The Twisted Business of Donating Plasma

I needed the cash.

That was how I found myself laying in a plasma “donation” room filled with about 40 couches, each equipped with a blood pressure cuff and a centrifuge. A white-coated attendant (workers aren’t required to have medical or nursing degrees) pricked my arm. He separated my plasma from my whole blood into a large bottle, and returned my protein-depleted blood, which flowed back into my arm to rebuild my nutrient supply.

“My house is so noisy with four kids so I come here for my relaxation,” said a middle-aged, haggard-looking woman on the next couch, the plasmapheresis machine at her side whirring. A clinician instructed us both to pump and relax our fists, like cows milking our own udders.

Before leaving I received a calendar that mapped out my pay, if I maintained a twice-weekly schedule for subsequent donations. Even a $10 bonus on my next visit!

How did I get here? My rent was due. I had insufficient funds in the bank. I was 48-years-old, a journalist running short on cash from writing assignments and odd jobs. That was when I saw an ad offering $50 per plasma donation: blood money, or more specifically, payment for my time and any small pain involved in the process of having protein-rich plasma extracted from the blood. Regulars call it “plassing.”

The ad I’d seen featuring smiling attendants suggested an experience similar to one at a sedate hospital. The facility I entered buzzed like a school lunchroom. There were first-timers waiting to complete the initial medical exam, and regulars hurrying to check in at automatic computer terminals. Easily 50 to 60 “plassers” were present at any given moment, the crowd continually ebbing and flowing. All were like me—hopeful, needy, and impatient to get paid.

I received an oral examination. I was not surprised by the many questions about my sexual behavior, but I was taken aback by repeated questions regarding tattoos. Three times I was asked if I had lied and “really” had tattoos. After the clinicians tested a blood sample for protein levels, I underwent a bare-bones medical checkup. But I questioned its efficiency given that my examiner ran through scores of questions so fast I had to ask him to repeat himself. I spotted a sign: NO PAYMENT UNLESS DONATION IS COMPLETED.

"Plassers" receive payments on a special debit card that extracts a surcharge whenever they use it. Curiously, while my examiner hurried me through the screening, he did patiently lay out the payment scheme. Did he know how desperate I was? His “Don’t worry. You’ll pass” attitude may have expressed condescension, unprofessionalism, or benevolence.

My extraction went smoothly. I left with a ray of hope that I could “plass” next month’s rent money. The literature provided at U.S. centers ubiquitously states that "donating plasma is safe." Its side effects are limited to "mild faintness and bruising." (My brochure also added, "Other possible side effects will be explained by our medical staff," though I can’t say any such explanation stayed with me.) But the following day my body received an impromptu schooling in the price tag of the world I had entered.

It happened at about five o’clock the next day. Unexpectedly, with no apparent cause or logical relationship to physical exertion, I felt my legs go rubbery. I was Silly Putty. This was something more than “mild faintness” and particularly disturbing because of the aspect of a random attack. I suddenly felt so weirdly fatigued that I couldn’t stand on my feet. I barely reached the couch before I passed out for five hours straight. Luckily, I was safely ensconced at home. But since I substitute teach as well as freelance write I woke up wondering: What would I do if that happened at my day job?

What had happened? I had received my welcoming to the subtle physical changes, possibly exacerbated by work and poverty, which may be the upshot of plassing. And my research began.

* * *

Biotest, CSL Plasma, Yale Plasma. These are some of the funny corporate names that dot my state, New Mexico, and maybe yours. Or OctaPharma. Or Biolife. Plasma reaped from paid U.S. donors makes up about 70 percent of worldwide collections. The United States is conversationally known in the industry as “the OPEC of plasma collections.”

But why plasma?

Proteins in the plasma collected at places like Biotest are necessary for the manufacture of a wide range of pharmaceuticals produced by for-profit corporations. The industry burgeoned in the 1950s thanks to a boom in new drugs for hemophiliacs. Plasma centers have historically worn the scarlet letter in the blood-collection universe.

Hospitals, Red Cross units, and nonprofit agencies relying on voluntary donations reject the plasma center model because cash incentives for whole blood may give donors an incentive to lie, heightening risks of a tainted supply. Such risks are higher overall for whole blood, too.

Prior to the AIDS crisis, plasma collection practices were often under the table, but the medical community still operated under a general assumption that those standards for plasma were good enough. The assumption proved disastrously wrong. Industry practices eventually cost the hemophiliac community dearly.

Throughout the '60s and '70s, plasma companies minimized their own overhead costs by relying on chancy prison populations paid a pittance: $5 to $10 dollars per “plassing” donation. Roughly 50 percent of American hemophiliacs contracted HIV from bad plasma-based pharmaceuticals (a much higher infection rate than that suffered by gay men at the time), making worldwide plasma medication HIV outbreaks the industry’s most publicized scandal.

People with hemophilia filed class-action suits. These included substantial evidence that a major plasma company continued to distribute “old supplies” of bad medications after becoming aware of the AIDS infection. The public was dismayed to discover that the industry operated under the protection of federal and state blood shield laws, limiting its liability.

By the 1990s, the industry’s public reputation reached a low point, with American collections dwindling, U.S. federal regulators clamping down, and revelations coming to light that spoke poorly of industry oversight and humanitarianism. Even before the AIDS crisis devastated U.S. plasma collections, other controversies, such as incidents of hepatitis C infection in plasma pharmaceuticals, led corporations to keep overhead low and avoid regulation by transporting the payment-incentives collections system to penniless countries abroad.

In the 1990s, China attempted to develop a plasma market to compete with Western companies by touting money for plasmapheresis in China’s most impoverished province, Henan. Villagers that were too poor to afford condoms soon realized they could earn more money by selling plasma than by farming the land, but the facilities offered substandard sterilization techniques, needles, and blood bags. By 1995, Henan Province had become a blood farm built on a criminalized plasma economy. Thousands of Chinese donors became infected with AIDS and Hepatitis C.

Today, many plasma products for hemophiliacs have been outdated by medical advances, but the industry thrives producing albumin for burns and intravenous immunoglobin, used to treat immune disorders and neurological conditions. The industry has returned to the United States in a big way with the help of brighter, user-friendly advertisements that include appeals to public service and reminders of the economy’s downfall to encourage donors. The number of centers in the United States ballooned during the Great Recession, with 100 new centers opening and total donations leaping from 12.5 million in 2006 to more than 23 million in 2011.

Monopolization has transformed the industry, which now consists of five international corporations operating in the United States under Food and Drug Administration regulation: Baxter International of Deerfield, Illinois; CSL of Australia; Talecris of Research Triangle Park, North Carolina; Grifols of Spain; and Octapharma of Switzerland. A possible sixth big player is Biotest AG, the for-profit arm of a Dutch nonprofit corporation, Sanquin. Since 2008, plasma pharmaceuticals have leapt from an approximate $4 billion to a more than $11 billion annual market.

* * *

Santa Fe, New Mexico, where I live, has a crowded but reasonably clean Biotech Plasma center. But the state’s largest city, Albuquerque, population 552,804, has three plasma centers that would have challenged my willingness to “plass” no matter how needy I was. Yale Plasma, located on a strip where panhandlers convene, resembles a pawn shop. The exterior window sports a motto for in-house lotto games; the interior is remarkably cramped. Another Albuquerque center, CSL Plasma, is larger, but has no chairs. Donors crouch on the floor, or stand in long lines until they plass. Asking a young man if he minded squatting, I’m told CSL removed the complementary seating to “keep the bums out of here.”

Plasma is “pooled” or collected in containers to prepare it for a process called “fractionation,” which will render it usable. The bigger the plasma pools, the cheaper they will be to process—which Dr. Lucy Reynolds, a research fellow at the London School of Hygiene and Tropical Medicine, cites as an example of the industry cutting corners.

Large pools maximize profits. Furthermore, although large pools are subject to advanced safety analyses (21st-century viral testing has made Hepatitis C and AIDS contamination rare) health officials have raised the concern that as market plasma spreads globally, the harm that could result if another AIDS-like pathogen infiltrated the system would be exponentially greater.

"Certain governments are people and people’s-rights centered," says Reynolds, who recently published a paper castigating the plasma trade. "In those places they make the plasma corporations play by the rules; sometimes they just choose to have as little as possible to do with them. But the United States is a corporate country"—that maintains the Western world's least restrictive plasma regulations.

U.S. centers also have a policy assured to reel in those with an ongoing, immediate need for small sums of cash: $50 for the first five donations, then $60 a week if you willingly go under the needle twice a week.

“I call it a grubby business because they knowingly endanger the health of donors in the U.S. by harvesting them twice a week, while in every other place in the world you’re only allowed to donate fortnightly, ” Reynolds says.

I interviewed plassers in Albuquerque but, given that my questions included asking if they lied to pass medical examinations, the people I spoke with often asked me not to use their last names.

"Going into the center makes me feel like a lab rat," says Ron, a 33-year-old single father and unemployed schoolteacher, who began regularly plassing six years ago to make ends meet for his new son. He was disqualified at a local center because he had many visible tattoos, but accepted at another center “that was less picky.” Ron reports no particular bad side effects but still worries. "They tell me there are no long-term effects but the answers they give at these places are so robotic."

A haggard man with bloodshot eyes standing outside the CSL center identified himself as “Bubba,” and said he was homeless and an alcoholic. He had suffered a serious head injury in youth and had been plassing for nearly 15 years with no ill effects other than "sometimes my arm hurts really bad." He also continually falls asleep on the couches. In fact, Bubba once collapsed in the standing lines at CSL, but he appreciated the extra cash. He says he was unhappy when he had been drinking too much to pass the protein level test, but claimed he later discovered, “If I swallow ketchup before going in I can pass any test they throw at me.”

Bubba was cognizant that donors who were homeless, alcoholic, or had suffered head injuries like his own were, in theory, barred. "Everybody lies," he said. "Nobody is honest on all those questions."

I left the conversation wondering whether Bubba was an example of why other nations don’t want to expose their citizens to the commercial plasma trade, and many make (increasingly unsuccessful) efforts to limit imports of commercial plasma from the United States. Should a homeless alcoholic be banned from plassing for his safety and ours?

Gabriella, a 51-year-old mother of three, began plassing eight years ago after she was laid off in a cut-back of state government employees. She admits to having lied to pass the screening after realizing that she had become too thin to pass the weight test, and "put on extra clothes, just to squeak past the weight minimum" of 110 pounds. Gabriella knows other regular plassers, often homeless, who use ankle weights.

Kevin Taylor, a 27-year-old student at the University of New Mexico, plassed to meet expenses, but found that over two years of plassing he lost 15 pounds.

“I definitely wasn’t eating regular meals, and I think the pressure of keeping up my two donations a week was making me sick,” he says.

Kevin Crosby, 48, began plassing 10 years ago to provide for his six-year-old daughter.

“Every time I’ve had this weird hollowed out feeling. And a lot of times the next day I will have serious fatigue," he says. "Then, about five years ago when I was working night shift at a security job, I had that weird fatigue. I don’t know what hit me but I woke up on the floor. They accused me of falling asleep; I know I blacked out.”

Crosby has had several blackouts, including one that hit when he was driving.

"I had to pull over," he says. "I had to sit there several minutes in a daze. It really freaked me."

The fact that other Western nations adopt a “better safe than sorry” attitude (when they sanction commercial collection centers at all) by insisting on two-week intervals between donations should raise eyebrows about U.S. practices. Many people I interviewed left me questioning whether, when poverty is the primary motivation, the advisability of twice-weekly plassing should be reconsidered. Not to mention the other likely health complications donators may suffer from, including stress, poor nutrition, and inadequately or untreated medical conditions.

All told, I interviewed almost three-dozen regulars at CSL and Yale Plasma. More than half of them confessed to frequent, bizarre tingling sensations, pains, rubbery legs, and severe dehydration, as well as to having been homeless, having lied to pass medical exams, and having used "tricks" that allowed them to pass protein-level tests. They lived in circumstances that made plassing a hardship, but said, "I can't eat if I don't plass."

I described the experiences above to medical historian Harriet A. Washington, author of Deadly Monopolies and Medical Apartheid: The Dark History of Medical Experimentation on Black Americans. Washington said, “Our blood supply is now very safe, although not perfectly so.” Hepatitis C and HIV infection are as rare as 1 in every 1 million blood recipients.

Washington is not opposed to payment centers that observe safety standards and adhere to regulations. Neediness and economic hardship don't necessarily make a donor unsafe, which is a historic prejudice. The crux, Washington says, "is how we screen donors."

"If these companies are winking at donors' deception, then they're putting us all in serious danger. In an ideal world, I'd want more government oversight to closely monitor these collection sites."

Why do donors, including myself, suffer fatigue akin to blackouts? During plasmapheresis, centers often use a chemical, sodium citrate, to keep blood from clotting, Washington explains.

"Sodium citrate and other citric-acid derivatives bond with the calcium in your blood, and afterwards the calcium is no longer available to your body. We know that some people respond badly to sodium citrate. The worst case is rare: extreme hypocalcaemia, which can be fatal. But more often, people will suffer fainting, tingling and numbness, muscle contractions, or even seizures. Walking around with depleted calcium can be extremely dangerous. It can lead to serious healthcare issues."

These issues include: heart arrhythmias, seizures, osteoporosis, eye strain, breathing problems, brittle bones, and chronic kidney conditions.

A summary of a 2005 report by Jeffrey L. Winters published in the Journal of Clinical Apheresis states that "the most common aphaeresis-specific reaction is hypocalcemia due to citrate anticoagulation, which, while usually mild, has the potential for severely injuring the donor." In fact, Winters writes, compared to whole-blood donations, “the risk of reactions requiring hospitalization is substantially greater.” Plasma centers that don't inform donors of these risks are abrogating patients' medical rights—yet none of the people I interviewed who experienced “funny fits” or weird tingling sensations were knowledgeable of the possibility of hypocalcaemia.

Several reported that they had inquired about such symptoms at centers but were given absolute guarantees of safety. And it seems preposterous to expect them to diagnose themselves when centers prominently display statements like the following one from a Baxter Inc. press kit: Donating plasma is a low risk procedure with minimal or no side effects.

I sat in a pizza parlor with Kevin Crosby near the Yale Plasma center. He rolled up his sleeves and showed me a huge sore where 10 years' of needles have gone into his arm.

"I never in my life thought I would have to do this to survive," he said. "A lot of the staff aren't competent with the needles. People get jittery talking about that stuff, but a lot talk about how much money they make off us. I say, if they’re going to exploit us they could at least pay us. I say they could pay us $100 for twice a week."

Crosby has also always been pestered by doubts: Why does he have black outs, and how safe is this plasma? Looking at the suspect patrons, "you can tell something is wrong with them," he says.

I tell Kevin about the industry’s history of negligence: the tragedies in South America, the American prison collections, and the AIDS outbreak among hemophiliacs who received medications tainted because the industry put market share above safety controls. I explain that today the monopolized industry harvests in the U.S. because only the FDA will allow them to reap enough plasma to support an international market. Nowhere else in the West believes twice-a-week donations are advisable, and the international community isn’t as sanguine regarding detrimental health effects. Kevin’s blackouts are probably a bad reaction to an anticoagulant, sodium citrate.

"I have read every word of every paper I've signed at CSL and Yale," Kevin claims. "I haven't seen a mention about this."

Critics today still question the wisdom of cutting costs by maintaining massive plasma pools. Safer systems operate on a not-for-profit basis, and only require sufficient amounts of plasma to meet domestic needs. A 2005 report published by writers at Ghent University in Belgium says that in Belgium, “approximately 5,000 donations are mixed into such pools. In Germany, pools containing up to 60,000 donations are considered.” In the United States, “some donor pool sizes are in excess of several hundred thousand [donations]. ”

The authors recommend alternative pooling strategies because the “risk of contamination of these pools increases rapidly with the pool size.” Zealous precaution today could spare us untold misery tomorrow.

“Hearing all this,” says Crosby, “I never want to walk into those places again.”

This piece was supported by the Economic Hardship Reporting Project, a journalism non-profit dedicated to stories about inequality.