toronto, it can’t afford to extend service to a hundred-andtwenty-five-mile strip from Oakville to Belleville and up to North Bay, covering about twenty thousand square miles and containing about half a million people outside of the Toronto area. The comparatively small volume of blood
that would be handled, coupled with the long distances it would have to be transported, would make unit operating costs too high.
So half a million people in that area are without the free Red Cross blood service —and Canada is without the full potential blood contribution of those half million people for the making of gamma globulin. According to the Red Cross, that is not the end of the influence of the Toronto hospitals on the blood picture.
Toronto has influenced other large Ontario centres, says Dr. Stanbury, and is responsible for the fact that cities like London and Ottawa have not been provided with blood service before many less-populated parts of Canada. Last year the London contribution to the Red Cross was six bottles of blood per thousand population, Ottawa’s eleven bottles, both considerably lower even than Toronto.
Although Hamilton and the Niagara area it serves have an outstanding blood-donation record, most of the rest of Ontario is without a Red Cross blood service. The other major areas of Canada which lack this service are Newfoundland and the province of Quebec east of Three Rivers. The
Red Cross is equally outspoken in the charge that non-participating hospitals handle blood inefficiently. Toronto hospitals make no gamma globulin from their blood; in general the blood in their banks is used solely for transfusions, either fresh or in the form of plasma. The hospitals keep fresh blood up to three weeks and if it is not needed for transfusions it is processed into plasma. And if a hospital builds up a surplus of plasma its stock of fresh blood may be thrown away as it reaches its age limit. An official of Toronto Western Hospital stated that last year the hospital discarded one hundred and fifty bottles of blood.
The Red Cross on the other hand contends that no blood donated to it is wasted. The Red Cross makes these uses of blood:
Fresh blood for transfusions.
Storage of residue for later byproduct use.
At present the substance left after gamma globulin is extracted from blood cannot be processed in Canada, but three highly useful products will be made from it by the new Connaught Laboratory equipment. And there is a backlog of the raw material, according to Dr. Stanbury, since all the residue from gamma globulin production this year has been saved in cold storage.
These byproducts of gamma globulin are fibrin foam, fibrin film and serum albumin. Fibrin foam is a whitish, sponge-like material used to stop bleeding from surgical or accidental wounds. It can be sewn up inside the body and eventually is absorbed and disappears. Fibrin film is a cellophane-like sheet which can be used to repair tissues in brain and nerve surgery. Serum albumin is superior to blood plasma for transfusion in case of shock or in emergencies until whole blood is available.
The Toronto hospitals’ blood policy,
the Red Cross maintains, ignores two important factors: that gamma globulin to be most efficacious should be made from blood gathered in the widest possible area; and that Toronto is falling down in its contribution to the nation’s supply of the precious stuff.
To be most useful in fighting the spread of a polio outbreak anywhere in Canada, gamma globulin should con! tain the antibodies—substances created ¡ in the blood to combat infection—of all three types of polio virus. One of these three types of antibodies exists in the blood of three adults out of every four, most of whom have had polio in so mild a form that they never knew it. But one part of the country mighthave been free of one of the three types of polio for years, and the blood of most people living there would not contain the antibodies which act on that type.
The Red Cross says this fact lends a double danger to the stalemate over blood in Toronto and the partial stalemate in Montreal. As a result of the stalemate it’s not getting enough gamma globulin and what it is getting may not contain the best possible mixture of antibodies.
Nevertheless, gamma globulin will be used in Canada next year wherever polio strikes in force. People in all parts of the country are being asked to give blood for its production, although it might not come back to them or even to their own province. It is a form of insurance, with a sharing of the total cost and sacrifice. But the present rate of Red Cross donations in Toronto, for example, means that city is not contributing its share. Should a polio epidemic strike its own citizens, Toronto’s use of quantities of gamma globulin would in effect be taking advantage of the good will of the rest of the country.
Hospitals Want to Charge
What is behind the refusal of some hospitals to join the Red Cross service?
In 1949 the opposition of Toronto hospitals to the service was summarized in the publication Canadian Hospital: “Hospitals now providing
their patients, rich and poor, with an adequate blood service, simply cannot understand the, to-put-it-mildly, arbitrary and undiplomatic methods adopted by the Red Cross ... It is absurd for Dr. Stanbury to say that hospitals can still maintain their blood banks when they cannot themselves accept blood from patients’ relatives or any other source.
“It is the possibility that the Red Cross may not be able to meet the anticipated large demand for free blood . . . that makes a number of the eastern hospitals reluctant to discontinue well-organized blood banks which it has taken years to bring to their present perfection . . .
“The Red Cross could keep faith with its donors and could avoid alienating a host of very fine people in the hospital field (which it is now doing) if it would issue a statement that the blood will be free, as promised, but that, because of various items of expense, the hospital will make a small service charge.”
There has been no apparent change of heart on the part of Toronto hospitals in the past four years. A member of the Toronto Hospital Council executive said the matter has not even been brought up at meetings since 1949. Arthur Swanson, superintendent of the Toronto Western Hospital, who was president of the Canadian Hospital Council in 1949 and has been referred to as “leader of the opposition,” refused to be quoted.
The Red Cross, in rebuttal, says member hospitals may keep their own banks, but the Red Cross must be the sole source of blood supply for legal reasons. If there are mixed sources, in the event of reaction to a transfusion and a resulting lawsuit it might be difficult to prove whether or not the blood came from the Red Cross, which is insured against such accidents. The Society makes an exception in cases of emergency, when the hospital may obtain blood from any source, so long as it informs the Red Cross of what it has done.
Red Cross officials claim one reason these hospitals have not joined the service is because it would mean giving up what has become a source of revenue. They point out that Dr. Lome Gilday, secretary of the Montreal Hospital Council, said in 1949, “We have accepted the free transfusion service although we regret the considerable income we will lose by this service.” It was estimated at the time that the income from a private blood bank ranges from about nine thousand dollars for a small hospital to thirty thousand for a large one.
Dr. Pritchard, of the Montreal General, says his bank, before he closed it, broke about even but he had asked replacement only on a onefor-one basis. “It can be a revenue producer,” he states.
“They can’t help but make a profit,” says Dr. Stanbury, “and it will not necessarily show on their balance sheet, because they can charge a proportion of every hospital service against the blood bank.” Ingram and Bell Ltd., when trying to sell transfusion equipment to hospitals, use the sales argument that blood banks make money. “Anybody knows it’s a source of revenue,” says the company’s president, C. C. White.
The hospitals concerned deny that they make any appreciable profit. Dr. Paul Weil, head of the bank at Montreal’s Royal Victoria Hospital, says the annual revenue from his bank is about forty-two thousand dollars, and the annual cost about forty-one thousand, including the cost of blood research.
The Royal Victoria, Montreal’s largest hospital, had accepted the service with the rest of the hospitals that belong to the Montreal Hospital Council but, according to Stanbury, withdrew after the Red Cross turned down its proposal that the society rent space in the hospital for the blood depot. The hospital, Stanbury says, asked that the society pay about a hundred thousand dollars for alterations to the building necessary to accommodate the depot, plus about fifteen thousand dollars yearly rental. Dr. Weil denies that the disagreement over space rental had anything to do with the hospital’s decision not to join the plan. His version is that the Royal Victoria approved the Red Cross program “in principle” along with other members of the Montreal Hospital Council, but since it had a good blood bank of its own it decided to “wait and see”—and is still doing so.
As to the ability of the Red Cross blood service to maintain supplies to hospitals, which opponents of the plan doubted, Dr. Cecil Harris, of Montreal, provincial director of the service, makes this statement: “A large central source of supply is able better to absorb the day-to-day fluctuations in demand, both over-all and in the various groups and types, than if each hospital relied on its own limited facilities. That is not to say that a Red Cross depot is never relatively short of blood and unable immediately to meet every demand made upon it. Such relative shortages are inevitable no matter what
system is used. Our experience is that the Red Cross units are much less frequently compelled to ration out the available supplies than are the independent banks.”
The Red Cross entered the blood supply field at a time when transfusions were in the midst of a tremendous increase. Fifteen years ago blood transfusions were given purely as an emergency measure; in the last decade alone the volume of transfusions has increased sevenfold. Today transfusions cut down deaths from several causes and enable surgeons to perform heart
brain and lung operations which were impossible or highly hazardous in the 1930s. In any major surgery blood is used almost as a matter of course. One large Toronto hospital which in 1944 gave fifteen hundred transfusions has this year given more than eight thousand.
The pay-or-replace policy of the hospitals—still adhered to by all Toronto hospitals and two Montreal hospitals—often resulted in staggering hardship to those people who were not poor enough to rate free treatment as indigents and not well enough off
to buy blood from their savings. Blood-bank files record the case of a Toronto woman who hemorrhaged after childbirth and required seventeen bottles of blood within a few hours; of another in Montreal who needed one hundred and ten bottles of blood in ten days; of Iginio Robesco, a Montreal carpenter who needed thirty-two bottles during one operation.
On the other hand there were large areas in Canada where blood couldn’t be had at any price; there were great metropolitan hospitals not getting nearly as much blood as they
needed. These conditions were discovered by Dr. Stanbury when he returned to Canada from his wartime job of running Britain’s largest Blood Transfusion Service. In Canada he was assigned to the organizing of an equally ambitious service for Canada. His first survey showed, in addition to the facts noted above, that many general hospitals lacked up-to-date transfusion facilities; that in Saskatchewan there was not a single blood bank, but that due to new uses and new techniques developed during the war the need for blood had increased many times.
Immediately the Red Cross blood service was set up. Tn 1947 all hospitals in British Columbia and Alberta joined the service. Nova Scotia and P. E. I. joined in 1948. A large section of Quebec, centred in Montreal, was embraced in 1949, and the same year a depot was established in Hamilton which services the whole of the Niagara Peninsula. Manitoba and New Brunswick joined in 1950 and Saskatchewan in 1952. Yellowknife, N.W.T., and Whitehorse, Yukon, are supplied by plane from Edmonton.
The Red Cross blood service now supplies about sixty-six percent of all hospital beds in Canada. These beds are within reach of half the country’s fourteen million people. The hospitals which run their own blood banks serve an additional two million. The other five million, living in small towns and rural areas, have no blood bank facilities to call upon.
Meanwhile the Society has invested heavily, in the success of its Blood Transfusion Service and on the appeal of the service to the public pocket. In 1952 the service was the largest single item on its budget, $1,754,263, representing nearly twenty-five percent of total expenditures. With the expanded gamma globulin program that percentage will increase.
The emotional appeal of one person being able to save the life of another by a free donation of blood has always been great, and the possibility of preventing polio has supplied a new element which has increased that appeal.
Not that gamma globulin is a surefire preventive for polio. Its recent widespread use is based on a report published in the Journal of the American Medical Association last April. The report described the work of a group of four doctors led by Dr. William McD. Hammon of Pittsburgh, who in the polio seasons of 1951 and 1952 conducted field tests with polio in Utah, Texas, Iowa and Nebraska. Fifty-five thousand children were inoculated, half of them with gamma globulin and half with a harmless gelatine.
A total of one hundred and four children became paralyzed, seventythree of them in the untreated group, the remainder having had gamma globulin. But between the second and fifth weeks only seven who had had globulin were stricken, compared to thirty-nine in the untreated group.
It was the best news yet in what seemed to the public, and perhaps even to researchers, a long and even hopeless fight against a disease which is far from being the most common but is one of the most dreaded.
Since 1948 the Connaught Medical Research Laboratories, a branch of the University of Toronto, have been working under the sponsorship of the United States National Foundation for Infantile Paralysis on the effect of gamma globulin upon polio. The Connaught researchers exchanged all information with three United States institutions, Johns Hopkins University of Baltimore, the Children’s Hospital of Philadelphia and the Children’s Medical Centre of Boston.
Directed by Dr. Andrew Rhodes, an international authority on polio and now Director of Research at Toronto’s Hospital for Sick Children, Connaught’s particular contribution was to discover that the effectiveness of a gamma globulin dose was temporary. This was done by injecting fifty Toronto children with the pale amber fluid and sampling their blood periodically over a period of eight weeks. The antibodies could be detected, but they disappeared after about five weeks.
Canada’s first move toward producing gamma globulin came in the fall of 1952 soon after the results of the U. S. field tests were known. The Connaught Labs still had several thousand bottles of dried blood serum, collected during the war, which had been found not entirely suitable for transfusion purposes. The serum had been set aside, according to Dr. R. D. Defries, the director, “because we wanted to find a use for it.” There was no inkling at the time that, it might play a part in the war against polio.
Old Blood Was Potent
Tests were conducted to see if the wartime serum, eight to ten years old, still contained the antipolio antibodies which ran in the veins of the donors. It did. Dr. Defries broke the news and the federal health department called a meeting of the country’s top health and research men to discuss its possibilities. As a result, Connaught Labs were granted seventy-five thousand dollars by the federal government to set up equipment immediately for production of gamma globulin. The group also recommended that, a committee be appointed to advise the national health department on distribution of the material, and that the Red Cross be enlisted as the collection
agency for the all-important blood which would be needed as soon as the wartime serum ran out.
Connaught Labs were soon—but none loo soon—turning out about fifteen hundred doses of gamma globulin a week.
The gamma globulin committee, with Dr. B. D. Layton as secretary, held its first meeting on April 25 and decided how the precious fluid would be distributed. Obviously there would not be enough for all needs. So it was decided it would be better to try to use the limited supplies for a field trial in epidemic areas.
It was believed there was lots of time before the polio season began in July —then in May, as one committee member put it, “Whitehorse blew up.”
It was one of those things which completely rule out any attempt to predict what polio will do. It usually comes with the heat of summer—and ill came in the middle of spring in the Yukon town of Whitehorse. Gamma globulin was rushed to Whitehorse. Supplying the serum by air was a combined army and civilian operation, first supplies going on June 5. By the end of June, when the scourge had run its course, there had been a hundred and thirty-eight cases of polio, including five deaths and thirty-three cases of paralysis. By mid-September there bid been only three more cases, one of them a health department nurse.
As the Yukon epidemic waned, the cirefully kept graphs in Dr. Layton’s office in Ottawa began to show a dangerous trend: In both Manitoba
and Ontario polio cases were on the increase. Gamma globulin—what pitifully little there was of it-—was made available to both provinces.
But by mid-July the Ontario curve began to drop off before reaching epidemic proportions while the disease
rate in the west continued to mount. More globulin was released for the Winnipeg area, by now suffering its worst polio outbreak. At the King George Isolation Hospital in Winnipeg at one time in September there were seventy-six polio patients in iron lungs. Quantities of gamma globulin were distributed also in Newfoundland, Alberta and British Columbia, where there were minor epidemics, and in scattered localities in Quebec, Ontario and Saskatchewan. By the end of the polio season Connaught had produced about twenty-five thousand vials of globulin, “A splendid production job,” according to Dr. Layton. With a new laboratory it is expected production by the end of next year’s polio season will be one hundred thousand, requiring about two hundred thousand blood donations.
The anticipated production still will be insufficient to immunize all children who might be exposed to polio next year—an estimated one hundred and fifty thousand of the country’s three and a half million children under the age of fifteen. But it is felt that the amount produced will minimize the effect of polio. In Winnipeg it was found that the number of household contacts for each case of polio averaged out to about four. Should there be a big outbreak of polio in, say, Ontario, the most populated province, even one as big as Ontario’s 1937 epidemic when there were a record 2,546 cases, it would take about ten thousand doses to inject all household contacts. Next year’s planned production, then, would be sufficient to handle several such epidemics—provided only household contacts were immunized.
Gamma globulin, according to Dr. Rhodes, gives a person what is called “passive immunity.” It does not induce the body to produce any immunity of its own, as diphtheria toxoid does, and the immunity is gone when the injected antibodies are excreted in a few weeks. It is sometimes necessary to give a second injection. The antipolio effort in the research laboratories now is toward the discovery of a permanent preventive.
“The situation is developing very quickly,” says Dr. Rhodes. “But gamma globulin, as far as polio is concerned, will be in the picture for three or four years, and it may always play a part in the prevention and lessening of disease.”
The Department of National Health and Welfare is working now on reports gathered in each area to which gamma globulin was sent. Health officers are convinced that what little globulin they were able to distribute helped limit the disease. A member of the gamma globulin committee says, “The general feeling is that it was reasonably effective.” But Dr. Layton said that until results have been completely analyzed it is impossible to make a positive assessment of the effectiveness of gamma globulin in Canada.
Certainly the need for a means of fighting polio is increasing. The incidence of the disease fluctuates from year to year, but the increase in the past three years, compared with the previous three, has been very great. In 1948, 1949 and 1950 there were an average of fifteen hundred polio cases in Canada; in 1951, 1952 and 1953 the average jumped to over four thousand —with this year’s estimated sixty-one hundred cases the highest on record.
If gamma globulin can reduce deaths and crippling from polio—and most medical authorities agree it is the most hopeful method to turn up yet—the disagreement over ways and means of obtaining sufficient raw material will become of increasing importance to us all. Vk