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 United States is the world leader in its “production”: By one estimate, plasma constitutes nearly 3 percent 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 ’90s. 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 U.S. 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 U.S. adult population sells plasma each year, some upward 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 U.S. 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, McLaughlin 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 U.S. 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 U.K. 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 U.S. 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, or 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, or 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 U.S., which supplies 70 percent 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 percent of the population, a 2019 article notes, it is one of the most costly drugs for the health care 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.
