Inside the Big Business of Blood

In
the ICU, we use blood—sometimes, by the gallon. A patient with, say, a gushing
stomach ulcer might need transfusion after transfusion to keep the heart
beating until the hemorrhage stops. Such blood products are not prescribed by
physicians like me in “whole” form, but rather in parts that are separated
after collection before being hung on IV poles at the bedside. Wine-red,
pint-sized bags of red blood cells boost the blood’s capacity to transport
oxygen; straw-colored thin liquid called plasma replenishes the proteins
that form clots; yellow bags of cell fragments called platelets likewise help
to staunch a bleed.

Although
I use blood often, until recently I hadn’t thought much about its provenance beyond
the general knowledge that we rely on good-natured volunteers to donate it. But
the truth of blood is murkier. While blood is mostly the gift of donors, some products
come from the market. Plasma contains important proteins that can be isolated
and used therapeutically for a range of ailments, from autoimmune disease to
bleeding conditions. In the ICU, for example, we use one plasma-derived product
to rapidly restore the blood’s ability to clot for some bleeding patients on
blood thinners (at the cost of thousands of dollars for a single dose), and another
less expensive product to expand the blood’s volume and improve circulation. These
products are manufactured by pharmaceutical firms that pay people to offer
their veins and give their plasma at collection facilities spread across the country. Plasma
is today a big and growing global industry, projected to be worth $47 billion by 2029, and the US is the world
leader in its “production”: By one estimate, plasma constitutes nearly 3% of American exports.

Previous reporting has drawn attention to the global
plasma industry, and the exploitative problem of paid “donation.” An illuminating
new book, Blood Money: The Story of Life,
Death, and Profit Inside America’s Blood Industry, by journalist Kathleen
McLaughlin, depicts the blood trade as yet another manifestation of our
society’s deep inequities: For Americans tight on cash, selling plasma has
become an increasingly common type of “gig” work.

The
largely overlooked emergence of a disenfranchised, atomized, gig-working class
of plasma sellers—so keenly illustrated by McLaughlin—is deeply troubling, both
for what it reveals about inequality in America but also, potentially, for the health
of the blood-workers themselves. At the same time, it is worth noting that the emergence
of this workforce was made possible, indeed made necessary, by an even larger
problem: the transformation of blood into a commodity in the first place. 

The
global plasma industry has, to say the least, a troubling past. McLaughlin opens
with a discussion of an HIV outbreak in the China in the 1990s, where the
transition to a market-based economy under Deng Xiaoping led to a new age of
market capitalism—including a flourishing plasma industry in the province of
Henan. Farmers found that they could suddenly sell a half liter of blood for $8
as often as every few days, a payment that was “impossible to resist” for the
impoverished. But although “the smell of blood started as the scent of wealth,”
she writes, “it became the odor of death.” Without adequate safeguards and
protections, the supply was soon contaminated by HIV—and an estimated 1 million
people were rapidly infected. The authorities shut down Henan’s plasma industry
and tried to hush the whole thing up. 

There
has also been scandal close to home. In Arkansas, a biomedical company based in
Little Rock began draining plasma from prisoners in exchange for miniscule
payments beginning in the 1960s, a system that continued through Bill Clinton’s
governorship into the 1990s. The plasma was sold to pharmaceutical companies
who exported it globally at profit, again contributing to HIV outbreaks abroad.

The
modern plasma industry has put safeguards in place. For one thing, in addition
to testing donors for infectious diseases, new laboratory procedures can kill viruses
in plasma, ensuring a safe supply. Plasma is also no longer taken from
prisoners as far as I am aware, at least in the US. Yet the system of paid
donations continues to take blood from the poor and give it to the wealthy. “In
many parts of this country,” McLaughlin notes, “the strip-mall plasma
extraction center has become as much of a community institution as a Dollar
Store or a Walmart.”

As
much as 8 percent of the US adult population sells plasma each year, some upwards
of 100 times annually. Plasma extraction facilities are disproportionately
located in disadvantaged communities, although there is no typical plasma
seller per se: McLaughlin interviews college students in a small Idaho
town who sell plasma for some extra pocket cash, and more desperate donors in Flint,
Michigan, a city where a slew of plasma extraction centers have arisen in the
post-industrial dust. She talks to a woman in Texas who is forced into plasma-selling
to pay off fines for various petty infractions. And she visits a border town in
Texas where, until recently, some 5 to 10 percent of the US plasma supply was
collected, mostly from Mexican citizens who took day trips across the border to
sell blood for some much-needed cash.

The
potential health impacts of frequent—as often as twice-weekly—plasma donation are
unclear and understudied. Subjects in the book describe feeling drained,
fatigued, and dehydrated from their sessions. They also have little control
over their “workplace”; their labor is contingent, and payment can be unsteady.
A person dependent on plasma payments might show up one week only to be turned
away, empty-handed, if they have a blood test that is out-of-bounds that day,
for instance. (This precarity led to the brief formation, back in the 1930s, of
a New York City-based blood sellers’ union—an idea, McCoughlin contends, that
perhaps should be resurrected today.)

Inequality
hence emerges as the central driver of injustice in her narrative. “Until we
fix the underlying problems that make ours an increasingly unequal society,”
she writes, “millions of people will be pressed to sell their blood plasma.” I
would phrase the issue a bit differently, however. Inequality might explain who
sells their blood, but less inequality would not, in itself, alter the reality
that the global plasma supply is largely reliant on these plasma sellers. An important
question, then, not answered by McLaughlin, is whether we should or could operate
a more solidaristic, decommodified blood system, or whether it is simply
impossible—or too late.

In
the 1960s, the British social theorist Richard Titmuss began to argue that
blood should never be a commodity. The trade in blood, he showed, was inferior
to an egalitarian model reliant on voluntary donation on grounds of
“efficiency, of efficacy, of quality, … of safety.” His 1970 treatise, The
Gift Relationship: From Human Blood to Social Policy, contrasted the US
system of blood donation, which at the time was increasingly commercialized and
dependent on paid donation, with the British system, used by the National
Health Service and entirely dependent on voluntary donors. The voluntary UK
supply, he found, was far less likely to be contaminated with the potentially
deadly hepatitis virus; it was also less wasteful and less susceptible to shortages.

The
book had a surprising impact. President Richard Nixon appointed a commission to investigate US
blood policy, and the next year the US National Blood Policy embraced a policy
of full-voluntary donation as a goal. Around the same time, the World
Health Organization (WHO) similarly called for 100 percent voluntary blood
donation worldwide—a framework it still endorses today in
the face of rising opposition.
And in 1978, the Food and Drug Administration (FDA) required blood products be labelled as
either paid or voluntary. Hospitals thereafter largely stopped using “paid”
blood.

Yet
because of the burgeoning demand for large quantities of plasma needed for
products such as intravenous immunoglobulin or IVIG, today no nation has a
fully voluntary blood supply. While many nations ban paid procurement, they
rely on imported (paid) plasma from the US, which supplies 70% of the global supply. In response,
some have called for an expansion of
“pay-for-plasma” throughout the globe—and an abandonment of the WHO embrace of
universal voluntary donation.

The
paid system of blood procurement isn’t just unfair on those who sell their
blood; the fact that blood is a saleable, profit-making commodity also distorts
the way it is used in medical care. Plasma-derived products can be enormously
expensive: a single infusion of IVIG costs thousands of dollars. As a result,
although IVIG is relied on by less than 1% of the population, a 2019 article notes, it is one of the most costly
drugs for the healthcare system. The out-of-pocket costs can be burdensome for
patients as well, likely putting it out of reach for many.

Meanwhile,
because IVIG can be lucrative both for the industry that makes it and for
healthcare providers that administer it, it is no doubt overused at times: for
some diseases, IVIG has unambiguous and lifesaving benefits, but it has long
been employed in clinical scenarios where evidence is lacking. “Much of its use is for off-label
indications for which there is minimal evidence of efficacy,” one 2018 study noted. “In nearly all descriptive
studies examining prescribing practices in hospitals, off-label use is
unexpectedly high and inappropriate use constitutes a significant portion of
total IVIG infusions.”   

How
plasma is used, and how it is procured, are linked: as long as plasma is sold
by pharmaceutical companies, it will be difficult to move toward a system on
voluntary donations. The global trade in plasma-based pharmaceuticals by
for-profit companies for IVIG alone is valued at $19 billion. Who wants to volunteer their time
and body to generate profits for a pharmaceutical firm? (Giving plasma, after
all, is more onerous and time consuming compared to the usual procedure of
blood donation). The very essence of voluntary blood procurement—what Titmuss
called the “gift donation”—is that it is an altruistic act embedded within a
broader egalitarian infrastructure and ethos of medical care. We donate blood
to help an anonymous fellow-patient in need, not to expand some business’
balance sheet.

Titmuss
argued for voluntary donation on the grounds of quality control, efficiency,
and fairness—but there was also a political and, arguably, sentimental element
to his argument. “Socialism,” he wrote, “is also about giving,” whereas “the
commercialization of blood … represses the expression of altruism…” We know
that this impulse is real and potent—it has been sufficient, after all, to
supply every unit of red blood cells or platelets I have ever prescribed in the
ICU, saving the lives of many of my patients. To restore, indeed expand that
impulse, we would first need to decommodify blood products themselves, bringing
the production and ownership of plasma-products to the public sphere. Then, and
maybe only then, might the “gift relationship” replace cash payment as the
basis for the giving of plasma.