SUPPLEMENT ARTICLE The symbolic roots of blood donation Johanne Charbonneau, and Nathalie Y-Lang Tran
INTRODUCTION BACKGROUND: Throughout history, blood has been embedded with powerful and paradoxical connotations. In the last decades, a more rational conception based on scientific knowledge has emerged, portraying blood as a “disenchanted” and utilitarian object, hence more apt for donation between strangers. This study aims to examine blood’s representations in Quebec, Canada. STUDY DESIGN AND METHODS: Data were collected in four separate studies carried out between 2009 and 2011 in Quebec. A total of 234 1 to 11⁄2 hour-long semistructured qualitative interviews were conducted with: 184 donors (including lapsed donors) and 50 nondonors; 106 women and 128 men from a variety of age groups eligible to donate; 76 minority informants from Asian, Middle-Eastern, Latin American, African, and Caribbean origins; and 158 informants from the majority society. RESULTS: Many respondents donated blood because it was a “useful” substance. Others associated blood donation with a gift of vitality, strength, and energy. Some stressed the irreplaceable nature of blood, its rarity, and preciousness. It can also be associated with worrisome representations and seen as “bad” or carry infections: as a fluid, it has the ability to cross troublesome body boundaries. CONCLUSION: This overview of contemporary representations of blood in relation to blood donation in Quebec illustrates that though this substance might be disenchanted for many, it still maintains its mysteriousness for others, which underpins the importance of its social, cultural, and religious representations that can potentially lead to useful avenues in improving donor recruitment and retention.
Research in the area of blood transfusion rarely takes an interest in donors’ representations regarding the symbolic meaning of blood. In 1971, Titmuss1 wrote that, in modern societies, a rational conception based on medical scientific knowledge would henceforward predominate over the beliefs and superstitions of ancient “cultures” regarding the representations of blood. As an example, Titmuss cited the fact that some would have preferred to die rather than receive blood from a different ethnic group. He also noted the idea that receiving blood could even be seen as a form of sacrilege in some cultures where blood is considered an inviolable part of the body. It is hardly surprising that, in societies where it has become crucial to be able to meet medical needs that require a growing use of blood products, a conception more favorable to the free circulation of blood between citizens has come to be promoted. According to Attali,2 the objective of modern medicine is precisely to eliminate the mystical nature and the symbolic charge of blood, so that it might be considered exclusively for its biological features. This is what he calls the “disenchantment of objects.” Blood consequently becomes a merchandise that can be given a price. The commodification of the body has been the subject of numerous reflections over the past decade.3-6 It is exactly because he did not want blood to become just another form of merchandise that Titmuss promoted an altruistic system of blood donation. Such a system guarantees safer blood products than remunerated or replacement donation systems, which remain common blood supply methods in a number of countries today.7-11
From the Université INRS—Centre Urbanisation Culture Société, Montreal, QC, Canada. Address reprint requests to: Johanne Charbonneau, Université INRS—Centre Urbanisation Culture Société, 385 Sherbrooke Street East, Montreal, QC, Canada H2X 1E3; e-mail: [email protected]. Source of support: This study was made possible with the financial contribution of Héma-Québec. doi: 10.1111/trf.12477 TRANSFUSION 2013;53:172S-179S. 172S
TRANSFUSION Volume 53, December 2013 Supplement
BLOOD’S REPRESENTATIONS
In an altruistic system, blood donation is conceived as an act of civic responsibility intended for an unknown “Other,” rather than one motivated by profit or social pressure. According to Titmuss, individuals today live in societies composed of strangers and their world is no longer restricted to their family, kin, or core social or ethnic groups. How can such a system of altruistic donation develop? This is what researchers have attempted to understand over the past decades by examining donor motivations12-20 or by comparing different supply systems.21-26 For their part, anthropologists have never stopped studying the symbolic representations of blood in both Western and non-Western countries. Beliefs associated with blood are thought to be the oldest among those pertaining to the body.27-29 The blood-related vocabulary never designates only the liquid but invariably touches upon the religious, medical, military, or political realms.27 Researchers have also pointed out the “quasi-universality” of blood symbolism among world cultures.29-31 They also underline the paradoxical and bipolar property of blood as a substance and symbol that is associated with both life and death.27,29,32-39 Gilders40 writes that blood is not just a symbol of life, but rather, as a substance, it truly is life. In many societies, blood foremost represents a principle of strength and is known for its regenerative, life-saving, and medical virtues.32,33,38 In some medical cultures, as in China and Vietnam, bodily fluids have specific functions relating to personal health.19,35,41,42 Until the mid-19th century, in Western premodern medicine, bloodletting was a key therapeutic practice used to regain balance between the body’s humors.43 In a historical survey, Binet27 points out that in Mesopotamia, classical Greece, and the Roman Empire, blood rather attracts death, symbolizes vengeance or a stain, and serves to separate the living from the dead.34,35,38,44 In many cultures,44 the body possesses attributes of integrity. It is dangerous to cross the corporeal boundary because it transgresses social conventions. The symbolism of blood is also associated with matters of lineage and race, in addition to the idea that blood is a fluid that carries the essential attributes of individual identity.29 In most cultures around the world, blood is foundational to bonds of kinship and rules that prohibit incest, even if the interpretation varies. As the practice of blood transfusion developed in the wake of the world wars, the positive qualities of blood—which saved the lives of soldiers making the ultimate sacrifice for their homeland—were especially emphasized.28 The duty to give blood for one’s country is also a form of rhetoric found in other countries to motivate blood donors.24,45 The symbolism of blood and its rituals further permeates religious history. In all the major religions, blood is considered a mediator between God and man, even if it may be approached differently.27,39,43,46,47 The interpreta-
tion of danger associated with blood outside the body, for example, has its origins in a conception of bodily integrity found in Christianity and the Islamic tradition, but not in the Buddhist tradition.45 Anthropologists have rightly observed that symbolic conceptions of blood have not disappeared with the passage to modernity. Moreover, certain new interpretations can emerge, as noted by Copeman.25 In India, marked by significant interethnic and interreligious conflict, voluntary donations during spiritual services have become a vehicle for political action and a passive and collective means of protest, not unlike a fast. Over the past few years, two journal issues have been devoted to the topic of blood symbolism (Body & Society, 2009; Journal of the Royal Anthropological Institute, 2013). These articles all demonstrate that the rational conception of blood as detached from its social, cultural, and religious significance is still not predominant in most of the countries studied. In Western countries, blood continues to be a strong symbol of legitimization in social relationships.35 Nelkin48 maintains that blood rituals are indicative of the way societies respond to tension, and interprets the events following the tainted blood affair accordingly. As she notes, at that time, the discourse of blame directed at foreign blood resurfaced, for example in Japan. In the United States, it was not long before Haitians were likewise singled out. Analysis of situations in which “foreign” blood was rejected following a blood drive49,50 reveals sensitive issues surrounding the belonging to a community and the refusal to share in a “blood fraternity.” Analysis of controversies surrounding the exclusion of homosexuals from the practice of blood donation51,52 also suggests that blood remains an important cultural symbol for maintaining order in society.52 In Quebec as in most Western countries, blood donation is voluntary, nonremunerated, and altruistic. One might therefore expect its population to share bloodrelated representations that are primarily influenced by a rational conception stressing the utilitarian role of blood as something that meets medical needs. Like the other Canadian provinces, however, Quebec is a society in which immigration plays a major role, and visible minorities represent a substantial part of its urban population. Among the G8 members (United States, United Kingdom, France, Germany, Japan, Russia, Italy, and Canada), Canada is the first country with the highest number of foreign-born residents (20.6%).53 According to the 2011 census, 87% of foreign-born residents in this province were located in the Montreal area, where they represent 22.6% of the total population. The influx of migration in Quebec is more diversified than in the rest of Canada, and this influx has greatly changed over the years. Between 2006 and 2011, the main countries of immigration in Quebec were Algeria, Morocco, France, Volume 53, December 2013 Supplement TRANSFUSION
173S
CHARBONNEAU AND TRAN
Haiti, China, Colombia, Mexico, and the Philippines. In addition, in the metropolitan region of Montreal, 20.3% of the population belongs to a visible minority. According to Murray,54 migration processes can make blood donation a medium by which to reinforce bonds with “strangers” within our modern societies, including the strangers belonging to migratory waves. Some researchers have taken an interest in representations of blood donation among ethnic minorities in Western cities.50,55-59 Invariably, these studies suggest the key importance of specific cultural conceptions in which belonging to the family and community plays a major role. What do blood donors in Quebec have to say when asked about their symbolic representations of blood? This is the question that our analysis has attempted to answer.
MATERIALS AND METHODS Qualitative methods were chosen because researchers were confident that it could reveal the complexities of blood donation beliefs. Chronologically, the steps undertaken to carry out the four studies were as follows: 1) the elaboration of the interview guides based on a preliminary international literature review; 2) the conducting of semistructured qualitative interviews; and 3) the data analysis. For the purpose of this article, empirical data were collected in four separate studies conducted in Quebec, Canada (Table 1). These studies comprised 234 1 to 11⁄2 hour-long semistructured interviews with: 184 donors (including lapsed donors) and 50 nondonors; 106 women and 128 men from a variety of age groups eligible to donate; 76 minority informants from Asian, Middle-Eastern, Latin American, African, and Caribbean origins; and 158 informants from the majority society. Donors were selected from HémaQuébec’s, the province’s blood supply agency, Progesa database. Nondonors were referred by blood donors chosen from the database, and minority nondonors were referred by leaders of ethnic communities’ organizations in the Montreal metropolitan area. Blood representations were explored through the same series of open questions in each study: • • •
Can you explain if blood means anything to you? How do you think most people would qualify blood? In your opinion, what are the main facilitators or barriers to blood donation?
•
• • • • •
Is blood related to your health in any way? Does blood donation affect your health in any way? If so, explain how. What is your blood type? Does it mean anything to you? For some people, blood means family, community, and society. What is your opinion about that? What is your opinion on anonymity regarding blood donation? What motivated you to donate blood for the first time? Do you know if your religion encourages blood donation? How? Why?
All interviews were carried out in French or in English and most were conducted with two team members present. All were recorded and transcribed. Ethical approvals were delivered by Université INRS and Héma-Québec, and informants were asked to sign consent forms before submitting to the interview. Informants’ anonymity and confidentiality was also always clearly stated. Data were analyzed manually using a grid. The elaborative process of constructing the grid categories was first developed on the basis of the main interview guide themes. Then, brainstorming team discussions were held to ensure that these categories adequately reflected perceptions and beliefs regarding the symbolic meanings of blood. Through the process of indexation, informants’ answers from each study were then categorized and analyzed. The last analytical step brought us to compare the results in light of the following sociodemographic characteristics: age, sex, socio-professional background, religious practices, and ethnic origin.
RESULTS A biological substance that is useful for meeting the needs of the sick Almost half of the respondents spontaneously said that they donated blood to meet the needs of the sick or because they consider it to be a “useful” gesture. In addition to accidents, the respondents mainly referred to problems of anemia, hemophilia, leukemia, and cancer, as well as the needs of women during childbirth. Everyone needs blood, accident victims, sick people, etc. And it’s processed in so many ways afterwards.
TABLE 1. Research projects and proportions of interviews Title of research project Ethnic Minorities and Blood Donation in Quebec (2009-01 to 2010-12) Youth, Altruism and Blood Donation (2009-05 to 2011-04) Families, Altruism and Blood Donation (2011-01 to 2012-05) Blood Donation and Living Environments (2010-11 to 2011-03)
174S
TRANSFUSION Volume 53, December 2013 Supplement
Project code
% N = 234
E1 E2 E3 E4
33% 26% 17% 24%
BLOOD’S REPRESENTATIONS
Blood donation can be used for so many things, it has so many uses, it’s essential. (Woman, 54 years old, civil servant, regular donor, E3) Blood is a product that costs nothing, is easy to extract from the body, and is “wasted” in any case if it is not offered for a blood donation. It is a substance that can be separated into several products, enabling multiple medical usages: They can separate platelets, red blood cells, white blood cells; there are plenty of things they can do with a donation. . . . If they divide it up. (Man, 37 years old, machine operator, regular donor, E4) Several factors have promoted this “disenchanted” view of blood. The respondents themselves may have needed transfusions in their youth or known people who needed them. They may also have witnessed accidents or have worked in a field that made them aware of blood needs. They always need blood and you know, with accidents, there’s often a lot of blood loss . . . There are a lot of road accidents. (Man, 35 years old, regular donor, accident witness, E4) I work at a hospital, I prescribe transfusions, I know it’s important and useful, and that there’s never enough blood. (Man, 26 years old, medical resident, regular donor, E2) They may also have become aware of the cause through information disseminated by the media and agencies. You know, we hear a lot about it and . . . about everything associated with it, accidents, disease and everything, all these people who need blood. (Woman, 40 years old, teacher, nondonor/refused, E4) Among our survey respondents, middle-aged regular donors with occupations in the lower-intermediate categories were most likely to define blood donation in such ways. The youngest and most educated donors, people belonging to ethnic minorities, and those with an active religious practice more often described blood donation as a gift of life and cited other properties of blood that do not reduce it to this utilitarian function.
(somehow) makes you feel like a superhero, I’m doing something good for society. That’s why I continued. (Woman of Senegalese origin, 25 years old, community organizer, regular donor, E1) A number of respondents associated blood donation with a gift of vitality, strength, and energy transmitted by blood transfusion. Some stressed the irreplaceable nature of blood. It is rare and therefore precious. For the respondents, scarcity was often cited in conjunction with blood groups. These groups appear to differentiate the most valuable blood from the rest. For those with the “rarest” blood types, this quality becomes the key motivation to donate and prompts the guilt of those who do not give blood regularly. Conversely, those who described their blood as “ordinary” sometimes used this argument to stop donating. The blood of a “universal donor” appears to be especially valued. Being a carrier of cytomegalovirus (CMV) or not is another factor that lends value to blood. Donors who are not carriers of CMV are informed that their blood can be used for young children. More than one third of the respondents were attentive to the “quality” and rarity of their blood group. This was especially true for young donors. Women were also more sensitive to this factor than men, with the exception of men who had young children and who were CMV negative. Fewer respondents from ethnic minorities assigned importance to this factor, but they were more sensitive to the idea that blood is a carrier of their identity and character traits. Every time you donate blood, your blood changes something in the body of the person receiving your blood, of that I’m sure. . . .. I think in fact that it’s our purpose in life, that our blood continues on. (Man of Vietnamese origin, 57 years old, teacher, regular donor, E1) Even if most of the respondents did not refer to blood as a carrier of identity, some nevertheless stated that it is an intimate and personal substance: “you’re the one who produces it.”
Life for oneself: blood donation and regeneration
The association between blood and life is the most frequently recurring element in the rhetorical discourse of blood product supply organizations. The obvious fact that respondents borrow this vocabulary from the discourse of Héma-Québec is made apparent when they themselves reference the agency’s advertising, which reiterates that “one blood donation saves four lives.”
A certain number of respondents, mostly donors, mentioned the benefits of blood donation for their own health. For some, this was their principal motivation. The respondents cited the advantages of regenerating their blood on both physical and psychological levels: “it cleanses the body,” “I feel less weak,” “it stimulates the body,” “you have less allergies,” “it gives me an energy boost,” “you purify your blood,” “it boosts your immune system.”
The first time, one of the nurses [told me], “you know, you can save four lives with one blood donation” . . . it
It’s good for oxygenating your blood, for creating new blood. Regenerating the blood. When I read that, I can
Blood donation as a gift of life?
Volume 53, December 2013 Supplement TRANSFUSION
175S
CHARBONNEAU AND TRAN
say this motivated me to donate. (Man of Salvadorian origin, 39 years old, pastor, former donor, E1)
can’t handle, it’s really silly. (Woman, 21 years old, student, former donor, E2)
I think a good bleeding, they used to do that back in the day. . . . I would say that it feels good, you see a difference. . . . (Man, 25 years old, student, regular donor, E2)
This fear of needles was frequently cited in our interviews by both nondonors and those who stopped donating after one or several donations. Their comments reveal an aversion to these instruments that pierce the boundary of the body and fail to respect its integrity. Others said they could not bear the idea of blood leaving their bodies.
This impression of personally benefitting from the physical advantages of renewed blood appears to be cited slightly more often by men than women, but it is mentioned by people of all ages. The respondents from ethnic minorities also mentioned this impression. The argument of regeneration has been emphasized by both Catholics of Vietnamese origin and Muslims of Lebanese origin. However, the respondents belonging to ethnic minorities more frequently associated blood donation with a loss of energy and the danger of an imbalance in bodily strength. The connection between blood and health, for some, also has to do with the importance of staying healthy to be able to provide “good blood.”
The worrisome side of blood donation Making a blood donation is a privilege reserved for those with “healthy” blood. The knowledge that their blood does not qualify for donation was very negatively received by our respondents. The respondents often used the expression “my blood isn’t good”: they understand that their blood might carry a risk of transmitting disease and they are disappointed that they fall short. Some protested and maintained that their blood was good (or fine), even if they had traveled to a country with high risks of contracting certain diseases, and even if they engaged in at-risk sexual practices. The tainted blood affair seems to have left few traces in the memory of the respondents. Since Héma-Québec has become responsible for supplying blood in Quebec, the respondents all stated that they are not afraid of becoming infected via blood donation. Independently of their characteristics, some respondents nevertheless remained anxious at the idea of receiving a blood transfusion. Douglas44 has shown the historical importance of respecting the integrity of the body in certain cultures, as well as dangers associated with crossing the corporeal boundary. One might expect that, today, only the active members of certain religious communities would assign importance to this conception of the body. Upon analysis of the respondents’ statements, however, the fear of needles—which is widely cited as an obstacle in surveys on blood donation motivations—appears to relate to this conception. I’m afraid of needles. When I went to donate, my fears were confirmed. I panicked. . . . It’s like an ordeal I 176S
TRANSFUSION Volume 53, December 2013 Supplement
My blood isn’t always easy to draw, and one time, she was using the needle, searching for the vein [and the blood] sort of came out . . . . It wasn’t a pretty sight. Seeing blood is always something, isn’t it? I guess I’m kind of a wimp, right? It scares me. (Woman, 46 years old, office clerk, regular donor, E4) A few, for their part, expressed reluctance about apheresis donation, as they could not bear the idea that their blood, once outside their body, could be returned to it. I don’t like the idea of having my blood removed and then put back into me, with something taken out of it. . . . I don’t like having my blood returned to me. (Woman, 23 years old, student in biomedical sciences, regular donor, E3) The respondents who expressed this fear of needles or the sight of blood outside the body often added that they were aware that this was not very rational; they were almost apologetic about it.
Blood donation and belonging to the community A third of the respondents justified their blood donation in terms that relate to the outlook of “generalized altruism” (directed toward an unknown “Other”). More women referred to this conception than men. These respondents expressed themselves in relatively abstract terms: they gave blood to do the right thing, to do a good deed, to act out of generosity, to give to their fellow man, to make a difference, to transmit good values, to compensate for those who do not give, etc. It is a gift that I give; no one will know that I made the donation. When you give blood, it really is a gift. (Man, 35 years old, civil servant, regular donor, E4) The altruistic motivations appeared to have numerous sources. Certain expressions indicate the influence of religious values, while others reflect a sense of belonging as a citizen or community member. In general, the donor motivations were often altruistic justifications, religious obligations, or reasons of civic duty and/or community solidarity. It’s a combination between a generous act and an obligation, for you and the community. People need
BLOOD’S REPRESENTATIONS
blood and no one else is going to make it. We are only going to get it from other people. (Man, Polish origin, Jewish, 56 years old, senior executive, regular donor, E1) A number of donors still said that they gave “for their children” or “for their family and neighbors,” even if they knew that these were not the people who would actually receive their blood. Some also expressed preferences about donating blood within their more limited communities. As mentioned earlier, one of the principal properties of blood cited by the respondents who associated it with the gift of life is the fact that it is rare and therefore precious. This property, according to some, justifies sharing blood exclusively with family and close acquaintances. These interpretations were more common among respondents from ethnic minorities, and in particular respondents of Asian origin or from Black communities. We inherited our blood. It’s very well looked upon to give our blood to family. . . . but giving to a stranger, I think that’s a little more limited. (Man, professional of Chinese origin, no donation, E1) You want to give the blood to who you want to give. You want to choose [. . .] For example Muslim person will say: “why should I give blood for other religion?” [. . .] If you go to the community and ask, they will say that, line of the family goes with the blood; you know that, blood lineage that you have [. . .] I am not giving my blood for common people. If I give blood, I will give for my own people. (Woman of Pakistani origin, Muslim, community leader, no donation, E1) None of the respondents from the majority population associated their blood with that of their ancestors or a limited community. “We’re all human, we all have the same blood flowing through our veins.” (Woman, 23 years old, student, nondonor/refused, E2) We met more individuals who refused to donate blood out of solidarity with specific people (homosexuals, immigrants from certain specific countries) that they saw on a daily basis, for example at work, and who are not allowed to donate blood because of restrictions established by Héma-Québec to ensure blood product safety. In other words, they acted out of solidarity because they deemed the rules to be too strict. These nondonors were therefore very much aware that refusing offered blood can be symbolically interpreted as a refusal of the social bond and can express a “moral boundary.” For its part, discourse that promotes the power of blood to create a fictional fraternity, which integrates minorities into Quebec society at large, has primarily been found in the representations of certain associations that use this argument to justify their organization of blood drives. None of our survey participants from the majority population said that they had an active religious practice.
As a result, they did not directly relate blood donation to religious prescriptions. At most, some recalled that they were raised in the Catholic faith and that their parents transmitted to them values of Christian charity, which are favorable to self-giving and hence to blood donation. In the study conducted with ethnic minorities, realities were different. These donors showed a more active religious practice than our respondents from the majority population. They also drew a connection with the fact that their religion—regardless of what it is—encourages self-giving, charitable deeds, volunteer work, and altruism, all values favorable to blood donation. Jewish, Muslim, and Christian leaders met in our study based themselves on sacred texts to encourage their followers to give blood. Muslims, and sometimes Christians as well, sometimes also mentioned the importance of donating blood to honor martyrs. We have an event in the Islamic calendar that’s very special, that really brings us into the history of Islam. It’s about martyrdom, the martyr of the grandson of the prophet Mohammed. . . . Muslims here say that, “during that period, sacrifices must be made.” Blood donation, or blood collection, is about connecting with that step, in the sense of a sacrifice. (Man of Lebanese origin, Muslim, blood drive partner, E1) In our Christian faith . . . blood is a symbol of sacrifice, of life . . . just as our martyrs spilled their blood to save people and to defend human rights, we have said that we would help our brother in humanity. (Man of Lebanese origin, Catholic, blood drive partner, E1) We approached the Rabbi and he said it’s a mitzvah, which is a Hebrew word which means an extremely good deed . . .. this he said, is a huge mitzvah, you are giving life when you are giving blood. (Woman, Jewish, blood drive partner, E1)
DISCUSSION This overview of contemporary representations of blood in relation to blood donation in Quebec illustrates that though this substance might be disenchanted for many, it still maintains its mysteriousness for others. We have seen that it is not only for those who hold religious values or for immigrants whose culture of origin might let to presuppose that blood, for them, is a symbolic substance. We have given many examples of cases where, for some, the seemingly common practice of giving blood might indeed reveal itself not so trivial: belief in regeneration of the body, fear of needles and spilt blood, the notion that part of one’s identity can be transmitted to the receiver, deception of learning that one’s blood does not qualify to be given to a dignified recipient such as a child. It is not conceivable that informants should suddenly give Volume 53, December 2013 Supplement TRANSFUSION
177S
CHARBONNEAU AND TRAN
up all these beliefs and as we have seen, many continue to apologize for maintaining these “irrational” conceptions of blood. Analysis of data from our survey suggests that when it comes to the cultural, social, and religious symbolism of blood, the greatest distinctions observed are between representatives of the majority Quebec population and those of ethnic minorities. It was therefore relevant to question the potential influence of ethnic diversity on symbolic representations of blood, especially in a society dominated by the Western model of altruistic donation, but that also welcomes a substantial percentage of groups with very diverse ethnic backgrounds. Less rational representations of blood were also clearly present in the statements of respondents belonging to the majority population. These representations are sometimes favorable to blood donation, as in the case of those who believe in a connection between well-being and the regeneration of blood. In other cases, they are not, for example when they entail an aversion to seeing the boundary of the skin pierced by a needle. A socio-anthropological approach to representations of blood and blood donation offers a useful contribution for identifying and interpreting donor motivations, as well as potential obstacles to the practice of blood donation. Recalling that blood is still associated with social, cultural, and religious representations that are important to many people can, additionally, lead to useful avenues to improve donor recruitment and retention. Like all studies, this one has its limitations. The first is undoubtedly the fact that its conclusions cannot be generalized, not only because of the qualitative method used but also because of the social, cultural, and demographic characteristics that are specific to each country. The other significant limitation has to do with the value of comparisons we have proposed based on these characteristics, particularly when they concern ethnic minorities. Ethnic minority donors recruited in this study were not necessarily representative of their groups. Furthermore, only a few members of each group were interviewed. It should also be mentioned that the recruitment process was very complicated. Before 2010, it was impossible to identify the donors in these communities using the Progesa database, and several complementary strategies had to be used to this end. Generally speaking, this population is also known to be difficult to reach and to have greater difficulty participating in such surveys than the majority population. ACKNOWLEDGMENTS We gratefully Héma-Québec.
acknowledge
the
financial
support
of
CONFLICT OF INTEREST The authors report no conflicts of interest or funding sources.
178S
TRANSFUSION Volume 53, December 2013 Supplement
REFERENCES 1. Titmuss RM. The gift relationship: from human blood to social policy. London: Allen & Unwin; 1971. 2. Attali J. La symbolique du sang dans la société. Transfus Clin Biol 2004;11:271-3. 3. Scheper-Hughes N, Wacquant LJ. Commodifying bodies. London: Sage Publications; 2002. 4. Waldby C, Mitchell R. Tissue economies: blood, organs, and cell lines in late capitalism. Durham: Duke University Press; 2006. 5. Andrews LB, Nelkin D. Body bazaar: the market for human tissue in the biotechnology age. New York: Crown Publishers; 2001. 6. Lock MM, Nguyen VK. An anthropology of biomedicine. Chichester: Wiley-Blackwell; 2010. 7. Shan H, Wang JX, Ren FR, et al. Blood banking in China. Lancet 2002;360:1770-5. 8. Martinez C. L’expérience d’un médecin de prélèvement au Chili. Transfus Clin Biol 2006;13:203-5. 9. Kalibatas V. Payment for whole blood donations in Lithuania: the risk for infectious disease markers. Vox Sang 2008;94:209-15. 10. Sampath S, Ramsaran V, Parasram S, et al. Attitudes towards blood donation in Trinidad and Tobago. Transfus Med 2007;17:83-7. 11. Allain JP, Sarkodie F, Asenso-Mensah K, et al. Relative safety of first-time volunteer and replacement donors in West Africa. Transfusion 2010;50:340-3. 12. Piliavin JA, Callero PL. Giving blood: the development of an altruistic identity. Baltimore: Johns Hopkins University Press; 1991. 13. Giles M, Cairns E. Blood donation and Ajzen’s theory of planned behaviour: an examination of perceived behavioural control. Br J Soc Psychol 1995;34:173-88. 14. Armitage CJ, Conner M. Social cognitive determinants of blood donation. J Appl Soc Psychol 2001;31: 1431-57. 15. Godin G, Conner M, Sheeran P, et al. Determinants of repeated blood donation among new and experienced blood donors. Transfusion 2007;47:1607-15. 16. Lemmens KP, Abraham C, Hoekstra T, et al. Why do young people volunteer to give blood? An investigation of the correlates of donation intentions among young nondonors. Transfusion 2005;45:945-55. 17. Misje AH, Bosnes V, Gasdal O, et al. Motivation, recruitment and retention of voluntary non-remunerated blood donors: a survey-based questionnaire study. Vox Sang 2005;89:236-44. 18. Sojka BN, Sojka P. The blood donation experience: selfreported motives and obstacles for donating blood. Vox Sang 2008;94:56-63. 19. Bednall TC, Bove LL. Donating blood: a meta-analytic review of self-reported motivators and deterrents. Transfus Med Rev 2011;25:317-34.
BLOOD’S REPRESENTATIONS
20. Ferguson E, Farrell K, Lawrence C. Blood donation is an act
41. Mok Chan WY. Blood donation in Hong Kong. A case study
of benevolence rather than altruism. Health Psychol 2008; 27:327-36. 21. Healy K. Last best gifts. Altruism and the market for
of the impact of the mass media on beliefs and behavior [M.A. thesis]. University of Hong Kong; 1978:205. 42. Maher L, Ho HT. Overdose beliefs and management prac-
human blood and organs. Chicago: University of Chicago Press; 2006. 22. Smith A, Matthews R, Fiddler J. Blood donation and
tices among ethnic Vietnamese heroin users in Sydney, Australia. Harm Reduct J 2009;6:1-10. 43. Rousseau V. Le goût du sang: croyances et polémiques
community: exploring the influence of social capital. IJSI 2011;4:45-63. 23. Simpson R. Blood rhetorics: donor campaigns and their
dans la chrétienneté occidentale. Paris: Armand Colin; 2005. 44. Douglas M. Purity and danger: an analysis of concepts of
publics in contemporary Sri Lanka. Ethnos 2011;76: 254-75. 24. Adams V, Erwin K, Le PV. Public health works: blood
pollution and taboo. London: Routledge & Kegan Paul; 1966. 45. Simpson R. Impossible gifts: bodies, buddhism and bioeth-
donation in urban China. Soc Sci Med 2009;68:
ics in contemporary Sri Lanka. J R Anthropol Inst 2004;10:
410-8. 25. Copeman J. Gathering points: blood donation and the scenography of “national integration” in India. Body Soc 2009; 15:71-99.
839-59. 46. Roux JP. Le sang: mythes, symboles et réalités. Paris: A. Fayard; 1988. 47. Biale D. Blood and belief. An introduction to a Jewish
26. Parmasad V. Elle est mon sang: don de remplacement, parentalité et liens transactionnels à Trinité-et-Tobago. In: Charbonneau J, Tran N, editors. Les enjeux du don de
symbol. In: Hart MB, editor. Jewish blood: reality and metaphor in history, religion, and culture. London; New York: Routledge; 2009. p. 15-30.
sang dans le monde: entre altruisme et solidarités, universalisme et gestion des risques. Rennes: Presses
48. Nelkin D. Cultural perspectives on blood. In: Feldman EA, Bayer R, editors. Blood feuds: AIDS, blood, and the politics
de l’École des hautes études en santé publique; 2012. p. 241-60.
of medical disaster. New York: Oxford University Press; 1999. p. 273-92.
27. Binet JL. Le sang et les hommes. Paris: Gallimard; 1988. 28. Danic B, Lefrère JJ. Le sang dans l’art, l’art dans le sang. Transfus Clin Biol 2010;17:382-5.
49. Seeman D. “One people, one blood”: public health, political violence, and HIV in an Ethiopian-Israeli setting. Cult Med Psychiatry 1999;23:159-95.
29. Meyer ML. Thicker than water: the origins of blood as symbol and ritual. New York: Routledge; 2005.
50. Sutterlüty F. The belief in ethnic kinship. Ethnography 2006;7:179-207.
30. Hart MB. Jewish blood: reality and metaphor in history, religion, and culture. London: Routledge; 2009.
51. Strong T. Vital publics of pure blood. Body Soc 2009;15: 169-91.
31. Hugh-Jones S. Analyses de sang. Terrain 2011; 56:2-19. 32. Camporesi P. Juice of life: the symbolic and magic signifi-
52. Valentine K. Citizenship, identity, blood donation. Body Soc 2005;11:113-28. 53. Statistics Canada. National Household Survey, 2011.
cance of blood. New York: Continuum; 1995. 33. Frazer JG. The golden bough; a study in magic and reli-
Ottawa: Minister of Industry, 2013. 54. Murray TH. The poisoned gift: AIDS and blood. In: Nelkin
gion. New York: Macmillan; 1951. 34. Lévy-Bruhl L. Le surnaturel et la nature dans la mentalité primitive. Paris: F. Alcan; 1931. 35. Cros M. Anthropologie du sang en Afrique: essai d’hématologie symbolique chez les Lobi du Burkina Faso et de Côte-d’Ivoire. Paris: L’Harmattan; 1990. 36. Mino G. Magia Sanguinis: blood and magic in Classical antiguity. In: Bradburne JM, editor. Blood: art, politics, and pathology. Munich: Prestel; 2001. p. 33-40. 37. Bynum CW. Wonderful blood: theology and practice in late medieval northern Germany and beyond. Philadelphia: University of Pennsylvania Press; 2007. 38. Cazeneuve J. Sociologie du rite (tabou, magie, sacré). Paris: Presses universitaires de France; 1971. 39. Chebel M. Le corps en Islam. Paris: PUF; 1999. 40. Gilders WK. Blood ritual in the Hebrew Bible: meaning and power. Baltimore: Johns Hopkins University Press; 2004.
55.
56.
57. 58.
59.
D, Willis DP, Parris S, editors. A disease of society: cultural and institutional responses to AIDS. Cambridge: Cambridge University Press; 1991. p. 216-40. Amponsah-Afuwape SA, Myers LB, Newman SP. Cognitive predictors of ethnic minorities’ blood donation intention. Psychol Health Med 2002;7:357-61. Grassineau D, Papa K, Ducourneau A, et al. Improving minority blood donation: anthropologic approach in a migrant community. Transfusion 2007;47:402-9. Fantauzzi A. Sangue migrante. Milan: Franco Angeli; 2012. Mathew SM, King MR, Glynn SA, et al. Opinions about donating blood among those who never gave and those who stopped: a focus group assessment. Transfusion 2007; 47:729-35. Polonsky MJ, Brijnath B, Renzaho AM. “They don’t want our blood”: social inclusion and blood donation among African migrants in Australia. Soc Sci Med 2011;73: 336-42.
Volume 53, December 2013 Supplement TRANSFUSION
179S
INTRODUCTION BACKGROUND: Throughout history, blood has been embedded with powerful and paradoxical connotations. In the last decades, a more rational conception based on scientific knowledge has emerged, portraying blood as a “disenchanted” and utilitarian object, hence more apt for donation between strangers. This study aims to examine blood’s representations in Quebec, Canada. STUDY DESIGN AND METHODS: Data were collected in four separate studies carried out between 2009 and 2011 in Quebec. A total of 234 1 to 11⁄2 hour-long semistructured qualitative interviews were conducted with: 184 donors (including lapsed donors) and 50 nondonors; 106 women and 128 men from a variety of age groups eligible to donate; 76 minority informants from Asian, Middle-Eastern, Latin American, African, and Caribbean origins; and 158 informants from the majority society. RESULTS: Many respondents donated blood because it was a “useful” substance. Others associated blood donation with a gift of vitality, strength, and energy. Some stressed the irreplaceable nature of blood, its rarity, and preciousness. It can also be associated with worrisome representations and seen as “bad” or carry infections: as a fluid, it has the ability to cross troublesome body boundaries. CONCLUSION: This overview of contemporary representations of blood in relation to blood donation in Quebec illustrates that though this substance might be disenchanted for many, it still maintains its mysteriousness for others, which underpins the importance of its social, cultural, and religious representations that can potentially lead to useful avenues in improving donor recruitment and retention.
Research in the area of blood transfusion rarely takes an interest in donors’ representations regarding the symbolic meaning of blood. In 1971, Titmuss1 wrote that, in modern societies, a rational conception based on medical scientific knowledge would henceforward predominate over the beliefs and superstitions of ancient “cultures” regarding the representations of blood. As an example, Titmuss cited the fact that some would have preferred to die rather than receive blood from a different ethnic group. He also noted the idea that receiving blood could even be seen as a form of sacrilege in some cultures where blood is considered an inviolable part of the body. It is hardly surprising that, in societies where it has become crucial to be able to meet medical needs that require a growing use of blood products, a conception more favorable to the free circulation of blood between citizens has come to be promoted. According to Attali,2 the objective of modern medicine is precisely to eliminate the mystical nature and the symbolic charge of blood, so that it might be considered exclusively for its biological features. This is what he calls the “disenchantment of objects.” Blood consequently becomes a merchandise that can be given a price. The commodification of the body has been the subject of numerous reflections over the past decade.3-6 It is exactly because he did not want blood to become just another form of merchandise that Titmuss promoted an altruistic system of blood donation. Such a system guarantees safer blood products than remunerated or replacement donation systems, which remain common blood supply methods in a number of countries today.7-11
From the Université INRS—Centre Urbanisation Culture Société, Montreal, QC, Canada. Address reprint requests to: Johanne Charbonneau, Université INRS—Centre Urbanisation Culture Société, 385 Sherbrooke Street East, Montreal, QC, Canada H2X 1E3; e-mail: [email protected]. Source of support: This study was made possible with the financial contribution of Héma-Québec. doi: 10.1111/trf.12477 TRANSFUSION 2013;53:172S-179S. 172S
TRANSFUSION Volume 53, December 2013 Supplement
BLOOD’S REPRESENTATIONS
In an altruistic system, blood donation is conceived as an act of civic responsibility intended for an unknown “Other,” rather than one motivated by profit or social pressure. According to Titmuss, individuals today live in societies composed of strangers and their world is no longer restricted to their family, kin, or core social or ethnic groups. How can such a system of altruistic donation develop? This is what researchers have attempted to understand over the past decades by examining donor motivations12-20 or by comparing different supply systems.21-26 For their part, anthropologists have never stopped studying the symbolic representations of blood in both Western and non-Western countries. Beliefs associated with blood are thought to be the oldest among those pertaining to the body.27-29 The blood-related vocabulary never designates only the liquid but invariably touches upon the religious, medical, military, or political realms.27 Researchers have also pointed out the “quasi-universality” of blood symbolism among world cultures.29-31 They also underline the paradoxical and bipolar property of blood as a substance and symbol that is associated with both life and death.27,29,32-39 Gilders40 writes that blood is not just a symbol of life, but rather, as a substance, it truly is life. In many societies, blood foremost represents a principle of strength and is known for its regenerative, life-saving, and medical virtues.32,33,38 In some medical cultures, as in China and Vietnam, bodily fluids have specific functions relating to personal health.19,35,41,42 Until the mid-19th century, in Western premodern medicine, bloodletting was a key therapeutic practice used to regain balance between the body’s humors.43 In a historical survey, Binet27 points out that in Mesopotamia, classical Greece, and the Roman Empire, blood rather attracts death, symbolizes vengeance or a stain, and serves to separate the living from the dead.34,35,38,44 In many cultures,44 the body possesses attributes of integrity. It is dangerous to cross the corporeal boundary because it transgresses social conventions. The symbolism of blood is also associated with matters of lineage and race, in addition to the idea that blood is a fluid that carries the essential attributes of individual identity.29 In most cultures around the world, blood is foundational to bonds of kinship and rules that prohibit incest, even if the interpretation varies. As the practice of blood transfusion developed in the wake of the world wars, the positive qualities of blood—which saved the lives of soldiers making the ultimate sacrifice for their homeland—were especially emphasized.28 The duty to give blood for one’s country is also a form of rhetoric found in other countries to motivate blood donors.24,45 The symbolism of blood and its rituals further permeates religious history. In all the major religions, blood is considered a mediator between God and man, even if it may be approached differently.27,39,43,46,47 The interpreta-
tion of danger associated with blood outside the body, for example, has its origins in a conception of bodily integrity found in Christianity and the Islamic tradition, but not in the Buddhist tradition.45 Anthropologists have rightly observed that symbolic conceptions of blood have not disappeared with the passage to modernity. Moreover, certain new interpretations can emerge, as noted by Copeman.25 In India, marked by significant interethnic and interreligious conflict, voluntary donations during spiritual services have become a vehicle for political action and a passive and collective means of protest, not unlike a fast. Over the past few years, two journal issues have been devoted to the topic of blood symbolism (Body & Society, 2009; Journal of the Royal Anthropological Institute, 2013). These articles all demonstrate that the rational conception of blood as detached from its social, cultural, and religious significance is still not predominant in most of the countries studied. In Western countries, blood continues to be a strong symbol of legitimization in social relationships.35 Nelkin48 maintains that blood rituals are indicative of the way societies respond to tension, and interprets the events following the tainted blood affair accordingly. As she notes, at that time, the discourse of blame directed at foreign blood resurfaced, for example in Japan. In the United States, it was not long before Haitians were likewise singled out. Analysis of situations in which “foreign” blood was rejected following a blood drive49,50 reveals sensitive issues surrounding the belonging to a community and the refusal to share in a “blood fraternity.” Analysis of controversies surrounding the exclusion of homosexuals from the practice of blood donation51,52 also suggests that blood remains an important cultural symbol for maintaining order in society.52 In Quebec as in most Western countries, blood donation is voluntary, nonremunerated, and altruistic. One might therefore expect its population to share bloodrelated representations that are primarily influenced by a rational conception stressing the utilitarian role of blood as something that meets medical needs. Like the other Canadian provinces, however, Quebec is a society in which immigration plays a major role, and visible minorities represent a substantial part of its urban population. Among the G8 members (United States, United Kingdom, France, Germany, Japan, Russia, Italy, and Canada), Canada is the first country with the highest number of foreign-born residents (20.6%).53 According to the 2011 census, 87% of foreign-born residents in this province were located in the Montreal area, where they represent 22.6% of the total population. The influx of migration in Quebec is more diversified than in the rest of Canada, and this influx has greatly changed over the years. Between 2006 and 2011, the main countries of immigration in Quebec were Algeria, Morocco, France, Volume 53, December 2013 Supplement TRANSFUSION
173S
CHARBONNEAU AND TRAN
Haiti, China, Colombia, Mexico, and the Philippines. In addition, in the metropolitan region of Montreal, 20.3% of the population belongs to a visible minority. According to Murray,54 migration processes can make blood donation a medium by which to reinforce bonds with “strangers” within our modern societies, including the strangers belonging to migratory waves. Some researchers have taken an interest in representations of blood donation among ethnic minorities in Western cities.50,55-59 Invariably, these studies suggest the key importance of specific cultural conceptions in which belonging to the family and community plays a major role. What do blood donors in Quebec have to say when asked about their symbolic representations of blood? This is the question that our analysis has attempted to answer.
MATERIALS AND METHODS Qualitative methods were chosen because researchers were confident that it could reveal the complexities of blood donation beliefs. Chronologically, the steps undertaken to carry out the four studies were as follows: 1) the elaboration of the interview guides based on a preliminary international literature review; 2) the conducting of semistructured qualitative interviews; and 3) the data analysis. For the purpose of this article, empirical data were collected in four separate studies conducted in Quebec, Canada (Table 1). These studies comprised 234 1 to 11⁄2 hour-long semistructured interviews with: 184 donors (including lapsed donors) and 50 nondonors; 106 women and 128 men from a variety of age groups eligible to donate; 76 minority informants from Asian, Middle-Eastern, Latin American, African, and Caribbean origins; and 158 informants from the majority society. Donors were selected from HémaQuébec’s, the province’s blood supply agency, Progesa database. Nondonors were referred by blood donors chosen from the database, and minority nondonors were referred by leaders of ethnic communities’ organizations in the Montreal metropolitan area. Blood representations were explored through the same series of open questions in each study: • • •
Can you explain if blood means anything to you? How do you think most people would qualify blood? In your opinion, what are the main facilitators or barriers to blood donation?
•
• • • • •
Is blood related to your health in any way? Does blood donation affect your health in any way? If so, explain how. What is your blood type? Does it mean anything to you? For some people, blood means family, community, and society. What is your opinion about that? What is your opinion on anonymity regarding blood donation? What motivated you to donate blood for the first time? Do you know if your religion encourages blood donation? How? Why?
All interviews were carried out in French or in English and most were conducted with two team members present. All were recorded and transcribed. Ethical approvals were delivered by Université INRS and Héma-Québec, and informants were asked to sign consent forms before submitting to the interview. Informants’ anonymity and confidentiality was also always clearly stated. Data were analyzed manually using a grid. The elaborative process of constructing the grid categories was first developed on the basis of the main interview guide themes. Then, brainstorming team discussions were held to ensure that these categories adequately reflected perceptions and beliefs regarding the symbolic meanings of blood. Through the process of indexation, informants’ answers from each study were then categorized and analyzed. The last analytical step brought us to compare the results in light of the following sociodemographic characteristics: age, sex, socio-professional background, religious practices, and ethnic origin.
RESULTS A biological substance that is useful for meeting the needs of the sick Almost half of the respondents spontaneously said that they donated blood to meet the needs of the sick or because they consider it to be a “useful” gesture. In addition to accidents, the respondents mainly referred to problems of anemia, hemophilia, leukemia, and cancer, as well as the needs of women during childbirth. Everyone needs blood, accident victims, sick people, etc. And it’s processed in so many ways afterwards.
TABLE 1. Research projects and proportions of interviews Title of research project Ethnic Minorities and Blood Donation in Quebec (2009-01 to 2010-12) Youth, Altruism and Blood Donation (2009-05 to 2011-04) Families, Altruism and Blood Donation (2011-01 to 2012-05) Blood Donation and Living Environments (2010-11 to 2011-03)
174S
TRANSFUSION Volume 53, December 2013 Supplement
Project code
% N = 234
E1 E2 E3 E4
33% 26% 17% 24%
BLOOD’S REPRESENTATIONS
Blood donation can be used for so many things, it has so many uses, it’s essential. (Woman, 54 years old, civil servant, regular donor, E3) Blood is a product that costs nothing, is easy to extract from the body, and is “wasted” in any case if it is not offered for a blood donation. It is a substance that can be separated into several products, enabling multiple medical usages: They can separate platelets, red blood cells, white blood cells; there are plenty of things they can do with a donation. . . . If they divide it up. (Man, 37 years old, machine operator, regular donor, E4) Several factors have promoted this “disenchanted” view of blood. The respondents themselves may have needed transfusions in their youth or known people who needed them. They may also have witnessed accidents or have worked in a field that made them aware of blood needs. They always need blood and you know, with accidents, there’s often a lot of blood loss . . . There are a lot of road accidents. (Man, 35 years old, regular donor, accident witness, E4) I work at a hospital, I prescribe transfusions, I know it’s important and useful, and that there’s never enough blood. (Man, 26 years old, medical resident, regular donor, E2) They may also have become aware of the cause through information disseminated by the media and agencies. You know, we hear a lot about it and . . . about everything associated with it, accidents, disease and everything, all these people who need blood. (Woman, 40 years old, teacher, nondonor/refused, E4) Among our survey respondents, middle-aged regular donors with occupations in the lower-intermediate categories were most likely to define blood donation in such ways. The youngest and most educated donors, people belonging to ethnic minorities, and those with an active religious practice more often described blood donation as a gift of life and cited other properties of blood that do not reduce it to this utilitarian function.
(somehow) makes you feel like a superhero, I’m doing something good for society. That’s why I continued. (Woman of Senegalese origin, 25 years old, community organizer, regular donor, E1) A number of respondents associated blood donation with a gift of vitality, strength, and energy transmitted by blood transfusion. Some stressed the irreplaceable nature of blood. It is rare and therefore precious. For the respondents, scarcity was often cited in conjunction with blood groups. These groups appear to differentiate the most valuable blood from the rest. For those with the “rarest” blood types, this quality becomes the key motivation to donate and prompts the guilt of those who do not give blood regularly. Conversely, those who described their blood as “ordinary” sometimes used this argument to stop donating. The blood of a “universal donor” appears to be especially valued. Being a carrier of cytomegalovirus (CMV) or not is another factor that lends value to blood. Donors who are not carriers of CMV are informed that their blood can be used for young children. More than one third of the respondents were attentive to the “quality” and rarity of their blood group. This was especially true for young donors. Women were also more sensitive to this factor than men, with the exception of men who had young children and who were CMV negative. Fewer respondents from ethnic minorities assigned importance to this factor, but they were more sensitive to the idea that blood is a carrier of their identity and character traits. Every time you donate blood, your blood changes something in the body of the person receiving your blood, of that I’m sure. . . .. I think in fact that it’s our purpose in life, that our blood continues on. (Man of Vietnamese origin, 57 years old, teacher, regular donor, E1) Even if most of the respondents did not refer to blood as a carrier of identity, some nevertheless stated that it is an intimate and personal substance: “you’re the one who produces it.”
Life for oneself: blood donation and regeneration
The association between blood and life is the most frequently recurring element in the rhetorical discourse of blood product supply organizations. The obvious fact that respondents borrow this vocabulary from the discourse of Héma-Québec is made apparent when they themselves reference the agency’s advertising, which reiterates that “one blood donation saves four lives.”
A certain number of respondents, mostly donors, mentioned the benefits of blood donation for their own health. For some, this was their principal motivation. The respondents cited the advantages of regenerating their blood on both physical and psychological levels: “it cleanses the body,” “I feel less weak,” “it stimulates the body,” “you have less allergies,” “it gives me an energy boost,” “you purify your blood,” “it boosts your immune system.”
The first time, one of the nurses [told me], “you know, you can save four lives with one blood donation” . . . it
It’s good for oxygenating your blood, for creating new blood. Regenerating the blood. When I read that, I can
Blood donation as a gift of life?
Volume 53, December 2013 Supplement TRANSFUSION
175S
CHARBONNEAU AND TRAN
say this motivated me to donate. (Man of Salvadorian origin, 39 years old, pastor, former donor, E1)
can’t handle, it’s really silly. (Woman, 21 years old, student, former donor, E2)
I think a good bleeding, they used to do that back in the day. . . . I would say that it feels good, you see a difference. . . . (Man, 25 years old, student, regular donor, E2)
This fear of needles was frequently cited in our interviews by both nondonors and those who stopped donating after one or several donations. Their comments reveal an aversion to these instruments that pierce the boundary of the body and fail to respect its integrity. Others said they could not bear the idea of blood leaving their bodies.
This impression of personally benefitting from the physical advantages of renewed blood appears to be cited slightly more often by men than women, but it is mentioned by people of all ages. The respondents from ethnic minorities also mentioned this impression. The argument of regeneration has been emphasized by both Catholics of Vietnamese origin and Muslims of Lebanese origin. However, the respondents belonging to ethnic minorities more frequently associated blood donation with a loss of energy and the danger of an imbalance in bodily strength. The connection between blood and health, for some, also has to do with the importance of staying healthy to be able to provide “good blood.”
The worrisome side of blood donation Making a blood donation is a privilege reserved for those with “healthy” blood. The knowledge that their blood does not qualify for donation was very negatively received by our respondents. The respondents often used the expression “my blood isn’t good”: they understand that their blood might carry a risk of transmitting disease and they are disappointed that they fall short. Some protested and maintained that their blood was good (or fine), even if they had traveled to a country with high risks of contracting certain diseases, and even if they engaged in at-risk sexual practices. The tainted blood affair seems to have left few traces in the memory of the respondents. Since Héma-Québec has become responsible for supplying blood in Quebec, the respondents all stated that they are not afraid of becoming infected via blood donation. Independently of their characteristics, some respondents nevertheless remained anxious at the idea of receiving a blood transfusion. Douglas44 has shown the historical importance of respecting the integrity of the body in certain cultures, as well as dangers associated with crossing the corporeal boundary. One might expect that, today, only the active members of certain religious communities would assign importance to this conception of the body. Upon analysis of the respondents’ statements, however, the fear of needles—which is widely cited as an obstacle in surveys on blood donation motivations—appears to relate to this conception. I’m afraid of needles. When I went to donate, my fears were confirmed. I panicked. . . . It’s like an ordeal I 176S
TRANSFUSION Volume 53, December 2013 Supplement
My blood isn’t always easy to draw, and one time, she was using the needle, searching for the vein [and the blood] sort of came out . . . . It wasn’t a pretty sight. Seeing blood is always something, isn’t it? I guess I’m kind of a wimp, right? It scares me. (Woman, 46 years old, office clerk, regular donor, E4) A few, for their part, expressed reluctance about apheresis donation, as they could not bear the idea that their blood, once outside their body, could be returned to it. I don’t like the idea of having my blood removed and then put back into me, with something taken out of it. . . . I don’t like having my blood returned to me. (Woman, 23 years old, student in biomedical sciences, regular donor, E3) The respondents who expressed this fear of needles or the sight of blood outside the body often added that they were aware that this was not very rational; they were almost apologetic about it.
Blood donation and belonging to the community A third of the respondents justified their blood donation in terms that relate to the outlook of “generalized altruism” (directed toward an unknown “Other”). More women referred to this conception than men. These respondents expressed themselves in relatively abstract terms: they gave blood to do the right thing, to do a good deed, to act out of generosity, to give to their fellow man, to make a difference, to transmit good values, to compensate for those who do not give, etc. It is a gift that I give; no one will know that I made the donation. When you give blood, it really is a gift. (Man, 35 years old, civil servant, regular donor, E4) The altruistic motivations appeared to have numerous sources. Certain expressions indicate the influence of religious values, while others reflect a sense of belonging as a citizen or community member. In general, the donor motivations were often altruistic justifications, religious obligations, or reasons of civic duty and/or community solidarity. It’s a combination between a generous act and an obligation, for you and the community. People need
BLOOD’S REPRESENTATIONS
blood and no one else is going to make it. We are only going to get it from other people. (Man, Polish origin, Jewish, 56 years old, senior executive, regular donor, E1) A number of donors still said that they gave “for their children” or “for their family and neighbors,” even if they knew that these were not the people who would actually receive their blood. Some also expressed preferences about donating blood within their more limited communities. As mentioned earlier, one of the principal properties of blood cited by the respondents who associated it with the gift of life is the fact that it is rare and therefore precious. This property, according to some, justifies sharing blood exclusively with family and close acquaintances. These interpretations were more common among respondents from ethnic minorities, and in particular respondents of Asian origin or from Black communities. We inherited our blood. It’s very well looked upon to give our blood to family. . . . but giving to a stranger, I think that’s a little more limited. (Man, professional of Chinese origin, no donation, E1) You want to give the blood to who you want to give. You want to choose [. . .] For example Muslim person will say: “why should I give blood for other religion?” [. . .] If you go to the community and ask, they will say that, line of the family goes with the blood; you know that, blood lineage that you have [. . .] I am not giving my blood for common people. If I give blood, I will give for my own people. (Woman of Pakistani origin, Muslim, community leader, no donation, E1) None of the respondents from the majority population associated their blood with that of their ancestors or a limited community. “We’re all human, we all have the same blood flowing through our veins.” (Woman, 23 years old, student, nondonor/refused, E2) We met more individuals who refused to donate blood out of solidarity with specific people (homosexuals, immigrants from certain specific countries) that they saw on a daily basis, for example at work, and who are not allowed to donate blood because of restrictions established by Héma-Québec to ensure blood product safety. In other words, they acted out of solidarity because they deemed the rules to be too strict. These nondonors were therefore very much aware that refusing offered blood can be symbolically interpreted as a refusal of the social bond and can express a “moral boundary.” For its part, discourse that promotes the power of blood to create a fictional fraternity, which integrates minorities into Quebec society at large, has primarily been found in the representations of certain associations that use this argument to justify their organization of blood drives. None of our survey participants from the majority population said that they had an active religious practice.
As a result, they did not directly relate blood donation to religious prescriptions. At most, some recalled that they were raised in the Catholic faith and that their parents transmitted to them values of Christian charity, which are favorable to self-giving and hence to blood donation. In the study conducted with ethnic minorities, realities were different. These donors showed a more active religious practice than our respondents from the majority population. They also drew a connection with the fact that their religion—regardless of what it is—encourages self-giving, charitable deeds, volunteer work, and altruism, all values favorable to blood donation. Jewish, Muslim, and Christian leaders met in our study based themselves on sacred texts to encourage their followers to give blood. Muslims, and sometimes Christians as well, sometimes also mentioned the importance of donating blood to honor martyrs. We have an event in the Islamic calendar that’s very special, that really brings us into the history of Islam. It’s about martyrdom, the martyr of the grandson of the prophet Mohammed. . . . Muslims here say that, “during that period, sacrifices must be made.” Blood donation, or blood collection, is about connecting with that step, in the sense of a sacrifice. (Man of Lebanese origin, Muslim, blood drive partner, E1) In our Christian faith . . . blood is a symbol of sacrifice, of life . . . just as our martyrs spilled their blood to save people and to defend human rights, we have said that we would help our brother in humanity. (Man of Lebanese origin, Catholic, blood drive partner, E1) We approached the Rabbi and he said it’s a mitzvah, which is a Hebrew word which means an extremely good deed . . .. this he said, is a huge mitzvah, you are giving life when you are giving blood. (Woman, Jewish, blood drive partner, E1)
DISCUSSION This overview of contemporary representations of blood in relation to blood donation in Quebec illustrates that though this substance might be disenchanted for many, it still maintains its mysteriousness for others. We have seen that it is not only for those who hold religious values or for immigrants whose culture of origin might let to presuppose that blood, for them, is a symbolic substance. We have given many examples of cases where, for some, the seemingly common practice of giving blood might indeed reveal itself not so trivial: belief in regeneration of the body, fear of needles and spilt blood, the notion that part of one’s identity can be transmitted to the receiver, deception of learning that one’s blood does not qualify to be given to a dignified recipient such as a child. It is not conceivable that informants should suddenly give Volume 53, December 2013 Supplement TRANSFUSION
177S
CHARBONNEAU AND TRAN
up all these beliefs and as we have seen, many continue to apologize for maintaining these “irrational” conceptions of blood. Analysis of data from our survey suggests that when it comes to the cultural, social, and religious symbolism of blood, the greatest distinctions observed are between representatives of the majority Quebec population and those of ethnic minorities. It was therefore relevant to question the potential influence of ethnic diversity on symbolic representations of blood, especially in a society dominated by the Western model of altruistic donation, but that also welcomes a substantial percentage of groups with very diverse ethnic backgrounds. Less rational representations of blood were also clearly present in the statements of respondents belonging to the majority population. These representations are sometimes favorable to blood donation, as in the case of those who believe in a connection between well-being and the regeneration of blood. In other cases, they are not, for example when they entail an aversion to seeing the boundary of the skin pierced by a needle. A socio-anthropological approach to representations of blood and blood donation offers a useful contribution for identifying and interpreting donor motivations, as well as potential obstacles to the practice of blood donation. Recalling that blood is still associated with social, cultural, and religious representations that are important to many people can, additionally, lead to useful avenues to improve donor recruitment and retention. Like all studies, this one has its limitations. The first is undoubtedly the fact that its conclusions cannot be generalized, not only because of the qualitative method used but also because of the social, cultural, and demographic characteristics that are specific to each country. The other significant limitation has to do with the value of comparisons we have proposed based on these characteristics, particularly when they concern ethnic minorities. Ethnic minority donors recruited in this study were not necessarily representative of their groups. Furthermore, only a few members of each group were interviewed. It should also be mentioned that the recruitment process was very complicated. Before 2010, it was impossible to identify the donors in these communities using the Progesa database, and several complementary strategies had to be used to this end. Generally speaking, this population is also known to be difficult to reach and to have greater difficulty participating in such surveys than the majority population. ACKNOWLEDGMENTS We gratefully Héma-Québec.
acknowledge
the
financial
support
of
CONFLICT OF INTEREST The authors report no conflicts of interest or funding sources.
178S
TRANSFUSION Volume 53, December 2013 Supplement
REFERENCES 1. Titmuss RM. The gift relationship: from human blood to social policy. London: Allen & Unwin; 1971. 2. Attali J. La symbolique du sang dans la société. Transfus Clin Biol 2004;11:271-3. 3. Scheper-Hughes N, Wacquant LJ. Commodifying bodies. London: Sage Publications; 2002. 4. Waldby C, Mitchell R. Tissue economies: blood, organs, and cell lines in late capitalism. Durham: Duke University Press; 2006. 5. Andrews LB, Nelkin D. Body bazaar: the market for human tissue in the biotechnology age. New York: Crown Publishers; 2001. 6. Lock MM, Nguyen VK. An anthropology of biomedicine. Chichester: Wiley-Blackwell; 2010. 7. Shan H, Wang JX, Ren FR, et al. Blood banking in China. Lancet 2002;360:1770-5. 8. Martinez C. L’expérience d’un médecin de prélèvement au Chili. Transfus Clin Biol 2006;13:203-5. 9. Kalibatas V. Payment for whole blood donations in Lithuania: the risk for infectious disease markers. Vox Sang 2008;94:209-15. 10. Sampath S, Ramsaran V, Parasram S, et al. Attitudes towards blood donation in Trinidad and Tobago. Transfus Med 2007;17:83-7. 11. Allain JP, Sarkodie F, Asenso-Mensah K, et al. Relative safety of first-time volunteer and replacement donors in West Africa. Transfusion 2010;50:340-3. 12. Piliavin JA, Callero PL. Giving blood: the development of an altruistic identity. Baltimore: Johns Hopkins University Press; 1991. 13. Giles M, Cairns E. Blood donation and Ajzen’s theory of planned behaviour: an examination of perceived behavioural control. Br J Soc Psychol 1995;34:173-88. 14. Armitage CJ, Conner M. Social cognitive determinants of blood donation. J Appl Soc Psychol 2001;31: 1431-57. 15. Godin G, Conner M, Sheeran P, et al. Determinants of repeated blood donation among new and experienced blood donors. Transfusion 2007;47:1607-15. 16. Lemmens KP, Abraham C, Hoekstra T, et al. Why do young people volunteer to give blood? An investigation of the correlates of donation intentions among young nondonors. Transfusion 2005;45:945-55. 17. Misje AH, Bosnes V, Gasdal O, et al. Motivation, recruitment and retention of voluntary non-remunerated blood donors: a survey-based questionnaire study. Vox Sang 2005;89:236-44. 18. Sojka BN, Sojka P. The blood donation experience: selfreported motives and obstacles for donating blood. Vox Sang 2008;94:56-63. 19. Bednall TC, Bove LL. Donating blood: a meta-analytic review of self-reported motivators and deterrents. Transfus Med Rev 2011;25:317-34.
BLOOD’S REPRESENTATIONS
20. Ferguson E, Farrell K, Lawrence C. Blood donation is an act
41. Mok Chan WY. Blood donation in Hong Kong. A case study
of benevolence rather than altruism. Health Psychol 2008; 27:327-36. 21. Healy K. Last best gifts. Altruism and the market for
of the impact of the mass media on beliefs and behavior [M.A. thesis]. University of Hong Kong; 1978:205. 42. Maher L, Ho HT. Overdose beliefs and management prac-
human blood and organs. Chicago: University of Chicago Press; 2006. 22. Smith A, Matthews R, Fiddler J. Blood donation and
tices among ethnic Vietnamese heroin users in Sydney, Australia. Harm Reduct J 2009;6:1-10. 43. Rousseau V. Le goût du sang: croyances et polémiques
community: exploring the influence of social capital. IJSI 2011;4:45-63. 23. Simpson R. Blood rhetorics: donor campaigns and their
dans la chrétienneté occidentale. Paris: Armand Colin; 2005. 44. Douglas M. Purity and danger: an analysis of concepts of
publics in contemporary Sri Lanka. Ethnos 2011;76: 254-75. 24. Adams V, Erwin K, Le PV. Public health works: blood
pollution and taboo. London: Routledge & Kegan Paul; 1966. 45. Simpson R. Impossible gifts: bodies, buddhism and bioeth-
donation in urban China. Soc Sci Med 2009;68:
ics in contemporary Sri Lanka. J R Anthropol Inst 2004;10:
410-8. 25. Copeman J. Gathering points: blood donation and the scenography of “national integration” in India. Body Soc 2009; 15:71-99.
839-59. 46. Roux JP. Le sang: mythes, symboles et réalités. Paris: A. Fayard; 1988. 47. Biale D. Blood and belief. An introduction to a Jewish
26. Parmasad V. Elle est mon sang: don de remplacement, parentalité et liens transactionnels à Trinité-et-Tobago. In: Charbonneau J, Tran N, editors. Les enjeux du don de
symbol. In: Hart MB, editor. Jewish blood: reality and metaphor in history, religion, and culture. London; New York: Routledge; 2009. p. 15-30.
sang dans le monde: entre altruisme et solidarités, universalisme et gestion des risques. Rennes: Presses
48. Nelkin D. Cultural perspectives on blood. In: Feldman EA, Bayer R, editors. Blood feuds: AIDS, blood, and the politics
de l’École des hautes études en santé publique; 2012. p. 241-60.
of medical disaster. New York: Oxford University Press; 1999. p. 273-92.
27. Binet JL. Le sang et les hommes. Paris: Gallimard; 1988. 28. Danic B, Lefrère JJ. Le sang dans l’art, l’art dans le sang. Transfus Clin Biol 2010;17:382-5.
49. Seeman D. “One people, one blood”: public health, political violence, and HIV in an Ethiopian-Israeli setting. Cult Med Psychiatry 1999;23:159-95.
29. Meyer ML. Thicker than water: the origins of blood as symbol and ritual. New York: Routledge; 2005.
50. Sutterlüty F. The belief in ethnic kinship. Ethnography 2006;7:179-207.
30. Hart MB. Jewish blood: reality and metaphor in history, religion, and culture. London: Routledge; 2009.
51. Strong T. Vital publics of pure blood. Body Soc 2009;15: 169-91.
31. Hugh-Jones S. Analyses de sang. Terrain 2011; 56:2-19. 32. Camporesi P. Juice of life: the symbolic and magic signifi-
52. Valentine K. Citizenship, identity, blood donation. Body Soc 2005;11:113-28. 53. Statistics Canada. National Household Survey, 2011.
cance of blood. New York: Continuum; 1995. 33. Frazer JG. The golden bough; a study in magic and reli-
Ottawa: Minister of Industry, 2013. 54. Murray TH. The poisoned gift: AIDS and blood. In: Nelkin
gion. New York: Macmillan; 1951. 34. Lévy-Bruhl L. Le surnaturel et la nature dans la mentalité primitive. Paris: F. Alcan; 1931. 35. Cros M. Anthropologie du sang en Afrique: essai d’hématologie symbolique chez les Lobi du Burkina Faso et de Côte-d’Ivoire. Paris: L’Harmattan; 1990. 36. Mino G. Magia Sanguinis: blood and magic in Classical antiguity. In: Bradburne JM, editor. Blood: art, politics, and pathology. Munich: Prestel; 2001. p. 33-40. 37. Bynum CW. Wonderful blood: theology and practice in late medieval northern Germany and beyond. Philadelphia: University of Pennsylvania Press; 2007. 38. Cazeneuve J. Sociologie du rite (tabou, magie, sacré). Paris: Presses universitaires de France; 1971. 39. Chebel M. Le corps en Islam. Paris: PUF; 1999. 40. Gilders WK. Blood ritual in the Hebrew Bible: meaning and power. Baltimore: Johns Hopkins University Press; 2004.
55.
56.
57. 58.
59.
D, Willis DP, Parris S, editors. A disease of society: cultural and institutional responses to AIDS. Cambridge: Cambridge University Press; 1991. p. 216-40. Amponsah-Afuwape SA, Myers LB, Newman SP. Cognitive predictors of ethnic minorities’ blood donation intention. Psychol Health Med 2002;7:357-61. Grassineau D, Papa K, Ducourneau A, et al. Improving minority blood donation: anthropologic approach in a migrant community. Transfusion 2007;47:402-9. Fantauzzi A. Sangue migrante. Milan: Franco Angeli; 2012. Mathew SM, King MR, Glynn SA, et al. Opinions about donating blood among those who never gave and those who stopped: a focus group assessment. Transfusion 2007; 47:729-35. Polonsky MJ, Brijnath B, Renzaho AM. “They don’t want our blood”: social inclusion and blood donation among African migrants in Australia. Soc Sci Med 2011;73: 336-42.
Volume 53, December 2013 Supplement TRANSFUSION
179S
![[Blood donation, iron donation].](/assets/img/hold.png)
