H Busby, J Kent and AM. Farrell, ‘Re-valuing donor and recipient bodies in the globalised health economy: transitions in public policy on blood safety in the UK’, (2014) 18 Health: An Interdisciplinary Journal for the Social Study of Health,

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  The clinical use of blood has a long history, but its apparent stability belies the complexity of contemporary practices in this field. In this article, we explore how the production, supply and deployment of blood products are socially mediated,
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    http://hea.sagepub.com/  Health:  http://hea.sagepub.com/content/18/1/79The online version of this article can be found at: DOI: 10.1177/1363459313476966 2014 18: 79 srcinally published online 6 March 2013 Health (London) Helen Busby, Julie Kent and Anne-Maree Farrell Transitions in public policy on blood safety in the United KingdomRevaluing donor and recipient bodies in the globalised blood economy:  Published by:  http://www.sagepublications.com  can be found at: Health:  Additional services and information for http://hea.sagepub.com/cgi/alerts Email Alerts:  http://hea.sagepub.com/subscriptions Subscriptions:  http://www.sagepub.com/journalsReprints.nav Reprints:  http://www.sagepub.com/journalsPermissions.nav Permissions: http://hea.sagepub.com/content/18/1/79.refs.html Citations: What is This? - Mar 6, 2013OnlineFirst Version of Record - Mar 24, 2013OnlineFirst Version of Record - Nov 8, 2013OnlineFirst Version of Record - Dec 19, 2013Version of Record >> at Monash University on January 14, 2014hea.sagepub.comDownloaded from at Monash University on January 14, 2014hea.sagepub.comDownloaded from   Health2014, Vol 18(1) 79  –94© The Author(s) 2013Reprints and permissions: sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1363459313476966hea.sagepub.com Revaluing donor and recipient bodies in the globalised blood economy: Transitions in public policy on blood safety in the United Kingdom Helen Busby University of Leicester, UK  Julie Kent University of the West of England, UK Anne-Maree Farrell Monash University, Australia Abstract The clinical use of blood has a long history, but its apparent stability belies the complexity of contemporary practices in this field. In this article, we explore how the production, supply and deployment of blood products are socially mediated, drawing on theoretical perspectives from recent work on ‘tissue economies’. We highlight the ways in which safety threats in the form of infections that might be transmitted through blood and plasma impact on this tissue economy and how these have led to a revaluation of donor bodies and restructuring of blood economies. Specifically, we consider these themes in relation to the management of recent threats to blood safety in the United Kingdom. We show that the tension between securing the supply of blood and its products and ensuring its safety may give rise to ethical concerns and reshape relations between donor and recipient bodies. Keywords biovalue, blood, donors, patients, risk, ‘tissue economies’ Corresponding author: Helen Busby, Department of Health Sciences, University of Leicester, Leicester, LE1 6TP, UK. Email: helen.busby@leicester.ac.uk  HEA   0   0   10.1177/1363459313476966HealthBusby et al.2013  Article  at Monash University on January 14, 2014hea.sagepub.comDownloaded from   80  Health 18(1) Introduction: perspectives on blood and tissue economies Modern biomedicine is dependent upon a range of human tissues and cells, which have applications in transfusion medicine, transplantation medicine and regenerative medi-cine. Blood has long been used in medicine and continues to have diverse applications in most health-care systems for emergencies and in planned care, hence its description by the World Health Organization (WHO) (2004) as an ‘essential health technology’. Although the use of blood in medicine is an established practice, its apparent stability  belies the complexity and change that characterise this field. We aim to explore some of the ways in which the production, supply and deployment of blood has been transformed, drawing on theoretical perspectives from recent work on ‘tissue economies’.Given the expanded repertoire of uses for human tissues in the 21st century, it has  been argued that there is a need to consider the ways in which ‘medical systems that exchange and circulate tissues are also social systems’ (Waldby, 2002: 309). Increasingly,  biotechnology has been applied to tissues extracted from humans with the intention of enhancing their applications in the clinic and in research. According to Waldby (2002), ‘Biovalue refers to the yield of vitality produced by the biotechnical reformulation of living processes’ (p. 310). As new forms of organisation have sprung up with a view to mobilising the potential value of these developments, sociologists and anthropologists have explored the fields of enterprise generating biovalue. Here, there has been a particu-lar focus on the novel ways of using human biological materials that have been devel-oped in recent years, their social and economic entanglements and their wider ethical implications – be they embryos, foetuses or other tissues from the living or dead (see, for example, Kent, 2008; Palsson, 2009; Svendsen and Koch, 2008). The prevailing empha-sis on new biological materials or innovative applications is in keeping with recent influ-ential accounts of biopolitics and the transformative potential of biosciences (Rose, 2007). Yet, use of blood associated with more established technologies remains highly significant, both in clinical and in economic terms.As with some newer kinds of tissue donation, ideals of altruism are influential in  public policy about blood services and ‘promulgated by professional groups and policy makers’ in these fields (Shaw, 2011: 299). These ideals inform the narrative appeals of organisations involved in soliciting blood (and other tissue) donations (Healy, 2006). While Richard Titmuss’ influential work on gift relationships has been a productive point of reference for thinking about blood services, perspectives from recent work on tissue economies also underline the difficulties in securing separation of human tissues from the commercial realm (Hoeyer, 2009). This difficulty can be understood in the light of a  broader argument that objects (including biological objects) often have rather complex lives in the social world, so that ‘the commodity is not one kind of thing rather than another but one phase in the life of some things’ (Appadurai, 1986: 17, cited in Waldby and Mitchell, 2006: 25). Notwithstanding this complexity, principles of voluntariness and altruism weigh heavily in the field of blood donation (ISBT, 2006).In this article, we argue that while traditional discourses continue to shape practices in some parts of the blood economy, the technical reformulation and division of blood into its component parts and the manipulation of those parts to create new products at Monash University on January 14, 2014hea.sagepub.comDownloaded from   Busby et al. 81 generates new forms of biovalue. Layered onto these processes are complex and shift-ing calculations about threats to blood safety, which in turn have implications for rela-tions between donor and recipient bodies. We explore these themes with reference to several key policy issues faced by the blood services in the United Kingdom over the  past 10 years. In developing our analysis, we shall draw on materials in the public domain, including documents from blood service organisations and regulators and gov-ernment policies in the United Kingdom together with reports from international organ-isations concerned with blood safety and supply, as well as on the scientific and social science literature. 1 Deconstructing ‘blood’ The clinical application of blood has a long history. According to the Oxford English  Dictionary , ‘Blood consists of a mildly alkaline aqueous fluid (plasma) containing red cells (erythrocytes), white cells (leucocytes), and platelets’ (Oxford English Dictionary, 2011). The discovery of the part played by this fluid in maintaining key physiological  processes and of the harnessing of blood for use in medical treatments has been well described in the popular book by Douglas Starr, as well as in the professional literature (Giangrande, 2000; Starr, 1998). The first blood banks  were established in the 1940s, with more systematic services to provide blood to hospitals being set up in the middle  part of the 20th century. In the early years of transfusion practice, whole blood was stored and transfused. A reliance on whole blood transfusion changed with the develop-ment of fractionating techniques in the United States through the following decades; developments in the 1950s and 1960s eventually allowed for the possibility of manufac-turing  products  from plasma proteins in one place, storing them until required and ship- ping them to where they were needed. Subsequent developments allowed for blood to  be broken down into other components . These components have specific therapeutic characteristics, and their storage requirements also vary. Over some decades, the use of ‘whole blood’ transfusion has reduced in countries that have resources to process and separate blood (Jersild and Hafner, 2008). Contemporary transfusion medicine is char-acterised by the use of different components of the blood, administered to patients according to their clinical needs. As well as allowing for better targeted interventions, this allows for each unit of donated blood to be deployed for the treatment of more than one patient. Blood increasingly came to be seen as a scarce resource that needed to be used in the most efficient ways possible. Hence, efficiency is a key principle underlying  blood services today.According to McClelland’s (2007)  Handbook of Transfusion Medicine , a blood prod-uct   is ‘any therapeutic substance prepared from human blood’ (p. 1). Within this group are two categories: blood components  and  plasma  (derived)  products . Blood components may be prepared and administered separately in transfusion as platelets, red cells, white cells, cryoprecipitate and fresh frozen plasma (FFP). Plasma proteins once separated from blood may form the basis for a range of manufactured plasma-derived products. These include immunoglobulin products that have applications in the fields of immunol-ogy, neurology, haematology and oncology; albumin that is used to help replace fluid loss after trauma and coagulation factors that are prescribed to alleviate the symptoms of at Monash University on January 14, 2014hea.sagepub.comDownloaded from   82  Health 18(1)  bleeding disorders. Although there have been many technical innovations in processing  blood, the long endeavour to produce ‘artificial blood’ with similar functions to blood components for clinical use has not to date been successful.Scientific and professional discourse distinguishes between  plasma products  and blood components . For the sake of clarity, we shall adopt these widely used terms in this article, and the term blood products  will be used to refer collectively to all therapeutic  products derived from blood and plasma. At the same time, we want to unpack the way that the use of these terms has the effect of implying that these are entirely different kinds of material, although they are of course all derived from human blood. In some contexts, two categories of donors have been created: the ‘blood donor’ who donates whole blood and the ‘plasma donor’ who provides plasma only, which is separated from the red blood cells at the point of donation. 2  This binary categorisation becomes important when we consider that in key supplier countries, ‘plasma donors’ may receive payments (some-times called compensation), whereas ‘blood donors’ may not. 3  At the same time, exchange relationships between donor and recipient bodies have become complex, medi-ated by a network of public and private and non-profit and for-profit institutions. Demand in the blood economy Dynamics of demand and supply in the blood economy have received little attention from those outside the blood services and plasma suppliers. However, we do know that there is a growing global demand for blood and plasma products. Data from the WHO (2004) Global Collaboration on Blood Safety give an indication of the volume of blood donated for therapeutic use in transfusion medicine: some 81 million units of whole  blood and 20 million litres of plasma were donated in 2001–2002. More recent data point to an increased demand for plasma for fractionation (O’Mahony and Turner, 2010). Globally, the main applications of whole blood and its components are in the course of surgical procedures, including treatment of trauma patients, and in obstetric care with major bleeding during childbirth (Jersild and Hafner, 2008). Blood is also used in the treatment of medical diseases, especially haematological diseases such as thalassaemia. The use of whole blood, blood components and plasma-derived products does vary con-siderably across different health systems, with more extensive use being made of a diverse range of blood products in countries with well-resourced health-care systems.  Nevertheless, managing periodic or enduring shortages of blood and plasma is a key  problem for blood services across the world. Worldwide, people with haemophilia have  been the primary users of plasma products, as they are often prescribed coagulation fac-tors on a long-term basis. However, global demand for plasma is today driven by the expansion of immunoglobulin therapies for diverse indications (Farrugia, 2006).Whereas traditionally blood was thought of in terms of its direct clinical applications, its value is also related to the information that can be derived from it. Once extracted from the body, blood can be used for the purpose of diagnostic tests and for research. Discussion of these wider uses of blood goes beyond the scope of this study, but we want to highlight their close relationship. For example, organisations that obtain blood for use in transfusion or transplant medicine do routinely make it available to research organisa-tions, especially if the blood is in some way ‘surplus’ to requirements or not suitable for at Monash University on January 14, 2014hea.sagepub.comDownloaded from 
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