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This paper examines emerging architectures of biocapitalthrough the banking and international trade in cord blood (CB)stem cells. It traces the commercialisation of cord blood and thecapitalisation of immunity in which CB has become a new form ofcurrency in the worlds international blood economies. CB is nowwidely recognised as rich in haematopoietic stem cells (HSCs)

their newborns for future private use (Brown & Kraft, 2006;Waldby, 2006). Private banking has been the site of considerablecontention having been characterised as a neoliberal privatisedmarket where individuals or families make an exclusive claim on anautologous (self-to-self) biological asset that remains privateproperty (Santoro, 2009). The cord blood debate has its history inthis binary polarisation of public and private economies, pitchinga solidaristic ethos of community inclusion against the atomisticseclusion of the self (Titmuss, 1970).

* Corresponding author.

Contents lists availab

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Social Science & Medicine 72 (2011) 1115e1122E-mail address: nik.brown@york.ac.uk (N. Brown).bling the exchange, reciprocity, regulation and brokerage of eshandmatter. Immunology and thematching of tissues and cells to beused in treatment, or to re-engineer matter to induce immunecompatibility, has become central to these emerging markets.While literature on the new tissue economies has either directly orindirectly addressed what we might call the capitalisation ofimmunology, less well understood are its links to the productionand orchestration of racially and ethnically devised bioeconomicsovereign resources (see also Benjamin, 2009 and Whitmarsh,2008).

areas including cancer, immune system disorders and gene therapy.Most of these public banks have been seen to operate withina traditionally established discourse structured around giving, thebasis of a social solidarity where anonymous donors contribute toa publicly available biological resource. Public blood economiesoperate according to an allogeneic regime in which blood is moreusually circulated between unrelated though immunologicallymatched donors and recipients.

There has also been a recent and rapid growth in a private CBbanking market with parents paying to deposit the stem cells ofIntroduction and background to g

Recent decades have witnessedbalised tissue economies (Waldbyvative industries established aroundcirculation of human tissues. Theseby a whole suite of infrastructural a0277-9536/$ e see front matter 2011 Elsevier Ltd.doi:10.1016/j.socscimed.2011.01.024suggest, an extension of what Roberto Esposito (2008) has termed an immunitary paradigm in whichimmunity 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.

ord blood banking

ergence of newly glo-hell, 2006) with inno-ourcing and economicconomies are mediatedeaucratic systems ena-

giving rise to the bodys entire blood and immune system. It hasbeen used clinically as an alternative to bone marrow for a range oftreatments since the late 1980s (Gluckman et al., 1989) with anincreasingly signicant prole in regenerative medicine (Brown,Kraft, & Martin, 2006). This led to the establishment in the early1990s of numerous international initiatives to source and bank CBstem cells to be made available in a widening number of treatmentEthnicity a form of corporeal currency. Based on recent international gures we reect upon the balance of tradebetween imports and exports across the worlds cord blood bioeconomy. Theoretically, this case is, weImmunityglobal network of immunologically typed and matched bodily matter in which immunity has becomeImmunitary bioeconomy: The economisblood market

Nik Brown*, Laura Machin, Danae McLeodScience and Technology Studies Unit, Department of Sociology, University of York, Unit

a r t i c l e i n f o

Article history:Available online 13 February 2011

Keywords:Cord blood bankingStem cellsBioeconomy

a b s t r a c t

This paper examines an emblood. Since the late 1980alternative to the use of bopopulations who have histthe mobilisation and comblood units trading intern

Social Scienc

journal homepage: www.eAll rights reserved.ion of life in the international cord

ingdom

ging bioeconomy centred on the international banking and trade in cordrd blood has been used in an expanding range of treatments and as anmarrow stem cells. This is particularly the case in treating ethnic minorityally been under-represented in bone marrow registries. The paper explorescialisation of an increasingly important bioeconomic resource with cordnally at high prices. This is a market mediated through a sophisticated

le at ScienceDirect

& Medicine

vier .com/locate/socscimed

& MNevertheless, this binary is far from straightforward and hasbecome increasingly unstable of late. Our focus here takes usbeyond a simple dichotomous division between the communityand the market, public and private. Instead we explore the bankingand international trade in CB between institutions that wouldnormally situate themselves organisationally within the terms ofpublic sector blood economies. This has been a sector highlydependent on the availability of freely donated CB units within themoral framework of altruistic giving. It is also a market model inwhich the costs associated with storage are offset through pricingstrategies for blood products, particularly if those products canattract a premium through international exportation.

The number of public and private CB banks operating interna-tionally has risen sharply over the course of the last two decades(Martin, Brown, & Turner, 2008). The World Marrow Donor Asso-ciation lists close to half a million units of CB made available forallogeneic treatment through fty six banks operating in thirty vecountries (WMDA, 2008). The establishment of internationalagencies and registries like the WMDA has been crucial in enablingclinical groups and banks to liaise in arranging the purchasing of CBunits across and within international borders.

As we discuss below, CB is a high value commodity frequentlytrading at 15,000 to 20,000 per unit. In a growing number ofcases patients receive costly multiple transplants to increase thelikelihood of therapeutic success (Hollands &McCauley, 2009). Thisrepresents a substantial income for those banks selling CB giventhat the cost of storage is, on average, considerably lower (usuallyless than 10% of the export price). Based on units traded throughthe WMDA, the international CB market was worth in excess of20 m during 2008 and is rising sharply.

The global market in CB is also distinctive in a number of othercrucial respects. First, while traditional marrow registries are digitallibraries cataloguing immunologically typed potential donors, CBbanks by contrast store the physical substance itself. CB is moreamenable than bone marrow to off-the-shelf and on-demandavailability and circulation within a time sensitive system of distri-bution andexchange. AsWaldbyandMitchell (2006) observe, . thelogic and rationale of a bank goes beyond storage and deposition ebutmore cruciallymobility and the readiness forwithdrawal (p. 36).Processing has been central to this accelerated mobilisation. Untilrecently CB was often frozen whole but is now processed to reducevolume, storage space and freight weight.

Second, while bone marrow donation involves invasive surgicalextraction with frequently long delays in scheduling, CB donors areseen to incur far less risk, discomfort and inconvenience. None-theless, collection is not without contention, taking place amidstthe many competing clinical demands of the birthing process(RCOG, 2006). Third, the use of CB as a substitute for bone marrowin treatment is growing rapidly. There are in the region of ftythousand blood stem cell transplants undertaken each year. Overthe course of the last decade, the number of CB units used in stemcell transplantation has risen eightfold (WMDA, 2008) and marrowtransplants decreasing proportionately (Pamphilon, 2009). CB nowaccounts for roughly twenty percent of all HSC transplants inchildren with the number rising for adults. As one of our inter-viewees from a charitable sector bank put it, CB is taking off.

Conceptualising immunitary theory

The CB market we elaborate upon here relies upon a sophisti-cated global network of immunologically typed and matchedbodily matter. Using ever more sophisticated technologies forgenetically distinguishing between immunities, networks like theWMDA link suppliers and clients, donors and recipients, with

N. Brown et al. / Social Science1116increasingly meticulous biological precision.Before discussing the CB economy in greater detail, we want toelucidate on immunity in the biopolitical theorisation of advancedpost-industrial modernity. The trade in immunology is, we argue,part of what Esposito (2006, 2008) refers to as nascent immunitaryparadigm, whereby politics, biology and economy have becomesteadily more intertwined. In this case, the immunitary paradigmtakes the form of a trade in immunotypes, an internationalisedpolitical economy built upon the capitalisation and globalisation ofdiasporic immunity (by which we mean the dispersal and heter-ogenisation of populations uponwhich the CB trade is based). Fortypercent of all CB units used in treatment are traded across nationalborders (Meijer et al., 2009, WMDA, 2008) following establishedpatterns of diasporic distribution.

For Haraway (1991) the immune system is . a plan formeaningful action to construct and maintain the boundaries forwhat may count as self and other in the dialectics of Westernbiopolitics. (p. 204). Esposito (2006) recognises the potential ofimmunological tolerance as the basis for productive forms ofassociation. 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 betweenimmunity and community. However, Esposito seeks to reconceivethese binaries.

Immunitas and communitas have their common etymology in themunus, literally meaning gift or obligation. Communitas expressesthe mutuality of the bond and reciprocity. Immunitas signalsa negative resistance to reciprocity, protection from obligation andthe commons. In both medical and juridical discourse, immunity isa formof exemptionor untouchability. Gift givingwithin the contextof an immunological regime can implya diminishmentof ones owngoods and in the ultimate analysis also of oneself (Esposito, 2006,p. 50). Immunity traditionally conceived negates life and threatenssocial circulation. Communitas and immunitasmap directly onto theequally traditional binaries of the blood economies with theirintellectual roots in Titmuss (1970) advocation of blood as a publicgood shielded from the market. Community suggests forms ofassociation premised on common access insulated from propertyand trade. The immunitary paradigm by contrast is seen to operateon principles that undermine free association: protective defence,proprietary claims to ones own biology, and the atomistic indi-vidualisation of privatisation.

However, Esposito (2008) questions this assumption and isparticularly keen to point to ways in which immunity creates theconditions for new formsof circulation. Inhiswriting, immunityandcommunity are far from polarised with gradations where someforms of immunity can lead to productive association and ow(transplantation for instance). He writes of generative hospitableforms of immunity within an afrmative biopolitics where immu-nity becomes the power to preserve life (Esposito, 2008, p. 53e54).

The important point to take away from these reections is theway immunity itself has become a corporeal resource and currencyfor community. CB banks provide a form of immunologically basedprotection or exemption for those fortunate enough to benet fromparticipation in the blood markets of advanced industrial bureau-cratic economies. Whether private or public, such banks areimmunitary ventures, stockpiles of immunity. As we argue below,the international trade in CB is not necessarily a freely givenexpression of common community. It is instead a form of protectionfor the trades participants from the vulnerabilities of beingdependent on an import market in premium goods. Being able toexport valuable units eases the cost burden associated with buyingCB on the international market. What we want to document in thispaper are the newly emerging arrangements for structuring theavailability and trade in, an immune-system resource that is the

edicine 72 (2011) 1115e1122basis of a globalised community built on CB.

& MMethod

This project was funded by the UK Economic and SocialResearch Council (ESRC) and explores changing patterns in theorganisation, donation and deposition of CB stem cells. Over a 14month period (2009e2010), 51 qualitative, semi-structured inter-views were conducted including site visits (total 14) with thefollowing groups: clinicians and researchers e including obstetricservices and stem cell bioscience researchers; policy makers andregulators e both at the UK domestic, European and internationallevels; interest groups e including members of royal colleges:health advocacy groups and charities; and interviews with actualand potential donors and depositors of umbilical CB. Intervieweeswere identied and recruited through several routes includingdirect contact with stakeholder organizations and searches ofscientic and policy literature. Actual and potential CB donors wererecruited through local and national childbirth support groups.Ethical approval was sought from our home institution ethicscommittee, 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 drawnfrom three sources including: interviews (procurement personnel,bank and senior health service staff); grey literature and internaldocumentation including recently commissioned governmentreports; and quantitative data generated by the World MarrowDonor Association documenting the release, importation andexportation of CB units across nation state borders. The WMDA isone of the few internationally recognised sources collecting andproducing annualised reports from 112 of 128 identied banksoperating worldwide. Our analysis recalculates this raw reporteddata to produce thebalanceof tradepercentageof exports relative toimports for each participating country for the year 2008. Qualitativedate was analyzed using a software coding system (Atlas.ti) tocategorize the data according to a broad range of empirically driventhemes. The research thus combines qualitative interview data andpolicy data to link cultural and economic dimensions of CB banking.As a number of commentators have noted, economy and politics arerarely considered together in sociological critiques of the biosci-ences (Cooper, 2008; Lemke, 2001; Waldby & Mitchell, 2006). Thiscase study makes a modest contribution to a growing literaturefocussing on the economisation of human biological life.

Cord blood collection - assembling diasporic immunity

The emergence of the CB banking sector is, we suggest, coex-tensive with contemporary globalisation and unprecedented levelsof immunitary migration and heterogenisation. The uid spatialdistribution of immunity is written into the foundational logic ofthe establishment of a public banking capacity. Most banks wereoriginally set up to overcome the disproportionately high repre-sentation of white Caucasian populations in traditional bonemarrow registries. Long established registries have had stronghistorical penetration amongst advantaged middle class blooddonors but recruited less well beyond the mainstream demo-graphic. Non-Caucasoid populations have generally been poorlyprovided for in the treatment of leukaemia where the chances ofnding an immunologically appropriate bone marrow matchremain considerably lower than for majority (usually white) pop-ulations. Recent gures suggest that while it is possible to nda match for up to 75% of patients of Western European origin, thatgure falls to 20% or 30% for other ethnic groups (Meijer et al., 2009).Beatty, Mori, and Milford (1995) were amongst the rst in the mid1990s to draw attention to the diminishing probabilities of ndingappropriate bone marrow matches for those who self-reported

N. Brown et al. / Social Sciencetheir ancestry as African American, Hispanic, Native-American andAsian-American. More recently, Kollman (2004), put the probabilityof nding a suitable match within the US National registry at 27%,45%, 75% and 48% for blacks, Asians/Pacic Islanders, whites andHispanics, respectively. (p. 89). As Navarrete and Contreras(2009) explain the probability of nding an HLA matched unre-lated donor depends not only on the degree and resolution. of theHLA matching required but also on ethnic background. (p. 147).

While these factors alone have been important in animating theestablishment of CB banks, many of the sectors target populationsare also disproportionately subject to heritable blood related hae-moglobinopathies (Atkin, Ahmad, & Anionwu, 1998). CB bankswere established to ll this gap, compensating for under-repre-sentation in the bone marrow registries with a readily availablestock in HSCs derived from minority populations. Investment hasbeen promoted within health services as an effort to remedy theseinherent inequities in bone marrow-based systems of circulationand exchange:

. [minority populations] are disproportionately affected by thedifculties of obtaining bone marrow. And so theyre oftenfound looking and searching and not being able to nd theappropriate match to help CB related disorders in the family.Theres a recognition that theres been too little CB for groupsand the government have sought to tackle that. Now, thecollection points presently are supposed to try and meet thatneed but I think its very limited (UK Member of Parliament 1).

The collectionpointsmentionedhere refer to thewayotherwiserare (and consequently high premium) CB units are sourced into thesystem. The US National Marrow Donor Programme has focussedintensely on recruiting from key minority populations includ-ing American Indian or Alaska Native, Asian, Black or AfricanAmerican, Hispanic or Latino, and Native Hawaiian or other PacicIslander (NMDP, 2009, p. 2). Elsewhere, the UK Cord Blood Bankcurrently recruits potential donors from ve London hospitals withconsiderably higher birth rates amongst ethnic minorities thanelsewhere. The rationale has been to maximise the statisticalpossibility of collecting from racially heterogeneous collection sites,rather than selectingminorities specically. Inclusion and exclusionhas both ethical and also scientic dimensions, as one respondentput it: I dont think it would have been ethical to say were notcollecting from you. because that might have been the onlyphenotype. 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 non-Caucasoid candidate donors, other cities have also been cited aspotentially signicant recruitment sites should the service expandto avoid dependence on overseas imports. As one UK Departmentof Health interviewee put it: .we have to think about if we wantan ethnic mix that can only be got from North America. theresa quid pro quo there. We have probably one of the most ethnicallymixed populations, especially in London, Liverpool, Manchesterand Cardiff. These were all once globally important port cities withlarge West Indian, Afro-Caribbean and near Asian populationsdating back historically to the slave trade and the textile industries.As one respondent put it, these are locations where health servicesare seen to have good personal relations with potential donorsfrom racial minorities.

Interviewees from the UK Cord Blood bank estimate that around40% of its units have been sourced from donors who self-reportthemselves as non-Caucasoid. However, collecting from thesepopulations has also had unexpected implications for the businessmodel upon which many of the public banks were established. Asthe following interviewee points out, the strategy was intended toincrease the therapeutic and also economic value of the collection.

edicine 72 (2011) 1115e1122 1117But it has since become apparent that donated units from these

& Mpopulations had unusually low stem cell counts that threaten theirvalue as units of exchange in the global immunitary marketplace:

we have been very successful. forty percent of our collection isfrom ethnic minorities. there has been a price that weve paidfor that in terms of business because weve. shown that thosefrom ethnic minorities have lower volume and lower TNCs[Total Nucleated Cell count]. so a large number of our units areconsidered not the optimal product. thats the price wevepaid. so from the business point of viewweve not been all thatsuccessful in selling them as it were. here is where you have tobalance the economics and the ethics (Director of a public CBbank 1).

In terms of recruitment, the question of race has proven to beacutely sensitive for populations with long established colonialhistories. For instance, staff frequently attribute fear and suspicionto ethnic minority communities as a major obstacle to improvingdonation rates. These are far from straightforward issues withcomplex connotations suggesting many multiple meanings asso-ciated with donation including ambivalence and the threat ofappropriation (see also Whitmarsh, 2008):

. Ive sat and spoken tomen and you kind of think they see thelight but they still dont want to donate. Now, is that becausethey dont want to lose face? Is that because they really dontunderstand whats being done?. just difcult trying to nda way in to that kind of group (Representative from a charitablesector bank 1)Its known that ethnic diversity is really something that needsto be brought out in the open and say there arent enough ethnicsamples being stored and their chances of a match are evenslight. (Director of a private CB bank 1).

Heritability of genotypic immunity are constantly subject tointergenerational and spatial redistribution continuous with post-colonialism and globalisation. It is that dynamism that hasprovided the incentive for an international system of exchangewhile at the same time turning it into a premium commodityresource. CB banking brings into view dimensions of globalisationdirectly linked to the vitalistic and corporeal. The migratory ow ofbodies is a diasporic dispersal of genetically indexed immunity.Within the developing immunitary regime documented by Espo-sito and others, immune system biology has itself become the focusfor bioeconomic enterprise. Newly heterogeneous populations arethe driving demographic factors in encouraging health servicesaround the world, but particularly in North America, Europe andEast Asia to establish CB banks. For example, one of our respon-dents from the private banking sector here comments on the waycommercial banks have sought new markets amongst the migra-tory communities displaced by the transition of Hong Kong fromBritish to Chinese rule:

.When Hong Kong closed down. the rich Chinese. movedto Toronto. but what you have then is a lot of mixed racecouples. [their] children are going to be. unusual genotypeand to get a transplant for that kind of child would be verydifcult. So private storage in that area is very popular.(Director of private CB bank 2).

Race has a profoundly volatile place within a post-colonialmodernity characterised on the one hand by the varied instabilitiesof diaspora, while also subject to new biometric measures for xingand determining biological identity. The CB sector spans and utilisesany number of technologies where the geneticisation (Lupton,1994) of race has been recently enlarged through populationgenetics, racial proling, and genetic genealogical and ancestry

N. Brown et al. / Social Science1118studies, etc. CB banking extends the way biological markers, withinthis nascent immunitary paradigm, have begun to operate as animportant register of racial and ethnic difference (Reardon, 2005).

Registries: brokerage and standards in the immunitaryeconomy

The search for CB units for use in treatment is, in most cir-cumstances, triggered by either a haematologist or oncologistthrough referral to a transplant centre. In most country contexts,searches are made rst of national registries before higherpremium and more costly international registries. The movetowards banking the physical substance of CB itself is in part drivenby 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 bonemarrow registries entails a necessary and time-consuming gapbetween the request for donation and the act of donation itself. Thisbecomes more complex as a search moves from the domestic to theinternational level:

. I found donors for people where their immediate consultantdidnt know those donors existed. So. the system isnt as ef-cient as it could be. donors are not searched fast enough, or.early enough. [T]he resources for looking for donors and fortesting potential donors are not as much as they could be. ifa patient in the UK has, I dont know, 10 matches overseas thefunds will only be available to test those one at a time, in manyinstances (Director of a charity sector bank 2).

CB registries position themselves at the very centre of a vastnetwork linking donors, recipients, clinicians, banks and regulatoryagencies. As obligatory passage points (Callon,1986), theymediatethe ow of CB between suppliers and consumers, banks and clini-cians. While banks operate as repositories or stores of the immu-nitary economys principle asset, registries are the trading zones(Galison, 1997) through which CB travels.

There are a number of such interlinking brokers operatingglobally, though they are primarily concentrated in Europe (theNetcord registry) and in the US (the Cord Blood Registry of theNational Marrow Donors Association). While registries are clearlyinternationalised, they nevertheless have a regional orientationpartly premised on providing a trading advantage within a globallycompetitive marketplace. For instance, the Eurocord registry of CBtransplants was established in 1995 primarily to keep pace with USbased infrastructures and has been nancially supported throughthree successive rounds of European Commission funding. Theprospect of dependence on high cost imports from the US has beenrepeatedly cited as grounds for the establishment of a European-wide bank. As one prominent advocate of European CB capacity-building recently put it, If nothing is done, we will have to rely onUS imports, which could cost $27,000, making transplants difcultto afford. Also, ethnicity is rather different in the US compared tothe EU, (Gluckman, 2006). This question of the balance of tradebetween different banking nations is explored in greater depthbelow.

The crucial factor for registries is the question of scale. The largerthe collection, and the wider andmore heterogeneous the network,the more likely it is that a clinically useful match can be establishedbetween donor and recipient. The advantage for any such registrydepends on its distributed geographical and tendrilous reach intowidely dispersed immunitary pools. It is less of a surprise then, thatwhile registries have something of an anchorage in the politicaleconomies of regional blood economies, they are fundamentallyglobally oriented in sourcing CB. As the following respondentexplains, the immunitary complexity of an outbred (the respon-

edicine 72 (2011) 1115e1122dents phrase) globalisation in which populations have become

seas. Other countries operating a signicant surplus include

& Mmuch more diverse means that very few national CB supplies arevaried enough to be able to meet domestic demand:

.the HLA is so polymorphic that no country would be ableto think itself sufcient even with the largest bank. thats whyyou need the international collaboration. were maximisingthe probabilities of nding a donor for the UK. countries set upthis registry to satisfy local need.we are all fully aware that wewill be providing for donors abroad as indeed beneting fromthose 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 onwidely agreed standards whereby buyers and sellers can be assuredof the quality of assets traded. The immunitary economy wedescribe here has been steadily built up through what Callon,Meadel, and Rabeharisoa (2005) have termed an economy ofqualities. If race is the asset, standardsmeasure of theworth of thatasset by attening the otherwise uneven spatial topographicalgeography of the CB trading zone (Webster & Eriksson, 2008). OneUK transplant director put it that . it becomes a worldwideresource. What we can offer in the UK is . lots of ethnic minor-ities.. Plus a system that will deliver quality.

There have been a number of overlapping and sometimescompeting initiatives to manage the variability of CB valueincluding the establishment of Netcord, FACT (Foundation for theAccreditation of Cellular Therapy) and the efforts of the WorldMarrow Donor Association. In addition to promoting clinicaleffectiveness, standard-setting is indispensible to the functioning ofan exchange economy in which CB assets command high prices.The promotion and facilitation of trade has been central to policy-making in this area as illustrated by the European Tissues and CellsDirective adopted by the European Parliament in 2004. One of theprimary purposes of the Directive was to put in place the sup-porting infrastructure for a buoyant economic market in cells andtissues across the eurozone. Nevertheless, while the internationaldistribution of the CB economy is vital to increasing the likelihoodof securing a close match, it necessarily highlights unevenness inpractise:

France is 22 miles away. South America is a 10 h ight. China is14 h. You have very little control over what happens in otherjurisdictions and so internationally it really is a case of the willto ensure that best practise is put in place and consent issues arefollowed. And I think the onewaywe can do it is by saying that ifyou are going to import material from elsewhere, its yourresponsibility to ensure that that has been procured in a waythat you would expect it to be procured in the UK. Outsidetheres not much we can do (Senior UK health service policymaker 1).

Standards extend the immunitary paradigm by creating spacesprotected from pollution. In writing of contamination, Esposito hasin mind the state-orchestrated biopolitics of, for example, immu-nitary protection from interhuman contamination that underpinsimmigration policy. Hewrites that the prevention of contaminationhas its apex in our own time, and no more so than in a biopoliticaleconomy dependent on the free circulation and exchange of dis-embodiedmobile matter, cells and tissues. Standards in these termsoperate to dene inclusion and membership of an immune-basedcommunity offering protection from potential contaminationacross the blood economies. Registries illustrate these efforts toestablish an immunitary community perfectly. But taken too far,protection from contamination can result in a negation of life. Theimmunitary paradigm can work to restrict the circulation of ow.

N. Brown et al. / Social ScienceFor example, government legislation and the registries themselvesBelgium (86%), Australia (83%), and the US at 512 units or 68% ofcross-border trade. The objective for most domestic haematologicalservices has been to maximise exports and increasing valuethrough quality control but more importantly through racial andhave had to be cautious in balancing the stringency of standards inorder to avoid complete exclusion of potential participants from theCB sector.

The immunitary balance of trade

The international economy in CB is a trade that largely advan-tages those countries able to capitalise on a higher ratio of exportsto imports. In other words, a balance of trade surplus allows tradingnations to derive economic value from premium payments onunits. This globally oriented feature of the market extracts a bio-economic surplus value (Cooper, 2008) from CB that substantiallyexceeds its value within internal domestic contexts. The high costpremium attached to international trade is a strong incentive forthe establishment of more comprehensive domestic supplies, andthis has become a pressing political and health economic questionas pointed out by the following respondent, a parliamentarymember of the UKs All party group on clinical CB and adult stemcells:

.theres an issue of domestically how we do that [generatesupply] and the cost of importing CB. And that has an impact onthe Health Service. If we can ensure that we have home-grownCB that must be cheaper. A good percentage of transplanted CBis from abroad and that costs money. So the purpose of this is tosave lives and saving lives does save money as well because itsaves the costs of care. (UK Member of Parliament 1).

The costs associated with banking CB vary considerably butgenerally do not exceed 2000. The UK NHS bank (NHS CBB) esti-mates the cost of unrelated (allogeneic) collection to be in theregion of 1400. Rates paid by private depositors to commercialbanks are fairly similar. However, the costs of purchasing CBthrough international registries are very signicantly higher. Boththe UK based charity, the Anthony Nolan Trust, and the NHS CBBpay in the region of 17,000 or more per unit imported fromoverseas. Where multiple units have to be used to treat singlepatients, as in the treatment of older children and adults, the costsof a viable match on the international market can be prohibitivelyexpensive. It is less of a surprise that many banks have based theirbusiness model on an export rather than import market:

. there are banks collecting as much as possible knowing thatits not for their own patients but for exporting them [so] theycan fund their own banks, if you think of it as a business, theymight be able to become economically self-sufcient but youwill never be able to be self-sufcient from the clinical point ofview (Director of a public CB bank 1).

There are very few data sources documenting internationalmarkets in CB but gures generated by theWMDA (2008) representthe most comprehensive source of information on the release,usage and destination of units. Based on the reported quantitativesurvey data for banks operating in each country it is possible togenerate a calculation of the balance of trade between participatingcountries (see Fig. 1). A cluster of countries can be seen to traderelatively high volumes of CB units across their borders (>50). Ofthese, a number operate a signicant trade surplus where exportsexceed imports. For example, of the 137 units traded by Germany in2008, the vast majority of these (110 or 80%) were exported over-

edicine 72 (2011) 1115e1122 1119ethnic variation.

Country Cord blood exported (%) Imported (%)

Totals traded % Exported of those released

US 512 (68) 236 (32) 748 36 France 74 (23) 247 (77) 321 35 Spain 123 (58) 90 (42) 213 69 Italy 94 (52) 86 (48) 180 67 Australia 133 (83) 28 (17) 161 75 Germany 110 (80) 27 (20) 137 87 UK 37 (29) 91 (71) 128 79 Canada 0 86 (100) 86 0 Belgium 68 (86) 11 (14) 79 92 Brazil 0 (0) 44 (100) 44 0

(56)(76)(57)18) (90)(63)10038) 10010071) 100(0) 75) (0) 10000)00)

ance

N. Brown et al. / Social Science & Medicine 72 (2011) 1115e11221120Netherlands 18 (44) 23 Israel 8 (24) 25 Switzerland 13 (43) 17 Taiwan 18 (82) 4 (Mexico 2 (10) 18 Singapore 7 (37) 12 Greece 0 18 (Czech R 8 (62) 5 (Sweden 0 11 (Argentina 0 10 (Finland 2 (29) 5 (Austria 0 7 (Japan 5 (100) 0 Poland 1 (25) 3 (Korea 2 (100) 0 Turkey 0 2 (China 0 (0) 1 (1Hong Kong 0 (0) 1 (1

Fig. 1. BalThe global patterning of the CB bioeconomy directly reectspopulation heterogeneity. Most East Asian countries, for example,are predominantly self-sufcient in the supply reecting, it isargued, the internally homogeneous composition of both theirpopulations and their blood economies. Japan, Korea, China andHong Kong source their CB almost exclusively through domesticsupply (see Fig. 2) with the exception of Taiwan. Of the 138 unitsreleased for treatment in Japan, none were imported and only 5exported. Asia then tends to have an internally-oriented supplychain removed from the international export market and ispredominantly self sufcient. As one recent report explains it: .Japan exports hardly any samples, as their specic HLA types areendemic to Japan (Meijer, et al., 2009, p. 37) This is a radicalcontrast to Europe and North America more strongly integratedinto globalised histories of migration and immunitary diversity. Anoutbred genetic pool is the raw material foundation for interna-tional capitalisation and the extraction of surplus value. But asthe following respondent suggests, the more outbred a population,the greater is the requirement to go beyond the nation state in thesearch for immunitary resources:

Country Exported Released Released

fordomestic

use

E

Japan 5 138 133 Taiwan 18 77 29 Korea 2 62 60 China 0 18 18 Hong Kong 0 11 11

Fig. 2. Market 41 95 33 80 30 100

22 23 20 5 19 37 ) 18 0

13 100 ) 11 0 ) 10 0

7 33 ) 7 0

5 4 4 100 2 3

) 2 0 1 0 1 0

of trade.I dont think theres one country that can be self-sufcient. theonly country is Japan because theyre such a homogeneousgroup. there may be other countries that are less diverse but ifyou look at Europe and the prole of the population theyre veryoutbred and you wont get a [single] bank that will provide youwith that (Director of a public CB bank 1).

The majority of countries operating through the WMDA (64% ofthe sample in Fig. 1) operate a trade decit with imports exceedingexports. Countries with signicant decits include Canada (100%),France (77%) and the UK (71%). Countries trading fewer than 50units but operating a trade decit include Mexico (90%), Israel(76%), Poland (75%) and Finland (71%). The question facing coun-tries in this group is whether the cost of relying on imports is less orgreater than the likely costs of increased investment in domestic CBbanking. For instance, if we conservatively estimate that the 86units imported into Canada during 2008 had a market value of$20,000 each, import costs for 2008 would total over $1.7 m. Thosecosts are unlikely to be borne by a single health services providerand there are a wide range of factors at stake in whether or not

%xported

of those released

Available Units used Imported

4 5455 133 0 23 42135 33 4 3 100545 60 0 0 8892 19 1

0 2885 12 1

s in Asia.

ed

lable

& Mindividual countries take the initiative to offset import coststhrough domestic supply. Much depends on variables beyond thescope of this paper including the structure of health service orga-nisation and the arrangement of funding mechanisms in individualcountries.

Another interesting featureof the CBeconomyhighlightedby thedata is that the difference between those countries that exporta high number of units, and those exporting comparably few, hasless to do with the number of units available, and more to do withtheir ethnic/racial diversity of individual banks. UK CB publiccollection was actually relatively small in 2008 by internationalstandards (10,589 compared with Germany [18,557], Australia[20,044], Belgium [14,533], Italy [17,503]). However, the majority ofUKCB released for treatmentwent overseas (see Fig. 3). Thirty sevenof the forty seven (79%) units it released were exported, a gureattributable to the very high success rate of the bank in recruitingfrom racial minority populations. Navarrete and Contreras (2009)calculate that .36% of units issued from the UK bank for trans-plantation are from ethnic minorities (p. 238). It is probable thata similarly proportionate percentage of the units exported are alsosources fromminority populations. The UK is estimated to have thesecond highest percentage of rare immunities (41%) across globalregistries (Pamphilon, Regan, Navarrete, &Watt, 2009). So while CBmay indeed be the raw material of the market, the actual asset isconstructed as race itself. The immunitary trade signicantlyadvantages those racially heterogeneous countries able to supplyglobally dispersed populations.

Nevertheless, strong exporters are not necessarily very suc-cessful at supplying their own domestic demands. Whereas the UKexported 37 of 47 released, it imported 91 units at an estimable costof around 1.5 m, paying nearly three times in import costs whatit earns from exports. Most sizeable exporters are much moresuccessful at supplying their own demand. Imports as a proportionof units used in treatment are generally lower than in the UK and

Country Available Exported Releas

France 7051 74 212 Germany 18557 110 127Australia 20044 133 178Belgium 14533 68 74 Switzerland 2212 13 13 Italy 17503 94 141 US 154749 512 1428UK 10589 37 47Spain 35802 123 179

Fig. 3. Units avai

N. Brown et al. / Social Scienceaccount for between 20% and 64% (US and France respectively) formost other countries in Fig. 3. The trend over the course of the lastdecade or so has been to see a rising dependence in Europe onimports, a tendency now motivating stronger investment in reg-ional CB capacity (Pamphilon, 2009). Indeed, a number of countrieshave provisions to protect domestic supply from export. Forexample, Spain allows the export of CB on the condition that it canbe shown that the unit does not have any current utility within itsnational borders. Like other competitive areas of trade, the CB bio-economy is characterised by mechanisms that both facilitate ow,while also protecting national ownership. As one commentator putsit, there ismuted competitionbetween thepublic banks themselvesseeking to achieve a critical size (Katz-Benichou, 2007, p. 464). Thebalance of trade in CB maps onto other similar tensions betweensovereign autonomy and yet global dependence where post-colo-nial countries engage in the capitalisation of ethnically or raciallyproduced resources including, for example, pharmaceutical invest-ment in ethnic drug markets (Benjamin, 2009; Whitmarsh, 2008).

The destination countries to which CB is exported are alsohighly signicant. The single highest export destination is the US,probably the most racially heterogeneous of the trading nations, onaverage accounting for roughly 30% of all exports. A notableexception is the absence of sub-Saharan Africa from these gures,excluded from prohibitively expensive premium markets andreecting the global patterning of traditional blood services withtrade mainly concentrated in and between afuent advancedindustrial bureaucracies.

Conclusion

CB presents both opportunities and challenges to the interna-tional organisation of blood and is profoundly telling of changes inthe global economisation of disembodied human matter. To returnto Esposito, the CB case eshes out, so to speak, his version ofbiopolitics as an immunitary paradigm. Communitas and immunitasexpress the changing characteristics of order and organisation intodays biopolitics. Communitas in its traditional meaning is asso-ciated with gift and giving but carries with it various risks. Giftsmay be costly and go unreciprocated and there may be tensionsbetween competing interests (the individual and the community,the state and the wider global commons). Immunitas develops asa means of protection from these risks, methods for self-defencefrom the otherwise boundless or insatiable demands of commu-nity. While immunitas has its roots in communitas it develops analternative logic replacing the gift economy with private marketsbased on nancial exchange, trade and the contract. The immuni-tary paradigm expresses this translation of blood and gift intoa global immune-based economy. The immunitary has a doublevalency here signalling a system of value, circulation and ow, butalso the predication of the bioeconomy on genotypic immunity.

Released for

domestic use

%Exported of those released

Units used Imported

138 35 385 247 17 87 44 27 45 75 73 28 6 92 17 11 0 100 17 17 47 67 133 86

946 36 1182 236 10 79 101 91 56 69 146 90

to those traded.

edicine 72 (2011) 1115e1122 1121Biology and life itself, rather than labour, is increasingly recog-nised as central to the production of surplus value in the contem-porary tissue economies. Within this relatively new framework,bioeconomisation is seen to efface the boundaries between thespheres of production and reproduction, labour and life, the marketand living tissues (Cooper, 2008, p. 9). However, it is in fact thedispersed internationalisation of these bioeconomies that allowsfor the multiplication of value that we can observe as CB units aretraded across state borders.

One of the more signicant aspects of the story told here is theway a surplus value is derived from CB in two complementary andinterlinked ways. First, internationalisation is essential to biovalueproduction because of the need to seek out widely dispersedimmunotypes. The global nature of matching across highly heter-ogenised immunities necessitates a widely distantiated reachthrough networks like that of the WMDA. The probabilities of

obtaining exactly the right match may be vanishingly small andonly ever possible where spatial reach has been widened suf-ciently to improve the statistical likelihood of securing a match. Inthis sense, the bioeconomy we document here extends and capi-talises upon an immunitary globalisation, historically structuredthrough outbred diasporic migration.

Second, internationalisation allows for the additional extractionof a monetary surplus by permitting an economic value to benegotiated and attached to CB units. Over and above the originalcosts associated with extraction and banking, internationalisationenables added indirect costs to be folded into prices set for CB in theglobal marketplace. That prot surplus is legitimated on the basisthat blood services should be able to offset costs and compensate

Acknowledgements

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Immunitary bioeconomy: The economisation of life in the international cord blood marketIntroduction and background to global cord blood bankingConceptualising immunitary theoryMethodCord blood collection - assembling diasporic immunityRegistries: brokerage and standards in the immunitary economyThe immunitary balance of tradeConclusionAcknowledgementsReferences