Blood; Blood transfusion and the Gift Relationship in ‘giving’ blood.

This week’s report on the blood infection scandal was the sort of brave document that British politics and government often need. Of course… of course it would be better if bravery was endemic to government and the NHS, and it would be better for our society not to need such inquiries to break open the layers of secrecy. But in the end the courage of the Langstaff Inquiry gave voice to the courage of the people who had died, those that are ill, and their relatives.

It says nearly everything that needs to be said about that scandal – but I have another take on the whole issue of infected blood. This one comes from the human and educational relationships that were a part of my undergraduate degree in social policy at the LSE 1966-1969 (the dates are important for this story).

I was part of that generation which was the first of our families to go to University. I didn’t know much about choosing a university but my non-graduate Dad – who had joined the Ministry of Pensions and National Insurance in 1947 (in order to create socialism) – did quite firmly suggest that if I was going to go to university, I should study something useful.

And for him that something useful was social policy. By 1965 he had his own opinion about the social policy he had been implementing in national insurance. Very good for those that were covered by their contributions – very bad for those that were not. So he wanted me to study how to make social policy more effective for everybody.

An old boy from my school came back to talk to us about which university to go to (this is one of those memories from 60 years ago that is very bright and clear – it was in a laboratory room. I can remember everything about it). He had gone to the London School of Economics. He said it was ‘very political’. So, I was hooked.

The LSE social policy department had just started teaching a new degree in social policy. So, in 1966 that’s where I went.

I didn’t know it at the time, but the degree had been set up by the great post-war Fabian intellectuals of the welfare state. Not only had they played an important role in creating a whole range of social policies, (including the national insurance contributions my Dad was collecting) but they had also spent much of the previous 5 years critiquing those policies for leaving big gaps that many people were falling through.

I didn’t really know anything about these lecturers and professors as people but within the first term I met,

·      Brian Abel Smith (who had written the Poor and the Poorest in 1965 about those that fell through the social security safety net. (And he was advising the then Labour Government on the NHS!!)

·      David Donnison on the failures of the 1957 Rent Act and soon to be on the Plowden Commission on primary education and,

·      Richard Titmuss

The most important point to make about their work as teachers is that they did not just study social policy, they made it. The three years I studied under them were only marginally academic. They were mainly practical and moral. I did not agree with some of their politics (this, dear reader, was the LSE between 1966-69 when no-one agreed with their teacher’s politics), but they always fought their moral and political corner. And on occasions (quite a few) when my politics became self-indulgent (about me and not a social outcome) I was ripped apart for failing to commit to a wider society.

Titmuss was older and in every sense the ‘father’ of this style of teaching and learning. In 1950 he had written a book about World War 2, Problems of Social Policy. This dissected the inequalities of British society that had become, up to and during the wat, normal. It majored in how the social and economic relationships of the War uncovered these inequalities in a ruthless way. People couldn’t miss them.

I remember his analysis of evacuation during the war, at a time when the whole of British society was characterised as having a single way of life – fighting fascism to survive – experience starkly revealed its inequalities. Millions of poor inner-city working-class children arrived at rural families, where they didn’t eat the same food, had different cultures, and even seemed to speak a different language.

On the surface we were one society fighting a common enemy, but we seemed to have little in common.

For both the soldiers in the battlefields and those on the home front what the social experience of the war uncovered was appalling inequality.

As students we didn’t just study social policy. We didn’t just learn what was wrong, we learnt that it was our job to do something practical about it.

Sorry, this is a long introduction before we get to blood, but it matters to this story.

At the time he was teaching me Richard Titmuss was working on a book, published  in 1970 called The Gift Relationship.

It was a comparative analysis of the different ways in which Britain and the USA organised the provision of blood for their two different heath systems. In the USA blood was sold to the health system by individuals for profit whilst in Britain people turned up to the blood transfusion service, and ‘gave blood’. It was, as Titmuss wrote at the time, a gift.

It was different from the gifts we gave and received on our birthdays and at Christmas, because you never met the stranger to whom you gave the gift. But we, as a society, organised the provision of blood around this gift relationship from one person to another. (And in 1961 Tony Hancock’s iconic Blood Donor half hour programme used comedy to explore the nature of this gift.)

In the USA blood was bought from donors, not given.

Titmuss begins with this basic philosophical difference – different societies organise things in very different ways.

But he went on to point out the implications resulting from having a market rather than a gift relationship with blood. The people who sold blood to the transfusion service in the USA tended to be poorer. They needed the money more than the better off who were less likely to sell their blood.

Because of the nature of health inequalities, people who were so poor that they needed to sell their blood were also sicker than those who did not have a financial need to sell. Since the blood used for transfusions was predominantly from poorer people, and because they were generally in poorer health, blood used for transfusions was more likely to carry illnesses that poor people were prone to.

And when you start taking blood from prisoners, the people are likely to be sicker still.

And this is where Titmusss’s teaching goes beyond morality to efficacy. Morality would tell us that it is better to organise these things around giving than selling. But in terms of efficacy, it is better to have healthy blood than infected blood. And you are more likely to have infected blood when it is sold by poorer people rather than given by all.

This insight was published in 1970. Throughout the 70s when I was teaching social policy this example of the limitations of the market was something that my students had to work through every year. That was in the 70s and 80s.

What does this mean for the current infected blood scandal? As a society we did not ourselves give sufficient blood for all our needs and we had to buy blood from the US. In 1970, Titmuss’s book gave us all a warning that the method of blood collection in the USA was more likely to lead to greater levels of infection.

Richard died in 1976 (he was 65 – I remember he smoked a lot). In 1997 his daughter Ann Oakley reworked his book into a second edition that was published in the USA by New Books. This is the blurb about the book.

Richard Titmuss’ the Gift Relationship has long been acknowledged as one of the classic texts of social policy. Honoured by the New York Times as one of the 10 most important books of the year when it first appeared in 1970. The gift relationship is even more topical now in an age of Aids and changing healthcare policy.

A seemingly straightforward comparative study of blood donating in the United States and Britain, the book elegantly raises profound economic political and philosophical questions. It contrasts the British system of reliance on voluntary donors to the American one in which the blood supply is largely in the hands of for-profit enterprises and shows how a non-market system based on altruism is more effective than one that treats human blood as another commodity.

This edition mentions the importance of aids as a danger in infected blood.

My point is NOT that everything in Britain is fine and everything in the USA is imperfect. Richard Titmuss was never Utopian and knew that mistakes would be made in the NHS as well as in other health systems.

But we knew in 1970 that there was a greater likelihood of infection in systems where blood was sold by poor people.

It appears that not enough decision-makers believed that if the blood you were using was ‘given’ it was more likely to be healthy than if it was sold by poorer people.

This was only one of the earlier problems in the infected blood scandal.

There were a host of other, consequent problems but let’s not forget the importance of the gift relationship at the core of our nation’s policy on blood.