“She is my blood”

On my first clinical rotation as a medical student in a public hospital in Trinidad, a senior doctor asked a young anemic patient, Mary, ² whether she had any “blood chits” so she could be “topped up” (i.e., transfused) before the surgery. Having only a textbook knowledge of the mechanics of blood transfusion, I was as puzzled as Mary by this question, prompting the doctor to begin what was clearly a routine explanation. Given that her “blood count” was so low, Dr. Williams explained, Mary needed a pre-operative blood transfusion. To obtain blood for this transfusion, however, Mary would have to ask her family and friends to donate blood to a blood bank, in return for which they would receive “blood chits” in Mary’s name. These chits were vital: the hospital blood bank would release blood to Mary’s doctors for her transfusion only upon receiving them. This form of “replacement donation” constitutes the main means of blood procurement in Trinidad and Tobago, and this explanation soon became my own uncomfortable if routine clinical duty as a medical student and junior doctor. My discomfort arose from the inconsistency of this routine practice with the standard recommendations of international biomedicine, which advocate solely non-remunerated voluntary donation. It also arose from a more general awareness of the discourse around voluntary donation – of blood donation as a purely altruistic act, a means of saving a life, a form of patriotism, a civic responsibility. I was not alone in feeling this discomfort, either as a clinician or as a citizen. Yet, in 2011, a government-mandated attempt to transition to solely non-remunerated voluntary donation on a national scale failed miserably. Operating theaters were forced to cancel their operative lists; entire wards were temporarily closed down. The attempt lasted for only four months. By April 29, it had been abandoned for a return to the “chit system” of replacement donation.