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Social Science & Medicine 72 (2011) 1115e1122

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Social Science & Medicine


journal homepage: www.elsevier.com/locate/socscimed

Immunitary bioeconomy: The economisation of life in the international cord


blood market
Nik Brown*, Laura Machin, Danae McLeod
Science and Technology Studies Unit, Department of Sociology, University of York, United Kingdom

a r t i c l e i n f o

a b s t r a c t

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

Introduction and background to global cord blood banking


Recent decades have witnessed the emergence of newly globalised tissue economies (Waldby & Mitchell, 2006) with innovative industries established around the sourcing and economic
circulation of human tissues. These new economies are mediated
by a whole suite of infrastructural and bureaucratic systems enabling the exchange, reciprocity, regulation and brokerage of esh
and matter. Immunology and the matching of tissues and cells to be
used in treatment, or to re-engineer matter to induce immune
compatibility, has become central to these emerging markets.
While literature on the new tissue economies has either directly or
indirectly addressed what we might call the capitalisation of
immunology, less well understood are its links to the production
and orchestration of racially and ethnically devised bioeconomic
sovereign resources (see also Benjamin, 2009 and Whitmarsh,
2008).
This paper examines emerging architectures of biocapital
through the banking and international trade in cord blood (CB)
stem cells. It traces the commercialisation of cord blood and the
capitalisation of immunity in which CB has become a new form of
currency in the worlds international blood economies. CB is now
widely recognised as rich in haematopoietic stem cells (HSCs)
* Corresponding author.
E-mail address: nik.brown@york.ac.uk (N. Brown).
0277-9536/$ e see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.01.024

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).

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N. Brown et al. / Social Science & Medicine 72 (2011) 1115e1122

Nevertheless, this binary is far from straightforward and has


become increasingly unstable of late. Our focus here takes us
beyond a simple dichotomous division between the community
and the market, public and private. Instead we explore the banking
and international trade in CB between institutions that would
normally situate themselves organisationally within the terms of
public sector blood economies. This has been a sector highly
dependent on the availability of freely donated CB units within the
moral framework of altruistic giving. It is also a market model in
which the costs associated with storage are offset through pricing
strategies for blood products, particularly if those products can
attract a premium through international exportation.
The number of public and private CB banks operating internationally has risen sharply over the course of the last two decades
(Martin, Brown, & Turner, 2008). The World Marrow Donor Association lists close to half a million units of CB made available for
allogeneic treatment through fty six banks operating in thirty ve
countries (WMDA, 2008). The establishment of international
agencies and registries like the WMDA has been crucial in enabling
clinical groups and banks to liaise in arranging the purchasing of CB
units across and within international borders.
As we discuss below, CB is a high value commodity frequently
trading at 15,000 to 20,000 per unit. In a growing number of
cases patients receive costly multiple transplants to increase the
likelihood of therapeutic success (Hollands & McCauley, 2009). This
represents a substantial income for those banks selling CB given
that the cost of storage is, on average, considerably lower (usually
less than 10% of the export price). Based on units traded through
the WMDA, the international CB market was worth in excess of
20 m during 2008 and is rising sharply.
The global market in CB is also distinctive in a number of other
crucial respects. First, while traditional marrow registries are digital
libraries cataloguing immunologically typed potential donors, CB
banks by contrast store the physical substance itself. CB is more
amenable than bone marrow to off-the-shelf and on-demand
availability and circulation within a time sensitive system of distribution and exchange. As Waldby and Mitchell (2006) observe, . the
logic and rationale of a bank goes beyond storage and deposition e
but more crucially mobility and the readiness for withdrawal (p. 36).
Processing has been central to this accelerated mobilisation. Until
recently CB was often frozen whole but is now processed to reduce
volume, storage space and freight weight.
Second, while bone marrow donation involves invasive surgical
extraction with frequently long delays in scheduling, CB donors are
seen to incur far less risk, discomfort and inconvenience. Nonetheless, collection is not without contention, taking place amidst
the many competing clinical demands of the birthing process
(RCOG, 2006). Third, the use of CB as a substitute for bone marrow
in treatment is growing rapidly. There are in the region of fty
thousand blood stem cell transplants undertaken each year. Over
the course of the last decade, the number of CB units used in stem
cell transplantation has risen eightfold (WMDA, 2008) and marrow
transplants decreasing proportionately (Pamphilon, 2009). CB now
accounts for roughly twenty percent of all HSC transplants in
children with the number rising for adults. As one of our interviewees from a charitable sector bank put it, CB is taking off.
Conceptualising immunitary theory
The CB market we elaborate upon here relies upon a sophisticated global network of immunologically typed and matched
bodily matter. Using ever more sophisticated technologies for
genetically distinguishing between immunities, networks like the
WMDA link suppliers and clients, donors and recipients, with
increasingly meticulous biological precision.

Before discussing the CB economy in greater detail, we want to


elucidate on immunity in the biopolitical theorisation of advanced
post-industrial modernity. The trade in immunology is, we argue,
part of what Esposito (2006, 2008) refers to as nascent immunitary
paradigm, whereby politics, biology and economy have become
steadily more intertwined. In this case, the immunitary paradigm
takes the form of a trade in immunotypes, an internationalised
political economy built upon the capitalisation and globalisation of
diasporic immunity (by which we mean the dispersal and heterogenisation of populations upon which the CB trade is based). Forty
percent of all CB units used in treatment are traded across national
borders (Meijer et al., 2009, WMDA, 2008) following established
patterns of diasporic distribution.
For Haraway (1991) the immune system is . a plan for
meaningful action to construct and maintain the boundaries for
what may count as self and other in the dialectics of Western
biopolitics. (p. 204). Esposito (2006) recognises the potential of
immunological tolerance as the basis for productive forms of
association. Isnt it precisely the immunitary system. he writes,
that carries with it the possibility of organ transplants (p. 54)?
Political theory has tended to adopt a polar contrast between
immunity and community. However, Esposito seeks to reconceive
these binaries.
Immunitas and communitas have their common etymology in the
munus, literally meaning gift or obligation. Communitas expresses
the mutuality of the bond and reciprocity. Immunitas signals
a negative resistance to reciprocity, protection from obligation and
the commons. In both medical and juridical discourse, immunity is
a form of exemption or untouchability. Gift giving within the context
of an immunological regime can imply a diminishment of ones own
goods and in the ultimate analysis also of oneself (Esposito, 2006,
p. 50). Immunity traditionally conceived negates life and threatens
social circulation. Communitas and immunitas map directly onto the
equally traditional binaries of the blood economies with their
intellectual roots in Titmuss (1970) advocation of blood as a public
good shielded from the market. Community suggests forms of
association premised on common access insulated from property
and trade. The immunitary paradigm by contrast is seen to operate
on principles that undermine free association: protective defence,
proprietary claims to ones own biology, and the atomistic individualisation of privatisation.
However, Esposito (2008) questions this assumption and is
particularly keen to point to ways in which immunity creates the
conditions for new forms of circulation. In his writing, immunity and
community are far from polarised with gradations where some
forms of immunity can lead to productive association and ow
(transplantation for instance). He writes of generative hospitable
forms of immunity within an afrmative biopolitics where immunity becomes the power to preserve life (Esposito, 2008, p. 53e54).
The important point to take away from these reections is the
way immunity itself has become a corporeal resource and currency
for community. CB banks provide a form of immunologically based
protection or exemption for those fortunate enough to benet from
participation in the blood markets of advanced industrial bureaucratic economies. Whether private or public, such banks are
immunitary ventures, stockpiles of immunity. As we argue below,
the international trade in CB is not necessarily a freely given
expression of common community. It is instead a form of protection
for the trades participants from the vulnerabilities of being
dependent on an import market in premium goods. Being able to
export valuable units eases the cost burden associated with buying
CB on the international market. What we want to document in this
paper are the newly emerging arrangements for structuring the
availability and trade in, an immune-system resource that is the
basis of a globalised community built on CB.

N. Brown et al. / Social Science & Medicine 72 (2011) 1115e1122

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

Asian-American. More recently, Kollman (2004), put the probability


of nding a suitable match within the US National registry at 27%,
45%, 75% and 48% for blacks, Asians/Pacic Islanders, whites and
Hispanics, respectively. (p. 89). As Navarrete and Contreras
(2009) explain the probability of nding an HLA matched unrelated donor depends not only on the degree and resolution. of the
HLA matching required but also on ethnic background. (p. 147).
While these factors alone have been important in animating the
establishment of CB banks, many of the sectors target populations
are also disproportionately subject to heritable blood related haemoglobinopathies (Atkin, Ahmad, & Anionwu, 1998). CB banks
were established to ll this gap, compensating for under-representation in the bone marrow registries with a readily available
stock in HSCs derived from minority populations. Investment has
been promoted within health services as an effort to remedy these
inherent inequities in bone marrow-based systems of circulation
and exchange:
. [minority populations] are disproportionately affected by the
difculties of obtaining bone marrow. And so theyre often
found looking and searching and not being able to nd the
appropriate match to help CB related disorders in the family.
Theres a recognition that theres been too little CB for groups
and the government have sought to tackle that. Now, the
collection points presently are supposed to try and meet that
need but I think its very limited (UK Member of Parliament 1).
The collection points mentioned here refer to the way otherwise
rare (and consequently high premium) CB units are sourced into the
system. The US National Marrow Donor Programme has focussed
intensely on recruiting from key minority populations including American Indian or Alaska Native, Asian, Black or African
American, Hispanic or Latino, and Native Hawaiian or other Pacic
Islander (NMDP, 2009, p. 2). Elsewhere, the UK Cord Blood Bank
currently recruits potential donors from ve London hospitals with
considerably higher birth rates amongst ethnic minorities than
elsewhere. The rationale has been to maximise the statistical
possibility of collecting from racially heterogeneous collection sites,
rather than selecting minorities specically. Inclusion and exclusion
has both ethical and also scientic dimensions, as one respondent
put it: I dont think it would have been ethical to say were not
collecting from you. because that might have been the only
phenotype. even in caucasoids there are unique phenotypes.
(Director of a public CB bank 1).
In terms of the UK, while London has the highest density of nonCaucasoid candidate donors, other cities have also been cited as
potentially signicant recruitment sites should the service expand
to avoid dependence on overseas imports. As one UK Department
of Health interviewee put it: .we have to think about if we want
an ethnic mix that can only be got from North America. theres
a quid pro quo there. We have probably one of the most ethnically
mixed populations, especially in London, Liverpool, Manchester
and Cardiff. These were all once globally important port cities with
large West Indian, Afro-Caribbean and near Asian populations
dating back historically to the slave trade and the textile industries.
As one respondent put it, these are locations where health services
are seen to have good personal relations with potential donors
from racial minorities.
Interviewees from the UK Cord Blood bank estimate that around
40% of its units have been sourced from donors who self-report
themselves as non-Caucasoid. However, collecting from these
populations has also had unexpected implications for the business
model upon which many of the public banks were established. As
the following interviewee points out, the strategy was intended to
increase the therapeutic and also economic value of the collection.
But it has since become apparent that donated units from these

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N. Brown et al. / Social Science & Medicine 72 (2011) 1115e1122

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

this nascent immunitary paradigm, have begun to operate as an


important register of racial and ethnic difference (Reardon, 2005).
Registries: brokerage and standards in the immunitary
economy
The search for CB units for use in treatment is, in most circumstances, triggered by either a haematologist or oncologist
through referral to a transplant centre. In most country contexts,
searches are made rst of national registries before higher
premium and more costly international registries. The move
towards banking the physical substance of CB itself is in part driven
by an attempt to rationalise a highly complex process of searching,
matching and testing potential donors. As one respondent put it,
the established methods of procuring HSCs through existing bone
marrow registries entails a necessary and time-consuming gap
between the request for donation and the act of donation itself. This
becomes more complex as a search moves from the domestic to the
international level:
. I found donors for people where their immediate consultant
didnt know those donors existed. So. the system isnt as efcient as it could be . donors are not searched fast enough, or.
early enough. [T]he resources for looking for donors and for
testing potential donors are not as much as they could be. if
a patient in the UK has, I dont know, 10 matches overseas the
funds will only be available to test those one at a time, in many
instances (Director of a charity sector bank 2).
CB registries position themselves at the very centre of a vast
network linking donors, recipients, clinicians, banks and regulatory
agencies. As obligatory passage points (Callon, 1986), they mediate
the ow of CB between suppliers and consumers, banks and clinicians. While banks operate as repositories or stores of the immunitary economys principle asset, registries are the trading zones
(Galison, 1997) through which CB travels.
There are a number of such interlinking brokers operating
globally, though they are primarily concentrated in Europe (the
Netcord registry) and in the US (the Cord Blood Registry of the
National Marrow Donors Association). While registries are clearly
internationalised, they nevertheless have a regional orientation
partly premised on providing a trading advantage within a globally
competitive marketplace. For instance, the Eurocord registry of CB
transplants was established in 1995 primarily to keep pace with US
based infrastructures and has been nancially supported through
three successive rounds of European Commission funding. The
prospect of dependence on high cost imports from the US has been
repeatedly cited as grounds for the establishment of a Europeanwide bank. As one prominent advocate of European CB capacitybuilding recently put it, If nothing is done, we will have to rely on
US imports, which could cost $27,000, making transplants difcult
to afford. Also, ethnicity is rather different in the US compared to
the EU, (Gluckman, 2006). This question of the balance of trade
between different banking nations is explored in greater depth
below.
The crucial factor for registries is the question of scale. The larger
the collection, and the wider and more heterogeneous the network,
the more likely it is that a clinically useful match can be established
between donor and recipient. The advantage for any such registry
depends on its distributed geographical and tendrilous reach into
widely dispersed immunitary pools. It is less of a surprise then, that
while registries have something of an anchorage in the political
economies of regional blood economies, they are fundamentally
globally oriented in sourcing CB. As the following respondent
explains, the immunitary complexity of an outbred (the respondents phrase) globalisation in which populations have become

N. Brown et al. / Social Science & Medicine 72 (2011) 1115e1122

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

have had to be cautious in balancing the stringency of standards in


order to avoid complete exclusion of potential participants from the
CB sector.
The immunitary balance of trade
The international economy in CB is a trade that largely advantages those countries able to capitalise on a higher ratio of exports
to imports. In other words, a balance of trade surplus allows trading
nations to derive economic value from premium payments on
units. This globally oriented feature of the market extracts a bioeconomic surplus value (Cooper, 2008) from CB that substantially
exceeds its value within internal domestic contexts. The high cost
premium attached to international trade is a strong incentive for
the establishment of more comprehensive domestic supplies, and
this has become a pressing political and health economic question
as pointed out by the following respondent, a parliamentary
member of the UKs All party group on clinical CB and adult stem
cells:
.theres an issue of domestically how we do that [generate
supply] and the cost of importing CB. And that has an impact on
the Health Service. If we can ensure that we have home-grown
CB that must be cheaper. A good percentage of transplanted CB
is from abroad and that costs money. So the purpose of this is to
save lives and saving lives does save money as well because it
saves the costs of care. (UK Member of Parliament 1).
The costs associated with banking CB vary considerably but
generally do not exceed 2000. The UK NHS bank (NHS CBB) estimates the cost of unrelated (allogeneic) collection to be in the
region of 1400. Rates paid by private depositors to commercial
banks are fairly similar. However, the costs of purchasing CB
through international registries are very signicantly higher. Both
the UK based charity, the Anthony Nolan Trust, and the NHS CBB
pay in the region of 17,000 or more per unit imported from
overseas. Where multiple units have to be used to treat single
patients, as in the treatment of older children and adults, the costs
of a viable match on the international market can be prohibitively
expensive. It is less of a surprise that many banks have based their
business model on an export rather than import market:
. there are banks collecting as much as possible knowing that
its not for their own patients but for exporting them [so] they
can fund their own banks, if you think of it as a business, they
might be able to become economically self-sufcient but you
will never be able to be self-sufcient from the clinical point of
view (Director of a public CB bank 1).
There are very few data sources documenting international
markets in CB but gures generated by the WMDA (2008) represent
the most comprehensive source of information on the release,
usage and destination of units. Based on the reported quantitative
survey data for banks operating in each country it is possible to
generate a calculation of the balance of trade between participating
countries (see Fig. 1). A cluster of countries can be seen to trade
relatively high volumes of CB units across their borders (>50). Of
these, a number operate a signicant trade surplus where exports
exceed imports. For example, of the 137 units traded by Germany in
2008, the vast majority of these (110 or 80%) were exported overseas. Other countries operating a signicant surplus include
Belgium (86%), Australia (83%), and the US at 512 units or 68% of
cross-border trade. The objective for most domestic haematological
services has been to maximise exports and increasing value
through quality control but more importantly through racial and
ethnic variation.

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N. Brown et al. / Social Science & Medicine 72 (2011) 1115e1122

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

Fig. 1. Balance of trade.

The global patterning of the CB bioeconomy directly reects


population heterogeneity. Most East Asian countries, for example,
are predominantly self-sufcient in the supply reecting, it is
argued, the internally homogeneous composition of both their
populations and their blood economies. Japan, Korea, China and
Hong Kong source their CB almost exclusively through domestic
supply (see Fig. 2) with the exception of Taiwan. Of the 138 units
released for treatment in Japan, none were imported and only 5
exported. Asia then tends to have an internally-oriented supply
chain removed from the international export market and is
predominantly self sufcient. As one recent report explains it: .
Japan exports hardly any samples, as their specic HLA types are
endemic to Japan (Meijer, et al., 2009, p. 37) This is a radical
contrast to Europe and North America more strongly integrated
into globalised histories of migration and immunitary diversity. An
outbred genetic pool is the raw material foundation for international capitalisation and the extraction of surplus value. But as
the following respondent suggests, the more outbred a population,
the greater is the requirement to go beyond the nation state in the
search for immunitary resources:

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

I dont think theres one country that can be self-sufcient. the


only country is Japan because theyre such a homogeneous
group. there may be other countries that are less diverse but if
you look at Europe and the prole of the population theyre very
outbred and you wont get a [single] bank that will provide you
with that (Director of a public CB bank 1).
The majority of countries operating through the WMDA (64% of
the sample in Fig. 1) operate a trade decit with imports exceeding
exports. Countries with signicant decits include Canada (100%),
France (77%) and the UK (71%). Countries trading fewer than 50
units but operating a trade decit include Mexico (90%), Israel
(76%), Poland (75%) and Finland (71%). The question facing countries in this group is whether the cost of relying on imports is less or
greater than the likely costs of increased investment in domestic CB
banking. For instance, if we conservatively estimate that the 86
units imported into Canada during 2008 had a market value of
$20,000 each, import costs for 2008 would total over $1.7 m. Those
costs are unlikely to be borne by a single health services provider
and there are a wide range of factors at stake in whether or not

%
Exported
of those
released
4
23
3
0
0

Fig. 2. Markets in Asia.

Available

Units
used

Imported

5455
42135
100545
8892

133
33
60
19

0
4
0
1

2885

12

N. Brown et al. / Social Science & Medicine 72 (2011) 1115e1122

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

Fig. 3. Units available to those traded.

individual countries take the initiative to offset import costs


through domestic supply. Much depends on variables beyond the
scope of this paper including the structure of health service organisation and the arrangement of funding mechanisms in individual
countries.
Another interesting feature of the CB economy highlighted by the
data is that the difference between those countries that export
a high number of units, and those exporting comparably few, has
less to do with the number of units available, and more to do with
their ethnic/racial diversity of individual banks. UK CB public
collection was actually relatively small in 2008 by international
standards (10,589 compared with Germany [18,557], Australia
[20,044], Belgium [14,533], Italy [17,503]). However, the majority of
UK CB released for treatment went overseas (see Fig. 3). Thirty seven
of the forty seven (79%) units it released were exported, a gure
attributable to the very high success rate of the bank in recruiting
from racial minority populations. Navarrete and Contreras (2009)
calculate that .36% of units issued from the UK bank for transplantation are from ethnic minorities (p. 238). It is probable that
a similarly proportionate percentage of the units exported are also
sources from minority populations. The UK is estimated to have the
second highest percentage of rare immunities (41%) across global
registries (Pamphilon, Regan, Navarrete, & Watt, 2009). So while CB
may indeed be the raw material of the market, the actual asset is
constructed as race itself. The immunitary trade signicantly
advantages those racially heterogeneous countries able to supply
globally dispersed populations.
Nevertheless, strong exporters are not necessarily very successful at supplying their own domestic demands. Whereas the UK
exported 37 of 47 released, it imported 91 units at an estimable cost
of around 1.5 m, paying nearly three times in import costs what
it earns from exports. Most sizeable exporters are much more
successful at supplying their own demand. Imports as a proportion
of units used in treatment are generally lower than in the UK and
account for between 20% and 64% (US and France respectively) for
most other countries in Fig. 3. The trend over the course of the last
decade or so has been to see a rising dependence in Europe on
imports, a tendency now motivating stronger investment in regional CB capacity (Pamphilon, 2009). Indeed, a number of countries
have provisions to protect domestic supply from export. For
example, Spain allows the export of CB on the condition that it can
be shown that the unit does not have any current utility within its
national borders. Like other competitive areas of trade, the CB bioeconomy is characterised by mechanisms that both facilitate ow,
while also protecting national ownership. As one commentator puts
it, there is muted competition between the public banks themselves
seeking to achieve a critical size (Katz-Benichou, 2007, p. 464). The
balance of trade in CB maps onto other similar tensions between
sovereign autonomy and yet global dependence where post-colonial countries engage in the capitalisation of ethnically or racially

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

N. Brown et al. / Social Science & Medicine 72 (2011) 1115e1122

obtaining exactly the right match may be vanishingly small and


only ever possible where spatial reach has been widened sufciently to improve the statistical likelihood of securing a match. In
this sense, the bioeconomy we document here extends and capitalises upon an immunitary globalisation, historically structured
through outbred diasporic migration.
Second, internationalisation allows for the additional extraction
of a monetary surplus by permitting an economic value to be
negotiated and attached to CB units. Over and above the original
costs associated with extraction and banking, internationalisation
enables added indirect costs to be folded into prices set for CB in the
global marketplace. That prot surplus is legitimated on the basis
that blood services should be able to offset costs and compensate
themselves for the economic risks and nancial burden of domestic
collection and storage.
Our focus here has been to elaborate on the international
political economy of life by documenting the production of an
increasingly vibrant market in CB stem cells. In so doing, we have
also sought to respond to the contention that social critique of the
biosciences has neglected economisation and too readily focused
on politicisation (Cooper, 2008; Lemke, 2001). It remains to be seen
how the economic realities of an international trade in blood are to
be reconciled with an enduring cultural attachment to a moral
economy of values where altruism and gift remain the primary
symbolic motivation for sourcing premium bioeconomic resources.
Acknowledgements
The authors would like to thank Paul Martin, Naomi Pfeffer,
Daryl Martin and Andrew Webster whose reections on an earlier
version of this paper proved invaluable. Our research was kindly
funded by the UK Economic and Social Research Council RES062-23-1386. We would like to thank the World Marrow Donor
Association for sharing with us their 2008 annual cord blood
survey.
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