1장
The Crimson Lifeline: Blood's Journey Through Our Bodies and Society
Every three seconds, somewhere in the world, someone receives blood from a complete stranger. This remarkable fluid-simultaneously commonplace and miraculous-contains stardust from supernovas in the form of iron atoms and carries the salt of ancient seas in its chemistry. When we donate blood, we give away 13% of our supply, knowing our bodies will regenerate it completely. The donation centers may emphasize gratitude with "thank you" Wi-Fi passwords, but our blood becomes both medicine and commodity-a substance more valuable than oil. Nine Pints, Rose George's fascinating exploration of blood, takes readers on a journey through history, science, culture, and commerce, revealing how this "stuff that spurts out when you are not very well" connects us all in ways both literal and metaphorical. The book has captivated readers from medical professionals to cultural anthropologists, with Bill Gates naming it one of his top five books of 2019 and praising its ability to transform a potentially squeamish subject into a gripping narrative about human resilience and scientific progress.
2장
The Gift of Life: Blood Donation's Complex Reality
In blood donation centers across the developed world, the clinical language of "bleeding" has been replaced with terms of altruism like "donation" and "gift." Yet this seemingly simple act exists within a complex global system. At Filton, Europe's largest blood processing facility, I witness the transformation of 1,000 gallons of blood daily. Each donation undergoes extensive testing before being separated into multiple products: red cells, plasma, platelets, and more. Blood hangs from hooks on an "overhead filtration device" resembling a chicken rotisserie-vivid red bags rotating as white blood cells are filtered out.
The finished products carry precise costs: standard red cells at 124.46, plasma at 28.75, and some specialized components reaching 1,113.45 per unit. All must be stored with exacting precision-red cells in refrigerators at exactly 39.2F, plasma frozen until use. Female plasma is often discarded due to hormone treatments turning it green, and fatty blood (visible as floating globs) is set aside, with donors notified of concerning results.
These precious products are delivered to hospitals by regular transport, with emergency deliveries handled by volunteer "blood bikers"-often "middle-aged and a bit flabby" motorcycle enthusiasts who deliver thousands of blood bags annually for free, along with breast milk, spinal fluid, and other medical materials. Their reward? "Free hot drinks in certain cafes [and] nods and waves from police and paramedics."
The World Health Organization recommends nations maintain blood supplies through voluntary non-remunerated donations from 1-3% of their population. Yet of 172 countries surveyed, 80 reported only 1% of their population donating-insufficient for safety. Seventy-one countries get over half their blood from "family replacement" systems or paid sellers.
Persuading people to donate isn't easy. Blood systems worldwide use various incentives, even supposedly non-remunerated ones. In the US, regulations forbid incentives exchangeable for cash but allow discounted hotel rooms, pizza, ice cream, haircuts, and gym memberships. Simple gestures often prove most effective-83% of first-time donors remembered being thanked. When Stockholm's blood bank began texting donors when their blood was used, the response was overwhelmingly positive. At just 3 pence per text, it's remarkably cost-effective for donor retention.
Blood and race have a sensitive history. Until 1972, US blood banks labeled blood by race, with hospitals like Johns Hopkins refusing to transfuse "Negro blood" into Caucasian patients. Today, NHSBT makes targeted appeals for "black blood"-not from racism but medical necessity. Black donors are more likely to have the Ro subtype needed to treat sickle-cell anemia patients, who require frequent transfusions.
Despite our sophisticated medical systems, we cannot manufacture blood. Its mysteries persist-how it works, what it carries, how to stop bleeding-even as our fascination with it endures. In the reception area at Tooting Blood Donor Centre, a leather-bound thank-you book contains simple but powerful messages from recipients to donors. Most moving is an elderly man's economical response to "What has this transfusion meant to you?" He wrote simply: "Good."
3장
The Healing Bite: Leeches in Modern Medicine
Six seconds. Perhaps ten. Twelve, if it is cautious or dopey. After that, the jaws will activate, the hundreds of teeth will engage, the leech will begin to eat, and its meal is your blood. Despite their reputation as primitive medicine, leeches have made a remarkable comeback in modern healthcare, particularly for microsurgery where their unique abilities can mean the difference between saving or losing reattached tissue.
At Biopharm in Wales, the nation's only leech production business, these remarkable creatures are bred with scientific precision. They're not slugs or insects but annelid worms-Hirudo verbana, Hirudo medicinalis (European varieties), and Hirudinaria manillensis (Asian or "buffalo" leeches for veterinary use). These remarkable creatures possess thirty-two brains, ten stomachs, nine pairs of testicles, and hundreds of teeth that leave a distinctive Mercedes-Benz-shaped bite mark. Their saliva contains the most powerful natural anticoagulants known, keeping blood flowing for up to ten hours after feeding.
The modern revival of leech therapy began dramatically in 1985 when three-year-old Guy Condelli had his ear bitten off by the family dog. After conventional microsurgery at Boston Children's Hospital, the reattached ear turned dangerously blue and black as blood flowed in through arteries but couldn't drain through damaged veins. Surgeon Joseph Upton desperately sought European medicinal leeches, which were flown across the Atlantic. When applied to the congested tissue, "the ear perked right up"-the color improved immediately as the leeches drained the trapped blood.
Today, leeches are standard practice for salvaging compromised tissue in flap surgeries, replanted digits, ears, nipples, nasal tips, and even penises. By 2002, a survey showed 80% of UK plastic surgery units had used leeches within five years. Despite their medical value, both Hirudo medicinalis and Hirudo verbana are now endangered species requiring special permits for export.
Medical literature consistently reports high patient tolerance for leech therapy, with minimal noncompliance. Hospital protocols treat leech application matter-of-factly, despite the visceral reality of applying bloodsucking creatures to human tissue. Nurses, the frontline practitioners of leech therapy, universally dislike using them, describing them as "the black slug," "bloodsucking, slimy bugs," and "creepy crawlies." Yet patients offered leech therapy never refuse it, as it's truly the last resort for saving reconstructed tissue.
Leech therapy has declined as surgical techniques have improved, though they remain essential for certain traumas where veins can't be stretched or reattached. They're particularly valuable for scalp injuries, degloving cases, and in disaster scenarios where surgeons lack time for lengthy procedures. After earthquakes, terrorist attacks, and in war zones, leeches become critical medical tools.
At 9.50 to 10 per leech, Biopharm's pricing represents remarkable value considering their two-year breeding process and medical efficacy. The humble leech, spanning old and new medicine, may yet reveal secrets in blood clotting, digestion, anti-inflammation, and pain management-a creature that has already given much to medicine but potentially harbors even greater gifts.
4장
Blood Pioneers: The Heroes Who Transformed Transfusion
Janet Vaughan, immortalized in a portrait at Oxford's Somerville College, played a crucial role in establishing modern blood transfusion practices, though her contributions often go unrecognized. Despite being deemed "too stupid to be educated" by an earlier headmistress and failing her entrance exams twice, she persevered and ultimately earned a first-class degree in medical sciences-an extraordinary achievement for a woman of her time.
Working as a pathologist, she secretly treated anemic patients with raw liver instead of ineffective arsenic treatments, collecting mincing machines (including Virginia Woolf's) to prepare liver extract. She tested the extract on herself before giving it to patients, saving lives while senior professors took the credit. Despite her brilliance, Janet faced constant gender discrimination. At London Hospital, doctors wouldn't speak to her in hallways, sending notes for consultations instead of allowing her bedside visits.
As war approached in the late 1930s, Janet became politically active and recognized that "we shall want some blood. We shall want a great deal of blood." With government estimates predicting up to a million casualties from London bombings, she received 100 to explore blood storage methods, purchasing rubber tubing, corks, and clips to make crude transfusion sets. By April 1939, she gathered doctors and pathologists in her Bloomsbury flat to plan an Emergency Blood Transfusion Service with four strategically located depots throughout London.
Meanwhile, Percy Oliver, a middle-aged civil servant and Red Cross volunteer, had established the voluntary blood donation system that continues today. In 1921, he organized twenty-two volunteers, creating a system that contrasted with prevailing practices where donors were typically paid. The Olivers wanted something different from the paid donor system. They believed strongly in the voluntary ideal, sharing Geoffrey Langdon Keynes' conviction that unpaid blood attracted better donors.
The voluntary system faced numerous challenges. Donors were sometimes treated with puzzling disdain by hospital staff who assumed they were paid. Logistics proved difficult in 1920s London, where few donors had telephones-of 2,050 registered donors a decade into the service, only 400 had phones. The Olivers creatively contacted donors by telegraph, constable, taxi-driver, bicycle, and even police officers. Their approach worked-by 1937, the service was receiving seven thousand calls yearly, with voluntary systems spreading throughout Britain.
During World War II, the Slough depot became the heart of wartime blood donation efforts. Donors came from all walks of life-elderly women who found purpose fixing wire filters for plasma storage, factory workers recruited on-site, and housewives from country villages who gave faithfully every three months. Mobile teams set up temporary bleeding centers in town halls, factory break rooms, church halls, and village pubs. People donated for various reasons-patriotism, health benefits, and simple practicality ("1941. War. Blood needed. I had some. Why not?").
By war's end, the South West London depot had increased distribution from 9,410 bottles in 1940 to 22,397 in 1945, while the Army Blood Transfusion Service grew from collecting 100 pints daily to 1,300. The foundations laid by these pioneers transformed emergency medicine and saved countless lives, establishing principles that continue to guide blood donation systems worldwide.
5장
Blood Borne: The HIV Crisis and Its Evolution
In Khayelitsha, a township serving as Cape Town's essential workforce, MSF runs a clinic that offers comprehensive health services beyond HIV testing to reduce stigma. Despite decades of public health campaigns and widespread HIV literacy among South Africans who speak fluently of viral loads and ARVs, the country still has seven million infected people-the world's highest national total.
The HIV virus attacks with terrifying precision, targeting CD4-positive T-cells-crucial white blood cells that coordinate immune responses like air traffic controllers. Though HIV campaigns use red symbolism for blood, the virus specifically targets transparent white blood cells-leukocytes that comprise just 2% of blood volume but perform "stupefyingly complex" immune functions.
The 1980s AIDS crisis triggered profound fear, exemplified by the UK's infamous 1986 tombstone advertisement featuring John Hurt's ominous narration. This deliberate scaremongering was necessary when HIV meant certain death. Hospital staff sometimes treated patients in full protective gear, though compassionate exceptions existed, like the author's aunt who worked on San Francisco's pioneering AIDS ward where "sixty-three people died in three weeks" amid both heartbreak and camaraderie.
The 1996 breakthrough of combination antiretroviral therapy transformed HIV from a death sentence to a manageable chronic condition. Today, properly medicated HIV-positive people can achieve undetectable viral loads, live normal lifespans, and pose virtually no transmission risk. Despite remarkable progress-18.2 million people now on antiretrovirals compared to under one million in 2000-HIV remains a tale of two epidemics. In wealthy countries, it's become a manageable chronic disease affecting specific populations. Elsewhere, particularly in South Africa, the virus continues its devastation.
In Khayelitsha's schools, students matter-of-factly describe the "levels" of transactional sex: Level 1 earns lunch money, Level 2 provides mobile phone airtime, Level 3 means hair extensions or a smartphone, Level 4 finances a trip to Durban, and the rarely-achieved Level 5 brings a Mercedes-Benz or Dubai vacation. This system perfectly facilitates HIV transmission, as research shows older men infect young women who then pass the virus to partners their own age.
HIV is surprisingly difficult to transmit-the chances of a woman passing it to a male partner range from 1 in 700 to 3,000 exposures, while male-to-female transmission is 1 in 200 to 2,000 exposures. These statistics seem counterintuitive for such a successful pathogen, but the virus compensates through adaptation rather than hardiness.
HIV began when a hunter, likely in 1920s Cameroon, cut himself while preparing chimpanzee meat, allowing simian immunodeficiency virus (SIV-cpz) to cross into human blood. This non-living entity that "borrows life from us, then takes it" became HIV-1 Group M-the deadliest pandemic in history. It thrived because of human behavior: unprotected sex, drug use, and increased mobility during colonialism allowed it to "percolate" unnoticed for eighty years as it spread worldwide.
Despite optimistic global targets like "90-90-90", HIV is far from over. Dr. Eric Goemaere fears "a second wave of the epidemic, made out of resistance and treatment fatigue" alongside donor and media fatigue. The virus remains resilient despite forty years of research and millions in funding. As the mural in Khayelitsha depicts-a strong young woman squinting into the distance-HIV is still coming despite our best efforts, particularly for vulnerable young women.
6장
The Yellow Stuff: Plasma's Precious Power
Plasma, the straw-colored liquid comprising over half our blood's volume, carries proteins including albumin, antibodies and clotting factors. Though it appears unremarkable compared to red blood cells, it's immensely valuable. While fresh frozen plasma from blood banks costs under 30 per unit, processed plasma products like immunoglobulin often exceed gold's price at 35 per gram. The United States, the "OPEC of plasma," exports $19 billion worth annually, with half of Europe's medicinal plasma coming from American donors who typically receive $30 per donation-though the resulting medicines are worth ten times that amount.
For hemophiliacs, who lack proteins essential to blood clotting, plasma-derived products are literal lifesavers. Hemophilia causes excruciating internal bleeding, not just excessive external bleeding as commonly believed. When blood vessels break, blood pours into joint spaces within twenty minutes, causing immense pressure and nerve pain that Justin Levesque describes as "the worst pain ever"-comparable to kidney stones. Frequent bleeds lead to arthritic joints and distinctive painful walking patterns.
Factor VIII revolutionized treatment in the late 1970s, allowing hemophiliacs to live more normal lives with home therapy and even preventative treatment. It was liberating but expensive, requiring plasma from thousands of donors pooled together. Tragically, this miracle carried hidden dangers. Because each dose required plasma from thousands of donors, the risk of infection increased dramatically. By 1983, industry insiders knew that "four infected persons could contaminate the entire world supply."
In the UK alone, 4,689 hemophiliacs were infected with HIV and hepatitis C from contaminated products, with 2,883 deaths so far. Globally, 40,000 hemophiliacs contracted HIV and hundreds of thousands got hepatitis C. At Treloar College, a boarding school for disabled children with a dedicated hemophilia center, fifteen-year-old Ade Goodyear and his schoolmates were casually informed of their HIV status in groups-"you haven't, you have, you have, you haven't." Of five boys in that room, only Goodyear survived.
By 1980, payment for whole blood was considered unethical in the US, yet 70% of plasma still came from paid sellers. Today, the plasma business continues to grow at 10% annually, with companies insisting their products are safe and their donors deserve respect rather than "negative characterizations." Many European countries' residents oppose blood selling but use medicines derived from paid American plasma. Britain, after mad cow disease infected its blood supply, now sources plasma internationally, with its national plasma company sold first to Bain Capital and then to a Chinese conglomerate.
For victims of tainted blood like Ann Hume, the consequences have been devastating. Infected with hepatitis C in 1982 through Factor VIII treatment, she suffered joint pain, fatigue, and osteoarthritis for years before diagnosis. Her medical records mysteriously disappeared-a common occurrence among tainted blood victims. The tainted blood scandal continues to unfold, with new lawsuits and investigations. MP Andy Burnham called it "a criminal cover-up on an industrial scale" rather than a mere tragedy. Of 89 hemophiliac boys at Treloar College during the contamination period, 72 are now dead.
7장
The Menstrual Taboo: Blood's Most Persistent Stigma
In remote Jamu village in western Nepal, nearly every house has a menstrual shed where women are banished during their periods. Sixteen-year-old Radha must sleep in a small, rough shed called a goth during her period, practicing chaupadi-the system of keeping menstruating women apart. She knows she'll be served boiled rice, the same meal as always, brought by her little sister who will throw it onto her plate from a distance, "the way you would feed a dog."
Women publicly defend the practice, claiming it prevents disasters and illness, but privately admit their hatred of it. Surprisingly, women themselves-grandmothers, mothers-in-law, and mothers-are the primary enforcers of these restrictions, perpetuating the belief that menstruation is dirty and dangerous.
Throughout history, menstrual blood has been viewed as a "noxious effluvium" with supernatural powers. Pliny the Elder claimed menstruating women could wither plants, dim mirrors, blunt steel, and even disperse storms when naked. Religious texts from the Old Testament to Buddhist practices prescribed cleansing rituals and separation for menstruating women.
Beyond Nepal, menstrual taboos manifest differently but remain powerful. In India, the author travels with the Great WASH Yatra, a sanitation carnival promoting hygiene across five states. While men eagerly participate in sanitation games, women queue at a revolutionary "MHM Lab" tent marked "FOR LADIES ONLY"-not just for free reusable cloth pads but for precious information. Over 70% of 747 women surveyed knew nothing about periods before menarche because mothers told them nothing. Girls like Khushi and Ankita initially thought cancer or injury caused their bleeding. Nearly all faced restrictions while menstruating, including not touching pickles "because we will rot them" or painting nails "because the varnish will go rotten."
In Bihar, India, the author observes a menstrual hygiene education session where male teachers dominate and spread misinformation. One claims menstruation makes women "ill" and can contaminate food. When discussing school attendance, there's confusion about whether girls can take time off during periods. Poor toilet facilities and fear of staining clothes are major barriers to education. Period pain without access to painkillers is another factor.
The author examines gender bias in pain treatment, citing studies showing men receive stronger pain medication while women's pain is often attributed to emotional factors. Female chronic pain patients are more likely diagnosed with "histrionic disorder" than males with similar symptoms-perpetuating the ancient stereotype of the "hysterical woman and her wandering womb."
When the photographer returned to Nepal years later, Radha was nineteen and married, now enduring only three days of isolation instead of five-a small measure of progress in a world where menstruation remains one of the most stigmatized aspects of human biology.
8장
Period Revolution: Breaking the Silence on Menstruation
Arunachalam Muruganantham, known as "Menstrual Man," revolutionized sanitary pad production in India after discovering his wife using "nasty cloths" for menstruation because commercial pads were unaffordable. After years of research and innovation, he created a simple, low-cost sanitary pad manufacturing machine that now operates in 25 countries.
Unlike large corporations, Muruga's "butterfly" business model takes without damaging-he accepts payment in various forms including livestock or vegetables. His micro, decentralized approach allows women to purchase exactly what they need-different absorbencies for different days of their cycle. The 990 brands across India made on his machines cost about 40 rupees (60 cents) for eight pads, significantly less than commercial options at 140 rupees ($2.13).
The feminine hygiene industry, worth an estimated $23 billion, has masterfully made its products both "indispensable and unspeakable." Throughout history, women have managed menstruation discreetly, with limited historical documentation since women's menstrual technology rarely made it into male-written histories.
The modern feminine hygiene industry truly emerged during World War I when nurses repurposed "cellucotton" wound dressings for menstruation, leading to Kimberly-Clark's 1920 launch of Kotex napkins. The tampon's commercial breakthrough came with Tampax's formal incorporation on March 7, 1936, when Dr. Earle Cleveland Haas developed a "catamenial device" with cotton sewn together and stored in an applicator.
Marketing has historically emphasized cleanliness, discretion, and freedom from limitation. Advertising of sanitary products was banned on American TV until 1972, and the word "period" wasn't spoken in television ads until 1985. Despite progress, menstruation remains stigmatized-even a 2016 "groundbreaking" Bodyform ad showing women bleeding in sports contexts avoided showing actual menstrual blood.
The last few years have witnessed a remarkable shift in menstrual taboos. In 2015, Time magazine featured a tampon on its cover declaring the "YEAR OF THE PERIOD." Athletes like Chinese swimmer Fu Yuanhui openly discussed period-related performance issues, while artists and activists created period-themed works challenging stigma.
This cultural shift has attracted significant investment. Venture capitalists have funded women-run period businesses like Thinx (period underwear) and Flex (menstrual discs), while organic tampon company Lola raised $10 million in 2017 alone. The menstrual tracking app Clue secured $20 million in funding.
Activism has spread globally, with Menstrual Hygiene Day growing to 349 events across 53 countries by its third year. Some governments, including Kenya's, have promised free sanitary products to schoolgirls. Campaigns have also targeted "tampon taxes"-sales taxes applied to menstrual products while items like condoms and lip balm remain exempt.
At the Association for Parents of Mentally Retarded Children in Coimbatore, I try Muruga's pad-making machine firsthand. The process is remarkably simple: cellulose is deconstructed in a grinder, tamped into a steel box, compressed with a lever to form the absorbent core, then enclosed in fabric with an adhesive strip and placed under UV light for thirty seconds.
This simple pad represents far more than its humble appearance suggests. For girls and women who previously dried their clothes with shame and risk, who missed school fearing odor and pain, this pad offers dignity and opportunity. For the women who earn livelihoods producing these affordable sanitary products, each pad represents freedom, prospects, and possibility.
9장
Blood's Future: From Ancient Fears to Modern Frontiers
The final chapter explores humanity's historical relationship with blood as life-force and potential elixir of youth. Throughout history, humans have consumed blood seeking its power. Romans rushed to dying gladiators to drink their blood as a cure for epilepsy, a practice documented across Europe where epileptics brought cups to public executions. Blood was widely believed to extend life, explaining the enduring tale of Pope Innocent VIII allegedly drinking three young men's blood on his deathbed.
Alexander Bogdanov, a doctor and revolutionary close to Lenin and Stalin, established the world's first blood transfusion institute in Moscow in 1926. He practiced "physiological collectivism"-exchanging blood with younger students. He claimed the transfusions halted balding, improved eyesight, and made him look ten years younger. However, after eleven blood exchanges, Bogdanov received blood from a student with tuberculosis and malaria, hoping to cure the young man. Despite being the correct blood group, Bogdanov's immune system reacted fatally-his body had developed antibodies from previous transfusions.
Modern attempts at blood-based rejuvenation include Jesse Karmazin's company Ambrosia, which charges $8,000 to transfuse clients with plasma from donors under thirty-five. The concept draws from parabiosis experiments where young and old mice are surgically connected, allowing blood exchange. Harvard researchers found that when older mice received young blood, their stem cells began acting younger, with improved healing, stronger hearts, and even shinier fur.
Jehovah's Witnesses accept most modern medicine but strictly refuse blood transfusions based on biblical prohibitions. The Witnesses' stance has inadvertently contributed to medical innovation in bloodless surgery techniques. Studies now question whether blood transfusions are always beneficial-one found nearly 60% of transfusions "inappropriate," with evidence suggesting restrictive transfusion policies often produce better outcomes.
The quest for synthetic blood is as old as our understanding of blood circulation. Today, despite billions spent on research, a viable blood substitute remains elusive. Products like PolyHeme, Hemopure, and Sanguinate-mostly hemoglobin-based carriers-have faced significant hurdles. Free hemoglobin scavenges nitric oxide from blood vessels, causing constriction and potentially heart attacks.
NHSBT scientists have made breakthroughs by "immortalizing" immature red cells that remain dormant until activated, potentially creating longer-lasting transfusions. However, the economics remain prohibitive for mass production. Meanwhile, companies like Illumina's Grail are developing blood tests that could detect cancer and other diseases through "liquid biopsies."
Despite our technological advances, blood remains partly mysterious-a substance that has carried our oxygen, fought our infections, and inspired our deepest fears and hopes throughout human history. As Samuel Pepys wrote five hundred years ago, we're achieving "the amending of bad blood by borrowing from a better body," but blood still has much to teach us about ourselves and our shared humanity.
