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A Tale of Two Donors
One morning in March 2009, a man in his mid-fifties arrived at one of the blood banks that I was observing to give blood, as he explained proudly, for the 104th time in his life. Dressed in shorts, a polo shirt, and flip-flops, he began a voluble and lively monologue on his history of donating blood. The donor booklets he carried, clipped together, attested to a long history of donating blood stretching back thirty-two years, which encompassed not just several hospitals in Penang but also others in different states of peninsular Malaysia. Along with his donor booklets, he carried other mementoes of his previous donations: certificates from hospitals, bus tickets to neighboring states, photographs of one of the hospitals that he favored, an envelope that had held a supermarket voucher given as a token of appreciation by one of the blood banks, a special cup that was a souvenir for regular donors from another hospital. He carefully unwrapped these various artifacts from document cases, envelopes, and boxes and displayed them in response to my interest, while lamenting the loss of an inscribed donor's T-shirt, a reward from one blood bank that, he said, had been stolen by a drug addict. I was struck not just by the expansive detail in which this man told me about his history of blood donation but also by how truncated his answers became when I asked him about his family. His wife had died twenty-five years before, he told me, and his only daughter did not live with him. Whereas for many donors it seemed easy to locate their acts of donations in stories of kinship and family lives, which were part of their personal significance, for this person, it seemed as though the value of blood donation had expanded to become the guiding principle that gave meaning to his life.
The embeddedness of acts of donation in particular lives, histories of kinship, and moral discourses was made more complex by the fact that the hospitals where I was located not only took blood from voluntary donors but also operated a system of requesting replacement donations from the families of patients who needed blood transfusions. Some donors had therefore been strongly encouraged to donate by staff keen to maintain the supply of blood available in the hospital blood banks. At the same time that the enthusiastic voluntary donor whom I have just described was expanding on his life history of donation, on the bed next to him in the blood bank another person was also donating blood. In marked contrast to his neighbor, this was a young man who spoke very little and who was clearly feeling quite unwell after donating. Several times, he tried to get up from the bed where he was resting but was seemingly overcome by nausea and giddiness. His mother, who accompanied him, explained that her son was there as a replacement donor for his grandmother, a patient at the hospital, and that he had a phobia about giving blood. On learning that this young man was giving blood for the first time and was clearly suffering the consequences, his older, more voluble, and more experienced neighbor on the next bed told him that if he gave blood more often he would become accustomed to it, and it would get easier. He too had been very tired the first time he had given blood, he said, but in time his body had adjusted to donating every three months. In fact, giving blood was a bit like tapping rubber from a rubber tree — it would quickly be replenished.
These two contrasting cases highlight just some of the differences between donors, as well as the fact that replacement donors may be subject to persuasion from family or friends. But as commentators pointed out to me, the contrast could also be misleading since voluntary donors are also subject to constraints or persuasion of various kinds. Notoriously, the army and police in Malaysia are on occasion more or less ordered to give blood — on a "voluntary" basis. And one university lecturer recalled that when she had been up for promotion and had nothing much to write under the heading "community service," she had been advised that the easiest thing to do would be to donate blood at the university clinic. So between "saving a life," "doing good," "helping others," and other such statements of virtuous altruism, and acting as a replacement donor (or donating more or less on order), a variety of motivating factors come into play. These might include the material signs of recognition with which blood banks sometimes reward donors, such as certificates, special T-shirts, and the like, as well as more overtly financial recompense, including supermarket vouchers, or outwardly less visible monetary compensation from the families of patients receiving blood transfusions. While for many donors less tangible emotions of pride or satisfaction are the central consequences of donating, other factors clearly also play their part. And in many cases, as I will elaborate, these complex motivations are also woven into career paths and family histories.
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This chapter examines the social life of blood from the point of view of donors and of the staff who take their blood. As the above vignette makes clear, the process of donation is an ambivalent one, capable of being read in multiple ways. In order to tease apart these nuances, I begin by describing some of the locations where blood donation takes place and the different contexts in which it occurs. I then examine some of the ways blood donors are categorized and the motivations they articulate for giving blood. What kinds of stories lie behind a willingness to donate blood? The different types of motivation at play — from the altruistic to the more self-interested — feed into a tension between payments and gifts that underlies the practices and discourses surrounding blood donation. Here social exchanges that are endowed with a positive moral aura through the rhetoric of gift-giving or saving a life can be shown to entail more ambiguous and morally loaded judgments and expectations. While Richard Titmuss's ( 1997) pathbreaking study emphasized the morality of the "gift relationship" as ensuring the safety of donated blood and its products, we see how the blood donation is a far from simple act and that an adequate understanding of it entails looking beyond the rhetoric of the gift to "the fine texture of life" (Das 2000, 284; see also Waldby and Mitchell 2006). The gift of blood donation is socially embedded in myriad ways and has the capacity to carry with it some of the personal qualities and history of the donor — in other words, to be gift-like in a more Maussian sense than Titmuss's utopian vision intended.
Preceding donation, a form must be completed by all intending donors and is handed in to blood bank staff. But the relations among the information on the form, the donor, and blood that is given are by no means transparent. Taking the form as a kind of "boundary object" (Bowker and Star 1999), which should standardize and also stabilize the meanings of blood embedded in donation, I look at the kinds of information that the form requires intending donors to supply, the possible answers that may be given, and what happens to this information once the form is completed. Donors themselves can be categorized in various different ways — and the donor form is one means by which such categorizations occur. Potential blood donors are assessed and sometimes turned away by blood bank staff. Some donors have long-term knowledge of those who work in the blood bank, and this can create complex scenarios if staff members feel they should refuse a donor. Such refusals are not always easy for staff to negotiate and must be seen as part of the nexus of social exchanges in which blood is situated. Once it has been donated, blood itself is labeled by blood group, screened, and separated into blood products. But other processes of categorization precede, accompany, and underlie the division of blood into particular categories. Different kinds of hospitals, contexts and modes of donation, as well as different sorts of donors and types of recompense are, as I will show, interwoven in histories of blood-taking.
Alongside the categorization of blood into blood groups, its screening and separation into blood products is a nuanced process of social engagement and distinction that I trace here. Blood itself is multiply embedded in layers of social processes and relationships. The rhetoric of gift-giving and saving a life thus overlays a range of scenarios and exchanges encompassing more coercive or nonvoluntary giving, different forms of nonmonetary recompense, and the difficulty of refusing donors. The transfer of blood to the blood bank and clinical pathology labs involves, by contrast, an attempt to sever these links and obliterate the social traces of donated blood (see chapter 3). Partly because of the imperative to safeguard patients from contamination, and because of the involvement of staff who are themselves social actors, this process of "recategorizing" blood, or re- creating it as an "objective" medical entity, following donation is by no means absolute or complete. The resonances and qualities which blood carries are, it would seem, too powerful to be effectively dispelled through the use of boundary objects and infrastructures. Its social embeddedness occurs in too many domains, and is too multilayered, to be easily disentangled or erased. Blood, as we shall see, has a tendency to overflow its boundaries.
There are many ways to give blood in Malaysia. These range from the most impromptu private gesture executed by lone individuals, simply by going to a hospital blood bank as in my opening vignette, to more populous "spectacles" of blood donation performed in various kinds of public places (including shopping malls, community halls, and temples) and involving several hundred people over the course of a half day or longer. I observed a variety of these sites during my fieldwork in Penang but by no means exhausted the possibilities available to donors. In the hospitals where I was based, intending donors could also come to the blood bank at any time during working hours to donate blood. Blood banks had a slow trickle of intending donors (generally just a few people on most days) who came to donate blood either alone, or sometimes with a spouse, or as a group of friends or colleagues. These donors included members of the public with no particular connection to the hospital, friends or relatives of hospital inpatients who had been encouraged to donate blood, and hospital staff, especially student nurses from the hospital nursing colleges, who were also encouraged to give blood.
The hospitals to which I was attached were small to medium-sized private institutions. Their blood banks had just a few beds to accommodate donors, and they usually had just one or two people on duty in the blood bank. Large-scale blood donation campaigns were organized in various ways. On some occasions a mobile blood campaign was set up by the hospital at a particular factory or other place of work. Workers were offered various kinds of health checks in return for donating blood, for example, blood pressure and blood sugar level checks or breast screening. Some of these were given free, others were paid for at a reduced rate. Workers might also be given a talk on some aspect of health care by one of the hospital doctors.
Other kinds of blood donation campaigns were organized by various civic organizations, such as the Lions Club, Buddhist charitable associations, and associations whose function was to encourage blood donation, with the participation of local hospitals. These were held at different venues, including hospitals, association premises, or community halls. Larger-scale events involved the collaboration of two or three hospitals and were held in large halls. The staff from the blood banks of two or three different hospitals would set up separate long tables for processing intending donors on opposite sides of the hall. Donors would first fill in their donor forms; they would have a short conversation about their answers either while filling in the form or immediately afterward, usually with one of the personnel from the voluntary organization involved, or sometimes with one of the hospital staff. These conversations were not necessarily completely private, as there were often people milling around or the donor was accompanied by members of his or her family.
Having filled in the form, donors would wait in rows of seats before being called forward for their predonation checks. These were carried out by lab staff and nursing students. Intending donors would proceed along one side of a row of tables, where staff members were seated in pairs on the other side carrying out the necessary checks. First, blood pressure was taken and noted by one pair, then hemoglobin level, and then the donor's blood group was ascertained. Once all the checks had been carried out, the donors would proceed with their form to the blood donation area. Here rows of folding beds would be set up — the different hospitals would each occupy different areas of one hall. Waiting donors would sit on seats near each hospital's beds and would be called forward when the staff from the hospital blood bank and clinical pathology labs were ready. Because of the numbers of people being processed, donors sometimes spent several hours at these events. Once a bed became available, the donor would lie down; the lab staff would swab their arm, anesthetize it, and insert a needle attached to a tube and blood bag. Donors were usually then given a small box or bag with various small gifts or a drink and a sandwich in it.
At many of the blood campaigns I attended, cooked food was served to donors and those accompanying them in a separate area. At the blood campaigns held at the hall of one Buddhist association, women from the association cooked various noodle dishes in large pans in the kitchen at the back, and food and cold drinks were served to donors and their families in a room off the main hall in a quite informal way, with some people sitting and some standing in a rather small space. At a blood campaign to honor donors who had given blood many times, which I attended on the mainland, a more elaborate meal was set out at tables for donors and visiting political dignitaries. And at a smaller- scale donation organized by the Lions Club within one of the hospitals, sandwiches and noodle dishes prepared by the hospital canteen as well as warm and cold drinks were served. Some but not all of these events also included speeches.
I take up in more detail below some aspects of the blood donation events that I have described, including the various kinds of exchanges within which they are embedded and the classification of donors through the information they write on their forms. Here I emphasize their flexibility of scale and content: they may constitute private and solitary acts undertaken by an individual at a convenient moment by quietly visiting their local hospital on the way to or from work or on a day off. But they may also involve hundreds of people and combine aspects of political events or civic or social gatherings harnessed to particular causes. Donation events are particularly appropriate for such enlargement because the rhetoric surrounding blood and organ donation is always already phrased in terms of saving a life and helping others. It thus appeals to the heightened moral sense of donors but at the same time can be expanded and co-opted for more overtly political purposes (see Copeman 2009b, 2009c).
Blood donors in Penang came in remarkable variety — men, women, married, unmarried, young or middle-aged, middle-class or working-class, Chinese or Indian Malaysian, Malay, and others. When I asked donors why they had come to donate blood, the replies would often come in the form of the stock phrases employed in public education campaigns and hospital posters, such as "to save a life" or "to help people." Such posters were prominently displayed in blood banks and at other sites of donation, including the mass campaigns that I have described. More persistent questioning could elicit more complex motivations tied to the life stories and kinship relations of donors.(Continues…)
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Table of ContentsForeword / Thomas Gibson ix
The Public Life of Blood I: Donation in the News 35
1. Blood Donation 43
The Public Life of Blood II: Newspapers and Laboratory Life 75
2. Lab Spaces and People: Categories and Distinctions at Work 79
The Public Life of Blood III: Elections and Their Aftermath 116
3. The Work of the Labs 125
The Public Life of Blood IV: Medical, Supernatural, and Moral Matters 158
4. "Work is Just Part of the Job": Ghosts, Food, and Relatedness in the Labs 165
What People are Saying About This
“Blood Work, based on fieldwork in hospital labs and surgeries, blood banks, and blood drives in Penang over ten years (2005–2015), draws on a deep well of insights springing from Janet Carsten’s innovative research on kinship, marriage, and migration in rural Malaysia in the 1980s. One of the most valuable contributions of Carsten’s distinctive sensitivity to the particulars of living and dying in this longtime global crossroads, combined with her keen comparative perspective, is her elucidation of the paradoxical capacity of blood everywhere to unite and divide simultaneously.”
“As Janet Carsten shows, blood is a thick moral substance: it can be bagged and tagged, but its powerful associations with vitality, connection, personhood, and life are not easily shed. Strikingly original, beautifully and often poetically written, Blood Work not only makes an important set of contributions to science and technology studies, anthropology, and Southeast Asian studies; it takes the long-standing themes in Carsten's career to a new level of conceptual innovation.”