Introduction
In the early 1950s, Sir William d’Auvergne Maycock visited blood transfusion institutions across Yugoslavia as an honorary guest, a role facilitated and warmly supported by Yugoslavia’s federal public health authorities, effectively the equivalent of a ministry of health. The Ministry was eager not only to showcase its progress but also to seek Maycock’s expert guidance, ranging from the latest advancements in blood grouping, blood products and transfusion technology to the broader organisation of the entire transfusion system. His recommendations covered the optimal location of facilities, the qualifications of medical personnel, available technologies and strategies for procuring materials from London. He also advised on the mobilisation of voluntary donors and provided technical guidelines on haemoglobin standards, further pledging to send additional materials from London related to the prevention of hepatitis in plasma production.Footnote 1
At the time, Maycock was already recognised as a leading global authority on blood transfusion. After the Second World War, he had joined the staff of the Lister Institute, directed the UK Ministry of Health’s blood products laboratory, and served for decades as a consultant adviser to both the UK Ministry of Health and the War Office.Footnote 2 Among his many roles, he was also involved with the World Health Organization, the International Society of Blood Transfusion and the League of Red Cross Societies, for which he co-authored the official guide for blood transfusion practices.Footnote 3 The significance of his visit to Yugoslavia cannot be overstated. It marked a moment of vital intellectual and professional exchange that took place at a critical juncture when the Yugoslav government was resisting intense pressure from Iosef Stalin. In the aftermath of the 1948 split with the Soviet Union, Yugoslav medical professionals were actively forging new ties with Western colleagues, broadening their avenues for knowledge-sharing and their access to essential medical supplies. Furthermore, Maycock and other Western scientists played a pivotal role in shaping the organisation of the Yugoslav blood transfusion service, facilitating a unique synthesis of Western approaches with elements of the Soviet model at the systemic level.
In this article, I demonstrate that the exchange of medical ideas across borders was substantial both before and after the Second World War, with concepts and practices frequently traversing the iron curtain. The development of the blood transfusion system in Yugoslavia underscores significant transnational influences and challenges the notion that healthcare reforms occurred in national isolation. The Second World War created an urgent need for blood transfusions, driving collaborative innovation among researchers and practitioners. Collaboration and knowledge exchange intensified after the war, as new international networks helped standardise practices and accelerate the circulation of expertise. In Yugoslavia, where transfusion medicine was still in its infancy, this period provides a valuable lens through which to examine how healthcare infrastructures were constructed despite major political challenges. The paper also contributes to the broader history of Cold War medicine by showing how a country on the European periphery, not a leader in biomedical research, sought to catch up and integrate into emerging international scientificcurrents.
Although Soviet models exerted a strong structural influence, Yugoslav doctors often pushed beyond the ideological constraints of the time, drawing on Western practices even before the official break with the Soviet Union in 1948. Using internal documents from the Ministry of Health, internal correspondence, reports, meeting minutes, and contemporary publications by Yugoslav medical professionals, this article shows that the scarcity of resources granted medical professionals a degree of autonomy, enabling them to adapt and reshape the system to align with the principles of Yugoslav socialism. The resulting blood donation model emerged as a hybrid, oscillating between British-style voluntarism and Soviet-style paid donations. While the Yugoslav authorities formally rejected paid donation, this article argues that, once initial incentive systems were introduced, they became deeply embedded and difficult to eliminate.
Blood Transfusion’s Inter-War Beginnings
Blood transfusion ideas and discoveries circulated rapidly, often transcending political divisions and geographic boundaries. Some of the earliest practical applications emerged during the First World War, when Canadian surgeons played a key role in introducing blood transfusion as a treatment for battlefield injuries within the British Army. The participation of American surgeons in the last year of the war, bringing their expertise in transfusion techniques, further legitimised the practice as a primary response to severe blood loss.Footnote 4 Significant breakthroughs continued throughout the 1920s and 1930s, with the Spanish Civil War forming another critical proving ground for transfusion methods in real-world medical emergencies.Footnote 5 Technological advances, such as the introduction of anti-coagulants like sodium citrate and improvements in refrigeration, made it possible to store blood safely, while later developments in fractionation allowed individual blood components to be separated and used for specific clinical needs.Footnote 6 Blood transfusion methods, apparatus, and clinical protocols also evolved, and indirect transfusion gradually became the preferred approach.Footnote 7
The swift spread of new medical techniques is reflected in the early adoption of blood transfusion by Serbian physicians as early as 1915. Notably, Yugoslav medical literature showed that Dr Nikola Krstić, who was educated in Vienna, carried out an experimental transfusion while stationed in northern Greece during the retreat of the Serbian army.Footnote 8 Though rudimentary and improvised, this early attempt shows a keen awareness of emerging medical practices, even under extreme conditions. It would take decades for Serbian and later Yugoslav doctors to establish a more systematic approach and build the necessary infrastructure, but this episode illustrates the strength of early knowledge exchange and a willingness to innovate despite limited resources.
During the inter-war period, physicians with an interest in blood transfusion frequently crossed national borders, with the United States, Britain and the Soviet Union emerging as key hubs for technological innovation and intellectual exchange. One notable example is the visit of the renowned Soviet doctor Sergei Yudin to the United States in the mid-1920s. He was particularly focused on understanding how the American blood transfusion system was organised. Yudin took note of the widespread use of paid blood donors and the ready availability of blood products, contrasting this with the Soviet system’s limitations, which stemmed from its exclusive reliance on voluntary donations. As highlighted by Alexi-Meskishvili and Konstantinov, Yudin expressed his frustration in a letter, remarking that although surgeries in the Soviet Union were provided free of charge, no one was willing to donate blood without compensation, whereas the US had a ready supply of donors and offered monetary incentives.Footnote 9 Over time the Soviet Union gradually shifted its approach, moving from a model based on pure voluntarism to one that incorporated incentives and, eventually, paid donations. Furthermore, Sergei Yudin successfully established the world’s first blood bank in Leningrad. Throughout the 1930s, the Soviet blood bank system expanded rapidly to regional centres across the country, setting a precedent that other nations soon followed by developing their own transfusion services.Footnote 10
American and British doctors were equally intrigued by scientific advancements emerging from the Soviet Union. The American Medical Association, for example, paid attention to publications from Soviet congresses, including new research by Oleksandr Bogomolets, which was notably published in Ukrainian. Still, they were puzzled by the structure of one edited volume, in which a third was devoted to Stalin and another third to subjects unrelated to medicine.Footnote 11 Despite these oddities, Bogomolets’s work on blood transfusion drew interest in American journals, particularly his theory that transfusion could rejuvenate the body. While unconventional, the idea was not entirely dismissed, and it was discussed in British academic journals as well. British and US scientists also visited Yudin’s clinic in Moscow, where they observed the process of obtaining cadaver blood.Footnote 12 However, as explained by Dame Janet Vaughan in 1939, the collection of blood from cadavers proved unsatisfactory and never moved beyond theoretical discussion in Britain.Footnote 13
Yugoslav doctors also paid close attention to international developments in transfusion medicine. In 1940, the leading Serbian physician Milivoje Dimitrijević published a detailed book on the subject that combined theoretical insights with practical recommendations. He explained that he wrote the book with urgency, anticipating the outbreak of war and hoping to distribute it widely, particularly to physicians in remote areas. The book was published a year before the war began in Yugoslavia in 1941, which is indicative of Dimitrijević’s foresight and sense of medical responsibility. The volume offers a detailed historical account of blood transfusion research and shows that Yugoslav doctors closely followed scientific progress in both the West and the Soviet Union. Dimitrijević provided clear explanations of blood grouping, transfusion techniques, contraindications, reactions, symptoms, treatments and the most recent technological developments. Dimitrijević also highlighted Sergei Yudin’s innovations in blood preservation, first presented at the 1930 Congress of the Ukrainian Surgical Society. He also referenced findings from medical congresses in Paris and Rome, along with field experiences from the Spanish Civil War. The breadth of his citations, including works published just months before his manuscript was completed, reflects a strong engagement with cutting-edge medical literature.Footnote 14
Despite growing medical interest, organised blood transfusion services in Yugoslavia were barely existent during the inter-war period. The country’s medical infrastructure was generally underdeveloped and concentrated in major urban centres, leaving much of the population without access to any modern care. Blood transfusion practices remained rudimentary, hindered by a severe lack of both technological equipment and trained personnel. In Zagreb, for instance, the first recorded blood transfusion took place at the Gynaecologic Clinic in 1920. It was performed using the direct method, without any blood-type testing.Footnote 15 Compatibility testing for both donors and recipients was not introduced until 1926. In these early years, blood donors were usually drawn from among hospital staff or the patient’s relatives.Footnote 16
Sporadic transfusions began at the First Surgical Clinic of the Faculty of Medicine in Belgrade, the Women’s Hospital in Ljubljana, the General Hospital in Maribor and the Surgical Clinic in Zagreb. However, it was not until late 1937 that Yugoslavia saw the establishment of its first organised blood transfusion service, located at the State Hospital in Belgrade. This facility also established serum production and operated primarily through direct transfusion methods, although in the late 1930s they started producing conserved blood. At the same time some smaller hospitals, including those in Novi Sad, also experimented with early transfusion efforts.Footnote 17
As healthcare in the Kingdom of Yugoslavia was not universal, the practice of paying for blood was established almost immediately. Hospitals maintained rosters of on-call donors who could be summoned when needed, though blood donation often occurred in an ad hoc manner. Practitioners described searches for professional donors or last-minute appeals to patients’ family members. Physicians also recalled cases in which professional donors attempted to manipulate the system for financial gain, including using multiple identity documents to donate more frequently than permitted.Footnote 18 In Novi Sad, blood donors were paid one dinar per cubic centimetre of blood and received hospital meals for eight days following their donation. To put this into perspective, a single day of hospital care cost twenty-five dinars, which made the financial incentive quite substantial. Patients, in turn, were required to pay for the blood they received, with hospitals offering subsidies only to the poorest individuals. In many cases, donors were aware of the recipients of their blood, and some physicians recalled instances in which donors attempted to extort patients. The situation began to improve somewhat once conserved blood could be transported from Belgrade, although methods for ensuring its safety remained underdeveloped. By 1939, the hospital in Novi Sad had established its own transfusion service. It employed eight workers who lived in a hospital dormitory and remained on call to donate blood when needed. These workers were compensated for their donations and provided with meals afterwards.Footnote 19 In Belgrade, women were barred from donating blood. This exclusion was reportedly due to both bureaucratic hurdles, such as the requirement for a husband’s permission, and widespread beliefs that women’s blood was harmful, especially during menstruation.Footnote 20 In Slovenia, by contrast, there were no such restrictions.Footnote 21 This attitude soon changed in other areas, as such discrimination conflicted with the Yugoslav communists’ programme of equality, and their war efforts in the later stages of the war required blood donations from women to meet both their own needs and those of the Soviet Army.
War Efforts and the Partisan Units
Nazi Germany invaded Yugoslavia in April 1941, which resulted in the country’s rapid disintegration. Over the next four years, the communist-led Partisan army waged a guerrilla resistance against the Nazis, eventually becoming one of the largest military forces in Europe and liberating the country. The nature of the Partisan struggle, with their guerrilla tactics, mobile field hospitals and a chronic shortage of resources, meant that a formal blood transfusion system could not be developed until the war’s later stages.Footnote 22
It is likely that many Yugoslav Partisans were already familiar with the potential of blood transfusion, particularly given that numerous communists had volunteered in the Republican Army during the Spanish Civil War. In Spain, figures like Dr Reginald Saxton carried out transfusions in improvised hospitals, employing both direct methods and stored blood. The Spanish Civil War was a pivotal moment for advancements in transfusion medicine, and several key Partisan doctors gained their initial experience in Spain, most notably Gojko Nikoliš, who later became the first head of the Partisan Medical Corps.Footnote 23
Once appointed to lead the Partisan Medical Corps, Nikoliš reflected on the harsh conditions under which wounded soldiers were treated, marked by constant evacuations, limited resources and a general lack of expertise in blood transfusion. When transfusions were carried out, Partisan medics typically relied on cross-matching because they had no access to serums or blood-type testing. These procedures were often improvised, performed under dangerous conditions, with compatibility assessed by monitoring patients for adverse reactions in real time.Footnote 24
By the spring of 1944, the Partisan Medical Corps had established contact with the Anglo-American Allies and began organising improvised blood transfusions within their units. These transfusions were still conducted carefully, using blood from universal donors because not enough tests were available for blood grouping. Donors were often medical staff and fellow soldiers. Improvised field hospitals also lacked refrigerators, so blood was stored underground.Footnote 25
The use of blood transfusion expanded significantly during the final year of the war, particularly after the Partisan army established direct ties with Soviet forces. After the liberation of Belgrade in October 1944, a formal blood transfusion service was quickly established. It was an initiative largely driven by the Soviet surgeon and scientist Anatoly Anatolyevich Kazansky, who had served as chief surgeon of the Karelian Front and later as the chief surgical adviser to the Yugoslav Partisans. During his year in Yugoslavia, Kazansky developed a close working relationship with Nikoliš and left a lasting impact on the organisation of the country’s transfusion system.Footnote 26 A major milestone was the shift from direct transfusion methods used in guerrilla warfare to the establishment of a structured system for storing and administering blood. The first conservation programme achieved an output of approximately 600 bottles per day. Yugoslav doctors proudly noted that their newly established Zavod Footnote 27 for Blood Transfusion was producing more blood units than any other facility in liberated continental Europe.Footnote 28
Recognising the potential of organised blood donation, the Yugoslav army, in collaboration with the Red Cross, launched its first campaign with the slogan ‘Blood for the Heroic Blood’. The initiative proved a remarkable success, drawing over 25,000 donors in less than a year.Footnote 29 It generated enough supplies both to meet the needs of the Yugoslav army and to support Soviet forces. The response from the Party’s mass organisations was so overwhelming that many donors reportedly waited over ten hours just to be screened for eligibility.Footnote 30 Data from the campaign revealed that the majority of donors were women, particularly housewives, who outnumbered peasants, workers, soldiers and students combined. Yet, despite this, Kulčar’s book on the campaign featured a stereotypical image of a male industrial worker to represent the 25,000 donors in a graph.Footnote 31 In contrast, the Party’s main magazine for women actively encouraged continued participation and framed blood donation as a vital way for women to contribute to the war effort and support the front lines.Footnote 32
The arrival of the Red Army marked a shift in the character of voluntarism. During the war, Yugoslavs had donated blood without financial compensation, typically receiving only a meal and a small sugar package in return. However, from late November 1944 onwards, the Soviets insisted that all donors be paid, while Soviet soldiers received nearly four times the compensation given to Yugoslav donors. After the Soviet army left and moved north, Yugoslav authorities faced the challenge of maintaining donation levels without undermining the spirit of volunteerism. They continued to offer food packages, but monetary compensation remained inconsistent, with individual centres adopting different approaches in the absence of a standardised model.Footnote 33
A New Socialist Blood Transfusion Network
The foundations of the new Yugoslav blood transfusion system were laid during the final stages of the war in 1944 and 1945, shaped by the immediate needs of the battlefield and modelled on Soviet practices. Immediately after the war, the Communist Party of Yugoslavia launched an ambitious economic and social transformation programme, drawing heavily on Soviet models. The new constitution and legal framework were often direct translations of Soviet legislation, while the strategy of industrialisation prioritised the development of heavy industry, mirroring the Soviet approach.Footnote 34
In 1947, the Communist Party launched the Five-Year Plan for Industrialisation and Electrification, which aimed to transform the entire economy. As the plan sought to encompass all sectors of society, the blood transfusion system was also incorporated into its framework. The objective was to establish a nationwide network based on Soviet organisational structures and terminology ranging from cabinets (small hospital-based units for local use), to stations (independent facilities), to zavods and institutes as the highest-level institutions within each republic.Footnote 35 The zavod was envisioned as a central hub for research, education and system oversight.Footnote 36 Integrating the blood transfusion system into such a centralised plan required Ministry of Health officials to oversee all aspects of its development: from the creation of institutions and factories to the training and deployment of personnel, and even the allocation of blood collection quotas for each centre.Footnote 37
One of the first challenges in building the system was achieving standardisation across the country. Doctors employed different methods and blood donation, processing and transfusion practices often relied on donated equipment, which was not always compatible. In late 1949, the Committee for the Protection of the People’s Health (the equivalent institution to the UK Ministry of Health; I refer to it as the Ministry of Health throughout this article) convened its first national conference on blood transfusion. The conference established key principles: a centralised organisational structure, standardised equipment, voluntary blood donations and a ban on blood sales and private initiatives.Footnote 38 At the conference, it was also decided that incentives such as groceries would be offered and that large-scale propaganda campaigns to encourage donations would be launched.Footnote 39 Nevertheless, for years Yugoslavia continued to depend on aid from organisations such as UNICEF and the WHO, although the donated equipment was often outdated and inadequate.Footnote 40 For example, the machines for drying plasma were delivered in a smaller size than specified in the contract, and according to the zavod director at the time, the donated bottle-washing machine was inferior to the one they used for washing beer bottles. A further complication was that the donated equipment varied widely across the country, making it difficult to coordinate and standardise practices among different blood donation centres.Footnote 41
Despite widespread shortages and the urgent need to rebuild a war-devastated country, the development of facilities and factories essential for the blood transfusion system advanced rapidly. In 1945, although they initially resorted to collecting old refrigerators left behind by the German army, the Belgrade zavod succeeded in producing its first batch of plasma.Footnote 42 Within a few years, Yugoslav centres were able to produce enough domestic serums for blood-type testing.Footnote 43 By the early 1950s, the state had begun constructing factories to manufacture dry plasma and plasma fractions, with the ultimate goal of producing all blood transfusion equipment domestically.Footnote 44 Around the same time, the government also began drafting legislation to regulate blood donation and formalise the role of blood transfusion services within the healthcare system.Footnote 45
By the late 1950s, Ministry officials were able to focus more on improving conditions in blood donation centres, particularly those that had been hastily established. A 1956 audit revealed that many centres in Serbia operated in inadequate conditions, often in improvised rooms that failed to meet basic standards, some of them cramped and located in basements.Footnote 46 Nevertheless, by 1960 the system had become largely standardised and self-sufficient in terms of equipment production, which allowed the focus to shift towards mobilising enough voluntary donors to meet the growing demand for blood products.Footnote 47
Staffing Problems
As the blood transfusion system expanded, the Yugoslav government faced growing challenges related to staffing. Trained specialist doctors were scarce, and both doctors and nurses had to be educated through short courses, with blood transfusion added to their existing responsibilities. The problem was particularly acute in the early years, when the entire health system suffered from a shortage of qualified personnel, and those assigned to blood transfusion often juggled multiple duties within their hospitals.Footnote 48
The Ministry of Health was deeply concerned about the lack of expertise, which carried serious risks, including blood contamination.Footnote 49 In some cases, the Ministry was forced to temporarily close donation centres. For example, the centre in Novi Sad was closed in 1949 because of poor blood-grouping practices, while centres in Valjevo and Šabac were shut down after cases of contaminated blood due to inadequate aseptic techniques. The Ministry was well aware that such errors had, in some instances, resulted in death.Footnote 50 It would take many years to address persistent problems such as the wastage of blood, often due to improper storage. In one case in early 1956, a hospital in Pančevo sent twelve bottles of blood as a ‘gift’ to the Belgrade zavod, only for it to be discovered that the blood was eight months old, far exceeding the standard twenty-one-day storage limit at the time. The situation was especially troubling because both the doctor and nurse involved had already completed zavod training on blood-storage procedures. The Ministry, concerned about not only safety but also public trust, reprimanded the hospital staff, worried that news of wasted blood would anger donors and discourage future contributions.Footnote 51
The shortage of doctors willing to work full-time in the blood transfusion system remained a persistent problem for decades. Although the Ministry of Health initially organised training courses, many doctors soon moved into other fields that offered clearer paths for specialisation and career advancement. In the mid-1950s, the Ministry debated the possibility of creating a dedicated residency for blood transfusion but ultimately rejected the idea, viewing the field as too narrow. Instead, the focus was on encouraging more surgeons and gynaecologists to integrate blood transfusion into their practice, a concept still unfamiliar to many doctors even in the late 1950s. It was only after 1960, when the Ministry introduced formal specialisation in blood transfusion, that the number of qualified doctors increased significantly, helping to resolve earlier shortages.Footnote 52
Global Knowledge Exchange
Although the blood transfusion infrastructure was built according to the Soviet model, a small group of specialist doctors within the system remained closely attuned to global medical developments. As early as 1944, a medical division of the Yugoslav Partisan army published a brochure on blood transfusion, outlining procedures for blood-type sampling using serums, methods to prevent contamination, compatibility guidelines, blood-storage techniques and the management of symptoms and therapies. Contact with the US and British forces further expanded their knowledge and exposed Yugoslav medics to innovations such as dry plasma and its application.Footnote 53 Early post-war publications reveal that Yugoslav doctors drew equally from Soviet and Western sources and maintained the tradition of intellectual openness characteristic of pre-war Yugoslavia. In the early years, much of the international medical literature was acquired through personal contacts, but by the 1950s, the state had begun organising broader exchanges through numerous European medical associations, national medical societies, and departments for specialised fields.Footnote 54
The conflict between the Soviet Union and Yugoslavia that erupted in the summer of 1948 forced Yugoslavia to find new partners outside the Soviet bloc. Long-standing ties with Eastern European institutes were rapidly severed. For instance, in March 1948, Slovenian doctors had established links with their counterparts in Prague to obtain medical literature and RH serums, an arrangement that became unfeasible by the end of the year.Footnote 55 Yugoslav specialists could no longer travel to the Soviet Union or its allied countries, which pushed them to find new venues for professional collaboration and exchange. For Yugoslav doctors, this transition occurred relatively quickly.
By leveraging their contacts with individuals, institutions and international organisations, Yugoslav doctors were invited to participate in the International Congress of Blood Transfusion in Lisbon, which was organised by the WHO in 1951. Eager to support this opportunity, the Ministry of Health funded the travel of its top specialists from the zavod.Footnote 56 Notably, no other Eastern European country took part. Reporting from the congress, the zavod’s director, Jerina-Lah Pavla, urged the government to invest more heavily in plasma drying and fractionation technologies. She also called on the Ministry to urgently send specialists to England, the Netherlands, the United States or Canada to gain expertise in advanced serological practices. During the congress, the Yugoslav delegation showed particular interest in securing new technology, either through direct acquisition from Western countries or with the assistance of the Red Cross.Footnote 57 While this first congress was instrumental in encouraging the Ministry of Health to broaden their engagement with international developments, by the next congress in Paris in 1954, the Yugoslav delegation, led by Artur Polak, presented a paper of their own.Footnote 58 By 1956, Yugoslav doctors were presenting their own findings in the top journals such as Vox Sanguinis on behalf of the International Society of Blood Transfusion.Footnote 59
As Yugoslavia increasingly opened to the West in the 1950s, more doctors began crossing borders for training and exchange. The Yugoslav Medical Association was eager to send its own specialists abroad and to invite foreign experts to Yugoslavia to deliver lectures, even though these visits were often unpaid. Some of the pioneers in blood preservation and transfusion, such as Greaves Ronald from Cambridge, visited on the invitation of the Bosnian Medical Association.Footnote 60 As explained in the introduction, British doctors became particularly involved, with Sir William Maycock playing a direct role in helping to establish standards and health procedures for Yugoslav blood transfusion services and blood products, and in facilitating the acquisition of equipment and supplies from London.Footnote 61
Yugoslav specialists also closely studied Western European models for organising blood transfusion services. One of the first comprehensive books on the subject, published in 1951, examined how systems were structured in countries such as the Netherlands and the United Kingdom, with a particular focus on methods of promoting blood donation. For instance, it recommended adopting ‘the English model’ of decentralised outreach, where local centres, rather than a central authority, would take responsibility for recruiting and organising donors. The publication also highlighted practices such as awarding donor badges and holding ceremonies to honour frequent donors, which the Ministry quickly adopted.Footnote 62 The following year, Živko Kulčar published another comprehensive book on blood transfusion, drawing heavily on the British and American literature. In his acknowledgements, he expressed gratitude to numerous professors from leading universities in the United States and the United Kingdom who had provided him with essential literature and documents. The book was intended for medical students and practitioners, offering both a brief overview of blood transfusion as a medical discipline and a detailed account of how blood transfusion systems were established in Belgium, England, Wales, France, Canada, the Netherlands and the United States. Kulčar, as well as Simonović and Janković before him, recommended developing a system based on voluntary donations, following the examples they saw in Western Europe.Footnote 63
Yugoslavia’s connections with the Eastern Bloc were re-established in the mid-1950s after Stalin’s death, and Yugoslav doctors soon resumed travelling to Eastern European countries.Footnote 64 By the late 1960s, they had established residency exchange programmes with many institutions across the region, often enabling them to study abroad without cost to them or the Ministry.Footnote 65 This placed Yugoslav doctors in a unique position, allowing them to draw on the experiences of both major political blocs, as well as the emerging non-aligned world. Meanwhile, doctors from other Eastern European countries, particularly from neighbouring Hungary and Bulgaria, also came to Yugoslavia, with their visits carefully organised, often down to the hour.Footnote 66
From the late 1950s onwards, Yugoslavia also developed an increasingly wide network of connections through WHO and the Red Cross initiatives, attended conferences across both political blocs and established links through various professional organisations. Yugoslav doctors also led important initiatives and aid efforts, particularly in Algeria and across Africa, despite the country facing severe shortages of medical staff at home.Footnote 67 As Dora Tot revealed, aid was also sent to other anti-colonial conflicts, including Vietnam, for which the Yugoslav Red Cross even organised a nationwide blood donation drive to collect plasma.Footnote 68 Connections were also made at the student level. For instance, medical students from the Yugoslav Union of Students took part in conferences organised by the International Union of Students, and in 1964 pledged to launch an annual blood donation week each April as part of a global initiative.Footnote 69 Although the number of donations fell short of expectations, the student body recommended evaluating the campaign primarily from an educational standpoint.Footnote 70
The Long Road to Voluntarism
Establishing a voluntary blood donation system proved to be a persistent challenge for Yugoslav health authorities for more than a decade after the war. While developing their own system, Yugoslav doctors closely studied how other countries motivated blood donors. They noted that in West Germany, donors were financially compensated, while in East Germany, donors received both monetary payments and food. Observations from the Soviet Union revealed a similar pattern: donors were paid and allowed to give blood up to eight times a year. Yugoslav doctors, however, firmly opposed the idea of paying for blood, and after the split with the Soviet Union, emulating the Soviet model was no longer palatable for Yugoslav health authorities.Footnote 71 As Siobhán Hearne has shown, the Soviet Union itself began to move towards a more voluntary blood donation system from the mid-1950s, relying on the Soviet Red Cross to mobilise donors.Footnote 72 That transition was far from rapid, as American observers noted that approximately half the Soviet donors were still paid in the 1960s. Besides days off work, holiday vouchers and meals, in some regions, donors also received benefits like free public transport passes or higher priority for housing. Paid donors collected payments directly from blood collection centres, without supplementary rewards. By 1965, donors could earn between fifteen and twenty-five roubles per donation, at a time when the minimum monthly wage was sixty roubles, making blood donation a lucrative activity. Hearne’s findings indicate that unpaid donors never became dominant during the 1970s either, representing only slightly more than 30 per cent of all donors by 1979.Footnote 73
The International Red Cross was more successful in Yugoslavia, where it played a crucial role in establishing a voluntary blood donation system. From the late 1940s, Yugoslav officials consulted with the Red Cross on various models used abroad, which at the time ranged from full operational control to a focus solely on promoting donations.Footnote 74 Eventually, it was decided that the Yugoslav Red Cross would be responsible for promoting blood donation, while each zavod would oversee collection and storage.Footnote 75 By the 1950s, this division of responsibilities was firmly established: the Red Cross handled all preparatory activities such as promotion, securing venues and providing badges and food. Meanwhile, each zavod managed the medical work, including processing the blood.Footnote 76 They also deployed mobile teams to reach remote areas, with the Red Cross assisting in organising the logistics.Footnote 77
The transition to a fully voluntary blood donation system advocated by the Red Cross, however, was slow. As mentioned, initially Yugoslav blood donors were incentivised with cash payments as Soviet troops insisted on this practice. Once the Soviets moved north, however, the new Yugoslav authorities tried to replace monetary rewards with grocery vouchers to maintain donation levels. For years after the war, there were no consistent standards for donor incentives. In their first months of operation, the zavod offered donors whatever it could, such as sugar and flour in late 1944 and early 1945.Footnote 78 As new blood donation centres opened, they also resorted to offering food packages. These incentives were considered a temporary measure, justified by the need for donors to regain their strength amid widespread post-war poverty. Doctors reporting to the Ministry of Health acknowledged the lack of scientific literature on the body’s nutritional needs following donation, instead relying on studies by Soviet doctors from the Leningrad Institute of Blood Transfusion.Footnote 79 Incentives varied across republics, but by the early 1950s, a typical reward for donating 250 millilitres of blood included 1.2 kilograms of lard, 1.2 kilograms of sugar, 3 kilograms of meat, and 15 kilograms of flour. Donating more than 250 ccm would double the amount.Footnote 80 Given the extreme poverty in the aftermath of the war, as described by Ivana Dobrivojević, these food packages were highly significant.Footnote 81
After grocery vouchers were discontinued for the general population, however, blood donors once again began receiving monetary vouchers. Federal health authorities grew increasingly concerned about the rising costs of the system, as the use of blood products expanded in regular medical practice and the overall demand for blood rose.Footnote 82 The demand for blood also surged during the industrialisation drive of the late 1940s and early 1950s, a period marked by frequent workplace accidents and injuries. This growing need prompted the federal government to establish new blood donation centres, particularly in Bosnian industrial hubs. These centres often struggled with a shortage of qualified staff, which placed additional pressure on existing personnel.Footnote 83 In Sarajevo, for instance, donors received one dinar per milligram of blood and were encouraged to donate every four weeks to continue receiving privileged access to food vouchers.Footnote 84
As expenses ballooned, the federal health authority decided in 1952 to gradually transition to an unpaid donation system and phase out non-monetary incentives. In the early stages, 95 per cent of unpaid donors were soldiers performing national service, who were rewarded with days off for donating blood.Footnote 85 By 1953, health authorities succeeded in raising the share of unpaid donors to 46.96 per cent, while also boosting participation among civilian donors.Footnote 86 Unpaid donors initially received two days off work and full reimbursement of their transportation costs, which was covered by their employer.Footnote 87
The shortcomings of the system and lack of strict standards were sometimes felt directly by patients. The Ministry of Health decided to intervene after receiving a letter from a certain Milica Marković, who pleaded for assistance as she could no longer afford to pay private donors for her husband’s transfusions. The hospital in Belgrade was unable to supply enough blood, forcing Marković to make private arrangements with individual donors. Although the case did not become public, only remaining an internal letter, the Ministry ordered the hospital to reimburse her and issued a directive to all republics to end such practices. This decision reaffirmed that hospitals, and the emerging public healthcare system, were responsible for ensuring access to blood for all patients, and that it was their duty to find sustainable ways to recruit more donors.Footnote 88
Despite efforts to eliminate ‘professional’ blood donations, the practice of hospitals paying donors continued well into the 1950s.Footnote 89 In some regions, such as Rijeka, a local donor society independently organised the blood supply and local hospitals paid donors for these contributions. It remains unclear when the Ministry ultimately succeeded in ending this practice, as local health authorities found themselves caught between the urgent need for blood and the persistence of an entrenched system.Footnote 90 In other areas, such as Bosnia and Herzegovina, civilian donors were also paid so that blood donation centres could meet their quotas throughout the 1950s.Footnote 91
By 1960, the Red Cross was able to mobilise around two-thirds of the required volunteers. To further increase donations, state officials turned to mass organisations, sports societies and other voluntary groups, such as alpinist clubs.Footnote 92 The state also regularly supported publication of various pamphlets aimed at prospective donors. For example, a 1973 publication titled ‘Lives of Many Depend on You’ outlined the multiple benefits of giving blood. Donors received a medical examination and the opportunity to consult doctors about any health concerns. The brochure also stressed that by donating blood, individuals helped ensure that they or their family members would have access to blood if ever needed. Additionally, it claimed that donating blood was beneficial to one’s health by stimulating blood regeneration. The brochure also worked to dispel common myths that blood donation could cause weight gain or impair work ability.Footnote 93
During the campaigns, blood donation was portrayed as both a humanitarian and patriotic duty. In practice, however, the most effective incentives were often material, such as offering workers paid days off and even paid vacations. As Yugoslavia became more industrialised in the 1970s, large factories and companies organised their own blood donation drives, offering substantial incentives to workers. For example, for five blood donations, employees at the Krušik ammunition factory in Valjevo received two weeks of paid vacation in a Montenegro resort, in addition to three days off for each donation. Such major enterprises often owned hotels and resorts along the Adriatic coast, where workers could stay at heavily subsidised or even free rates as part of these reward schemes. Local hospitals organised large monthly blood drives at such factories, ensuring a steady local supply and allowing surplus blood to be sent to the central facilities in Belgrade.Footnote 94
With these additional efforts, the Yugoslav system had become sufficiently established that paid donations were successfully eliminated in the 1970s, which enabled Yugoslavia to endorse the 1975 World Health Organization resolution calling on all countries to develop national blood services based on voluntary donation.Footnote 95 This also reshaped the gender dynamics of blood donations. While in this early post-war period donors were compensated with either cash or groceries, the majority of blood donors were unemployed women.Footnote 96 This shifted once incentives became more closely tied to workplace benefits, such as days off and as a significant share of blood donations began coming from the military. By the 1970s and 1980s, men made up the majority of donors.Footnote 97 Furthermore, by creating a system in which donors were motivated by the assurance of future access for themselves or their families, Yugoslavia developed a form of blood banking. Even so, Yugoslav officials consciously avoided the term ‘blood bank’, which was dominant in the United States, and instead framed blood donation as a scientific and voluntary act that was free from capitalist associations.Footnote 98
The Yugoslav blood donation system also suffered from discriminatory practices observed elsewhere in Europe and North America, although in Yugoslavia there was never racial or ethnic discrimination as seen in the United States. Yugoslav patients with mental health issues, however, were excluded from donations in the early 1950s.Footnote 99 Homosexual men were also discriminated against during the entire period, although this was only particularly apparent in the 1980s whenmen who had sex with men were barred from donating blood.Footnote 100 After the dissolution of Yugoslavia, individual states kept the ban, but with differences in rules concerning the time period since the last instance of sexual intercourse.
Conclusions
The case of the Yugoslav blood transfusion system shows that doctors crossed borders and learned from one another, even in the most difficult circumstances. A lack of resources, and even guerrilla warfare, did not prevent the exchange of knowledge, nor did these circumstances dampen the curiosity and determination to find new ways to save lives. Yugoslav doctors were interested in blood transfusion as early as their counterparts abroad. They engaged in experimental methods during the First World War, and again over the following decades.
The political and economic constraints during the Cold War did not stop collaboration either. In fact, after the war experience, the new socialist government developed a national infrastructure for blood transfusion, trying to obtain help from the Allies and international institutions. Despite the vast devastation caused by the war, considerable efforts were made to institutionalise blood transfusion as a standard medical practice. Centres were established in major cities, and medical personnel were given structured training in modern transfusion techniques. By the 1950s, the network of transfusion services had expanded considerably, with a robust state-led initiative that integrated modern transfusion practices into the country’s healthcare system.
Even though the blood transfusion system was initially based on the Soviet model at the systemic level, personal contacts and a professional push by Yugoslav doctors allowed Yugoslav practices to develop with influence from Western countries. Yugoslav doctors remained in touch with their Western colleagues, from whom they obtained new literature and learned about new techniques. After the split with the Soviet Union, the Yugoslav state also promoted knowledge exchange with Western medical institutions, which allowed Yugoslav doctors to develop an extensive transnational knowledge exchange network that drew from experiences of both political blocs.
With the collaboration with the Red Cross, Yugoslavia moved to a culture of voluntary blood donation by launching public awareness campaigns and blood drives. Still, the Yugoslav case shows that once various incentives were ingrained in the system, they were hard to eradicate. The transition from the Soviet paid system imposed during the war to a system of non-monetary incentives was slow; eventually, donors were rewarded with days off work and other perks until the end of socialism.
As Yugoslavia began to collapse in the late 1980s and into the 1990s, the blood donation system underwent significant changes. Large factories, companies and public institutions could no longer offer substantial incentives to encourage blood donation, even as the demand for blood increased, particularly in areas near conflict zones. Local hospitals increasingly reverted to the family replacement donation system, a practice that had existed in fits and bursts during Yugoslavia and was more common elsewhere in Eastern Europe. Under this system, patients were expected to recruit blood donors from among their family members and friends. Although often an unwritten rule, failure to provide donors could result in the postponement of medical procedures. In such cases, donors would come specifically to give blood on behalf of a particular patient.Footnote 101
Workers continued to receive days off for donating blood, although the benefit was reduced to just two days. The same rules formally applied to employees in newly established private companies, but in practice, it became increasingly difficult for donors to have these rights respected. As economic pressures grew, company profits often took precedence over the broader public need for blood products.Footnote 102 What began as a wartime necessity and evolved into a symbol of socialist solidarity ultimately fractured under the weight of post-socialist transition and the unravelling of the social contract that had sustained it.
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