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Article history:
Available online 13 February 2011
This paper examines an emerging bioeconomy centred on the international banking and trade in cord
blood. Since the late 1980s cord blood has been used in an expanding range of treatments and as an
alternative to the use of bone marrow stem cells. This is particularly the case in treating ethnic minority
populations who have historically been under-represented in bone marrow registries. The paper explores
the mobilisation and commercialisation of an increasingly important bioeconomic resource with cord
blood units trading internationally at high prices. This is a market mediated through a sophisticated
global network of immunologically typed and matched bodily matter in which immunity has become
a form of corporeal currency. Based on recent international gures we reect upon the balance of trade
between imports and exports across the worlds cord blood bioeconomy. Theoretically, this case is, we
suggest, an extension of what Roberto Esposito (2008) has termed an immunitary paradigm in which
immunity has become the basis for new forms of bioeconomic ow, circulation and exchange. Esposito
(2008). Bios: Biopolitics and Philosophy. Minnesota, MN: University of Minnesota Press.
2011 Elsevier Ltd. All rights reserved.
Keywords:
Cord blood banking
Stem cells
Bioeconomy
Immunity
Ethnicity
giving rise to the bodys entire blood and immune system. It has
been used clinically as an alternative to bone marrow for a range of
treatments since the late 1980s (Gluckman et al., 1989) with an
increasingly signicant prole in regenerative medicine (Brown,
Kraft, & Martin, 2006). This led to the establishment in the early
1990s of numerous international initiatives to source and bank CB
stem cells to be made available in a widening number of treatment
areas including cancer, immune system disorders and gene therapy.
Most of these public banks have been seen to operate within
a traditionally established discourse structured around giving, the
basis of a social solidarity where anonymous donors contribute to
a publicly available biological resource. Public blood economies
operate according to an allogeneic regime in which blood is more
usually circulated between unrelated though immunologically
matched donors and recipients.
There has also been a recent and rapid growth in a private CB
banking market with parents paying to deposit the stem cells of
their newborns for future private use (Brown & Kraft, 2006;
Waldby, 2006). Private banking has been the site of considerable
contention having been characterised as a neoliberal privatised
market where individuals or families make an exclusive claim on an
autologous (self-to-self) biological asset that remains private
property (Santoro, 2009). The cord blood debate has its history in
this binary polarisation of public and private economies, pitching
a solidaristic ethos of community inclusion against the atomistic
seclusion of the self (Titmuss, 1970).
1116
Method
This project was funded by the UK Economic and Social
Research Council (ESRC) and explores changing patterns in the
organisation, donation and deposition of CB stem cells. Over a 14
month period (2009e2010), 51 qualitative, semi-structured interviews were conducted including site visits (total 14) with the
following groups: clinicians and researchers e including obstetric
services and stem cell bioscience researchers; policy makers and
regulators e both at the UK domestic, European and international
levels; interest groups e including members of royal colleges:
health advocacy groups and charities; and interviews with actual
and potential donors and depositors of umbilical CB. Interviewees
were identied and recruited through several routes including
direct contact with stakeholder organizations and searches of
scientic and policy literature. Actual and potential CB donors were
recruited through local and national childbirth support groups.
Ethical approval was sought from our home institution ethics
committee, our regional NHS Research Ethics Committee.
The political economy data detailing the relative cost of CB units
(storage, deposition, procurement cost and overseas trade) is drawn
from three sources including: interviews (procurement personnel,
bank and senior health service staff); grey literature and internal
documentation including recently commissioned government
reports; and quantitative data generated by the World Marrow
Donor Association documenting the release, importation and
exportation of CB units across nation state borders. The WMDA is
one of the few internationally recognised sources collecting and
producing annualised reports from 112 of 128 identied banks
operating worldwide. Our analysis recalculates this raw reported
data to produce the balance of trade percentage of exports relative to
imports for each participating country for the year 2008. Qualitative
date was analyzed using a software coding system (Atlas.ti) to
categorize the data according to a broad range of empirically driven
themes. The research thus combines qualitative interview data and
policy data to link cultural and economic dimensions of CB banking.
As a number of commentators have noted, economy and politics are
rarely considered together in sociological critiques of the biosciences (Cooper, 2008; Lemke, 2001; Waldby & Mitchell, 2006). This
case study makes a modest contribution to a growing literature
focussing on the economisation of human biological life.
Cord blood collection - assembling diasporic immunity
The emergence of the CB banking sector is, we suggest, coextensive with contemporary globalisation and unprecedented levels
of immunitary migration and heterogenisation. The uid spatial
distribution of immunity is written into the foundational logic of
the establishment of a public banking capacity. Most banks were
originally set up to overcome the disproportionately high representation of white Caucasian populations in traditional bone
marrow registries. Long established registries have had strong
historical penetration amongst advantaged middle class blood
donors but recruited less well beyond the mainstream demographic. Non-Caucasoid populations have generally been poorly
provided for in the treatment of leukaemia where the chances of
nding an immunologically appropriate bone marrow match
remain considerably lower than for majority (usually white) populations. Recent gures suggest that while it is possible to nd
a match for up to 75% of patients of Western European origin, that
gure falls to 20% or 30% for other ethnic groups (Meijer et al., 2009).
Beatty, Mori, and Milford (1995) were amongst the rst in the mid
1990s to draw attention to the diminishing probabilities of nding
appropriate bone marrow matches for those who self-reported
their ancestry as African American, Hispanic, Native-American and
1117
1118
populations had unusually low stem cell counts that threaten their
value as units of exchange in the global immunitary marketplace:
we have been very successful. forty percent of our collection is
from ethnic minorities. there has been a price that weve paid
for that in terms of business because weve. shown that those
from ethnic minorities have lower volume and lower TNCs
[Total Nucleated Cell count]. so a large number of our units are
considered not the optimal product. thats the price weve
paid. so from the business point of view weve not been all that
successful in selling them as it were. here is where you have to
balance the economics and the ethics (Director of a public CB
bank 1).
In terms of recruitment, the question of race has proven to be
acutely sensitive for populations with long established colonial
histories. For instance, staff frequently attribute fear and suspicion
to ethnic minority communities as a major obstacle to improving
donation rates. These are far from straightforward issues with
complex connotations suggesting many multiple meanings associated with donation including ambivalence and the threat of
appropriation (see also Whitmarsh, 2008):
. Ive sat and spoken to men and you kind of think they see the
light but they still dont want to donate. Now, is that because
they dont want to lose face? Is that because they really dont
understand whats being done?. just difcult trying to nd
a way in to that kind of group (Representative from a charitable
sector bank 1)
Its known that ethnic diversity is really something that needs
to be brought out in the open and say there arent enough ethnic
samples being stored and their chances of a match are even
slight. (Director of a private CB bank 1).
Heritability of genotypic immunity are constantly subject to
intergenerational and spatial redistribution continuous with postcolonialism and globalisation. It is that dynamism that has
provided the incentive for an international system of exchange
while at the same time turning it into a premium commodity
resource. CB banking brings into view dimensions of globalisation
directly linked to the vitalistic and corporeal. The migratory ow of
bodies is a diasporic dispersal of genetically indexed immunity.
Within the developing immunitary regime documented by Esposito and others, immune system biology has itself become the focus
for bioeconomic enterprise. Newly heterogeneous populations are
the driving demographic factors in encouraging health services
around the world, but particularly in North America, Europe and
East Asia to establish CB banks. For example, one of our respondents from the private banking sector here comments on the way
commercial banks have sought new markets amongst the migratory communities displaced by the transition of Hong Kong from
British to Chinese rule:
.When Hong Kong closed down. the rich Chinese. moved
to Toronto. but what you have then is a lot of mixed race
couples. [their] children are going to be. unusual genotype
and to get a transplant for that kind of child would be very
difcult. So private storage in that area is very popular.
(Director of private CB bank 2).
Race has a profoundly volatile place within a post-colonial
modernity characterised on the one hand by the varied instabilities
of diaspora, while also subject to new biometric measures for xing
and determining biological identity. The CB sector spans and utilises
any number of technologies where the geneticisation (Lupton,
1994) of race has been recently enlarged through population
genetics, racial proling, and genetic genealogical and ancestry
studies, etc. CB banking extends the way biological markers, within
much more diverse means that very few national CB supplies are
varied enough to be able to meet domestic demand:
.the HLA is so polymorphic that no country would be able
to think itself sufcient even with the largest bank. thats why
you need the international collaboration. were maximising
the probabilities of nding a donor for the UK. countries set up
this registry to satisfy local need. we are all fully aware that we
will be providing for donors abroad as indeed beneting from
those donors in other registries. the gures with export/
import are quite clear. this is an international collaboration
(Director of a public CB bank 1).
The international market has come to depend fundamentally on
widely agreed standards whereby buyers and sellers can be assured
of the quality of assets traded. The immunitary economy we
describe here has been steadily built up through what Callon,
Meadel, and Rabeharisoa (2005) have termed an economy of
qualities. If race is the asset, standards measure of the worth of that
asset by attening the otherwise uneven spatial topographical
geography of the CB trading zone (Webster & Eriksson, 2008). One
UK transplant director put it that . it becomes a worldwide
resource. What we can offer in the UK is . lots of ethnic minorities.. Plus a system that will deliver quality.
There have been a number of overlapping and sometimes
competing initiatives to manage the variability of CB value
including the establishment of Netcord, FACT (Foundation for the
Accreditation of Cellular Therapy) and the efforts of the World
Marrow Donor Association. In addition to promoting clinical
effectiveness, standard-setting is indispensible to the functioning of
an exchange economy in which CB assets command high prices.
The promotion and facilitation of trade has been central to policymaking in this area as illustrated by the European Tissues and Cells
Directive adopted by the European Parliament in 2004. One of the
primary purposes of the Directive was to put in place the supporting infrastructure for a buoyant economic market in cells and
tissues across the eurozone. Nevertheless, while the international
distribution of the CB economy is vital to increasing the likelihood
of securing a close match, it necessarily highlights unevenness in
practise:
France is 22 miles away. South America is a 10 h ight. China is
14 h. You have very little control over what happens in other
jurisdictions and so internationally it really is a case of the will
to ensure that best practise is put in place and consent issues are
followed. And I think the one way we can do it is by saying that if
you are going to import material from elsewhere, its your
responsibility to ensure that that has been procured in a way
that you would expect it to be procured in the UK. Outside
theres not much we can do (Senior UK health service policy
maker 1).
Standards extend the immunitary paradigm by creating spaces
protected from pollution. In writing of contamination, Esposito has
in mind the state-orchestrated biopolitics of, for example, immunitary protection from interhuman contamination that underpins
immigration policy. He writes that the prevention of contamination
has its apex in our own time, and no more so than in a biopolitical
economy dependent on the free circulation and exchange of disembodied mobile matter, cells and tissues. Standards in these terms
operate to dene inclusion and membership of an immune-based
community offering protection from potential contamination
across the blood economies. Registries illustrate these efforts to
establish an immunitary community perfectly. But taken too far,
protection from contamination can result in a negation of life. The
immunitary paradigm can work to restrict the circulation of ow.
For example, government legislation and the registries themselves
1119
1120
Cord blood
exported (%)
512 (68)
74 (23)
123 (58)
94 (52)
133 (83)
110 (80)
37 (29)
0
68 (86)
0 (0)
18 (44)
8 (24)
13 (43)
18 (82)
2 (10)
7 (37)
0
8 (62)
0
0
2 (29)
0
5 (100)
1 (25)
2 (100)
0
0 (0)
0 (0)
Country
US
France
Spain
Italy
Australia
Germany
UK
Canada
Belgium
Brazil
Netherlands
Israel
Switzerland
Taiwan
Mexico
Singapore
Greece
Czech R
Sweden
Argentina
Finland
Austria
Japan
Poland
Korea
Turkey
China
Hong Kong
Imported (%)
236 (32)
247 (77)
90 (42)
86 (48)
28 (17)
27 (20)
91 (71)
86 (100)
11 (14)
44 (100)
23 (56)
25 (76)
17 (57)
4 (18)
18 (90)
12 (63)
18 (100)
5 (38)
11 (100)
10 (100)
5 (71)
7 (100)
0 (0)
3 (75)
0 (0)
2 (100)
1 (100)
1 (100)
Totals traded
% Exported of
those released
36
35
69
67
75
87
79
0
92
0
95
80
100
23
5
37
0
100
0
0
33
0
4
100
3
0
0
0
748
321
213
180
161
137
128
86
79
44
41
33
30
22
20
19
18
13
11
10
7
7
5
4
2
2
1
1
Country
Japan
Taiwan
Korea
China
Hong
Kong
Exported
Released
5
18
2
0
138
77
62
18
11
Released
for
domestic
use
133
29
60
18
11
%
Exported
of those
released
4
23
3
0
0
Available
Units
used
Imported
5455
42135
100545
8892
133
33
60
19
0
4
0
1
2885
12
Country
Available
Exported
Released
France
Germany
Australia
Belgium
Switzerland
Italy
US
UK
Spain
7051
18557
20044
14533
2212
17503
154749
10589
35802
74
110
133
68
13
94
512
37
123
212
127
178
74
13
141
1428
47
179
Released
for
domestic
use
138
17
45
6
0
47
946
10
56
%
Exported
of those
released
35
87
75
92
100
67
36
79
69
1121
Units
used
Imported
385
44
73
17
17
133
1182
101
146
247
27
28
11
17
86
236
91
90
produced resources including, for example, pharmaceutical investment in ethnic drug markets (Benjamin, 2009; Whitmarsh, 2008).
The destination countries to which CB is exported are also
highly signicant. The single highest export destination is the US,
probably the most racially heterogeneous of the trading nations, on
average accounting for roughly 30% of all exports. A notable
exception is the absence of sub-Saharan Africa from these gures,
excluded from prohibitively expensive premium markets and
reecting the global patterning of traditional blood services with
trade mainly concentrated in and between afuent advanced
industrial bureaucracies.
Conclusion
CB presents both opportunities and challenges to the international organisation of blood and is profoundly telling of changes in
the global economisation of disembodied human matter. To return
to Esposito, the CB case eshes out, so to speak, his version of
biopolitics as an immunitary paradigm. Communitas and immunitas
express the changing characteristics of order and organisation in
todays biopolitics. Communitas in its traditional meaning is associated with gift and giving but carries with it various risks. Gifts
may be costly and go unreciprocated and there may be tensions
between competing interests (the individual and the community,
the state and the wider global commons). Immunitas develops as
a means of protection from these risks, methods for self-defence
from the otherwise boundless or insatiable demands of community. While immunitas has its roots in communitas it develops an
alternative logic replacing the gift economy with private markets
based on nancial exchange, trade and the contract. The immunitary paradigm expresses this translation of blood and gift into
a global immune-based economy. The immunitary has a double
valency here signalling a system of value, circulation and ow, but
also the predication of the bioeconomy on genotypic immunity.
Biology and life itself, rather than labour, is increasingly recognised as central to the production of surplus value in the contemporary tissue economies. Within this relatively new framework,
bioeconomisation is seen to efface the boundaries between the
spheres of production and reproduction, labour and life, the market
and living tissues (Cooper, 2008, p. 9). However, it is in fact the
dispersed internationalisation of these bioeconomies that allows
for the multiplication of value that we can observe as CB units are
traded across state borders.
One of the more signicant aspects of the story told here is the
way a surplus value is derived from CB in two complementary and
interlinked ways. First, internationalisation is essential to biovalue
production because of the need to seek out widely dispersed
immunotypes. The global nature of matching across highly heterogenised immunities necessitates a widely distantiated reach
through networks like that of the WMDA. The probabilities of
1122
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