SYLVIE DOUGLIS, BYLINE: This is PLANET MONEY from NPR.
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KEITH ROMER, HOST:
When I first met Robert Matthews (ph), he was lying on a black reclining bed in a room full of black reclining beds, about to have a phlebotomist stick a very large metal needle into his arm.
UNIDENTIFIED PHLEBOTOMIST: Can you lift your arm up, please? Thank you. OK, you can out your arm down, Robert with the good vein.
ROBERT MATTHEWS: (Laughter).
ROMER: She just call you Robert with the good vein?
MATTHEWS: Yeah (laughter). Yes, can't miss that one.
ROMER: Robert was here in Cherry Hill, N.J., to donate his blood plasma. Inside his right elbow on the skin above his good vein was a small, black, circular scar from all the times before today that the needle had gone in.
UNIDENTIFIED PHLEBOTOMIST: OK, you're going to feel a pinch. Make a fist and just relax.
MATTHEWS: See, it's not that bad (laughter).
ROMER: That's because you aren't scared of needles.
MATTHEWS: No.
ROMER: Plastic tubing leads from the needle in Robert's arm to a white machine a little larger than a case of beer. As Robert clenches and unclenches his fist over and over, his dark red blood flows through the tube into a centrifuge hidden inside the box.
So does it seems strange at all that your blood is going into the white machine next to you?
MATTHEWS: No, no, it's not bad. It's not bad at all.
ROMER: As we talk, a plastic one-liter bottle attached to the front of the white machine slowly begins to fill with a liquid the color of strawberry lemonade. That is Robert's plasma, basically Robert's blood minus the red and white blood cells, which end up going back up the tube into Robert's arm. And even though the plasma industry insists on calling what is happening here a donation, Robert is actually selling that plasma. After 45 minutes or so, the bottle will be mostly filled, and Robert will get money loaded onto a debit card. Robert works as an electrician, but he also makes several hundred dollars each month selling his plasma. [LB] Does it hurt when the needle goes in?
MATTHEWS: No, no, no, it doesn't hurt. It's a big needle, but it doesn't hurt.
ROMER: Robert's plasma will be frozen, then sold on to a pharmaceutical company that will extract all these different proteins, which the company will turn into medicine. Those treatments could end up in American hospitals or on a boat or a plane going pretty much anywhere around the world. Hello, and welcome to PLANET MONEY. I'm Keith Romer.
AMANDA ARONCZYK, BYLINE: And I'm Amanda Aronczyk. Blood plasma products are this massive global industry. Sales are around $25 billion a year. And two-thirds of the world's plasma supply comes from the United States.
ROMER: We live in a globalized world. All of these industries have left the U.S. to set up shop in countries where it's just cheaper to make things. But with plasma, the rest of the world comes to the United States.
ARONCZYK: Today on the show, why is that? Why hasn't the world plasma industry found a different, cheaper solution than relying on an electrician from New Jersey? And what are the consequences of the system we've set up?
You can think of blood plasma as a kind of strange version of a natural resource, like it's trees or iron or whatever. So in that metaphor, the plasma collection centers are the places where you extract that resource. It's the forest or the mine. But the rules about where and how you can extract plasma have this pretty complicated history.
ROMER: In the early days of plasma collection, the resource extraction was mostly a local affair - American plasma for Americans, French plasma for the French. Eventually, some European countries needed even more plasma than they could collect, so they started to buy extra plasma from the U.S.
ARONCZYK: But in the 1960s and 1970s, like a lot of other industries, plasma companies started to wake up to the possibilities of globalization, to the idea that it would be cheaper to buy plasma not in the U.S., but in the developing world.
ROMER: And one of the places this ended up happening was Nicaragua, which at the time was controlled by the dictator Anastasio Somoza. One of his buddies sets up this absolutely enormous plasma collection center with the idea that he could get plasma on the cheap and sell it on to the big international pharmaceutical companies.
ARONCZYK: The Nicaraguan plasma center ran 24 hours a day. And they were paying thousands of people a week to donate their blood plasma. And from the beginning, something seemed off about this place. So much so that the editor of one of the big newspapers started looking into it, publishing all these articles about it. He reported that the donors were a mix of alcoholics, and the very poor, that a lot of them ended up having all of these health problems. There were even allegations that one of the donors had died on site.
ROMER: People took to calling the place Casa de Vampiros, the house of vampires. But the plasma center kept on collecting plasma and selling it on to the international market. And the editor kept complaining about it until one day three men with shotguns rolled up on the newspaper editor and shot him dead in the street. His funeral turned into riots, which turned into burning the giant plasma center to the ground. And a year and a half later, the dictator, Somoza, was overthrown.
ARONCZYK: So bad look for the plasma industry. But actually, at this point, the big wave of trying to globalize plasma collection, that actually mostly passed. A few years before the murder and the riots and the burning down of the plasma center, the World Health Organization had actually come out with a blanket declaration against paying for plasma for all the reasons that the newspaper editor in Nicaragua had been so worried about.
ROMER: Like how paying for plasma could attract people to donate whose health was too vulnerable or how paying for plasma could take advantage of the poor or how it might incentivize donors to lie about not having diseases to make sure they got paid, even if it meant contaminating the plasma supply.
ARONCZYK: And just about every country in the world fell in line with that WHO declaration, including, ultimately, Nicaragua.
ROMER: But you know who didn't? The United States. And for the most part, this is the system we still have today. The United States allows companies to pay for plasma, and most other countries do not.
ARONCZYK: Treatments from plasma are used for things like hemophilia and autoimmune diseases and for people undergoing chemotherapy. And whenever scientists find some new treatment, global demand goes up. And the solution is always to open more plasma collection centers in the U.S. In 2005, there were about 300 of these centers. Today, there are more than 900 across the U.S.
ROMER: To try to get a better idea of how one of these collection centers, one of these blood plasma mines, works, I arranged to get a tour of the one I visited in New Jersey.
BENJAMIN RUDER: My name is Benjamin Ruder, and I'm the CEO of B Positive Plasma.
ROMER: The B Positive Plasma Center in Cherry Hill is one of two centers Ben runs. The walls here are a sort of standard medical off-white, but all the signs and stuff are a different color.
Did you choose the blood red color scheme? OK, it's, like, very much - you're, like, oh, blood. Blood is everywhere.
RUDER: (Laughter) Yes. Yes, we like the - I don't know. We like the red (laughter).
ARONCZYK: Plasma is actually not usually red - it's more like a pale yellow, sort of a straw color. Though apparently, the color can change depending on your diet.
ROMER: Fun fact, the plasma of women on birth control often comes out with a light green tint.
ARONCZYK: Is that a fun fact, Keith? I guess it is.
ROMER: It's a fact.
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ARONCZYK: Yeah, all right.
ROMER: So Ben shows me the freezer where they store all the plastic bottles of many colored plasma they collect throughout the day.
RUDER: So this is -40 degrees Celsius. Our Day 1 bottles are put in the coldest part of the freezer to drop to the -25 core temp as quickly as possible.
ROMER: Between this first freezer where that day's plasma is stored and the second freezer where the plasma that's ready to ship is stored, there are hundreds and hundreds of bottles, each of which Ben paid somewhere between $20 and $100 for.
RUDER: We're shipping weekly now. So between the two centers, I want to say we're shipping about 80 cases every week.
ROMER: In each case, there are 15 one-liter bottles, so about 1,200 bottles of blood plasma a week. Depending on the exact makeup of the proteins in each sample, Ben can sell each one of those bottles for hundreds or even thousands of dollars.
ARONCZYK: The drug company that buys them will then thaw out all the bottles and just dump them in together - thousands of gallons of strawberry lemonade or light green-colored blood plasma all mixed together in one enormous metal tub.
RUDER: I hate to say it this way, but have you ever been to, like, a brewery where you've seen, like, one of those giant metal - it's, like - it's the same kind of container, maybe larger than that, depending - but just as a visual (laughter).
ROMER: The B Positive Plasma center I visited was in this kind of drab strip mall off the highway. There was a beauty supply store, a Dollar Tree, a Walmart.
ARONCZYK: And looking at where the 900-plus collection centers are located around the U.S., you can start to see an echo of the strategy that led the plasma industry to places like Nicaragua back in the 1970s.
ROMER: According to one market report, around 70% of plasma centers in the U.S. are located in zip codes with higher than average poverty rates.
ARONCZYK: These centers are mostly near cities. There's also a big cluster down near the Mexico border. These are apparently some of the most productive centers in the country. Lots of donors there actually come across the border from Mexico in order to sell their plasma and make a little bit of money.
ROMER: FDA rules say donors can give twice a week, up to 104 times a year. The centers are required to test donors every four months to make sure their health is holding up. And there has been some research that suggests that donating this much is probably fine, but there's also a fair amount of anecdotal evidence that some high frequency donors are having health problems and that testing every four months may not be enough.
ARONCZYK: But people keep showing up, in part because of the money. Ben, the guy who runs B Positive Plasma, he's pretty upfront about how important money is in getting people to sell their plasma.
RUDER: The way I would put it is that - so if you were to donate throughout the year - right? - you know, about $3,000 would have a fairly significant impact to your - to you. So if you're in a place where that amount of money would have a big impact in your life, then this is typically the program for you.
ROMER: Refer a new donor, you get $50. And the person you're referring, they get a bonus, too.
RUDER: I mean, new donor promotions run the gamut. It could be anywhere from a hundred dollars a donation or maybe $150 a donation just to try to get people to be part of the program and lure people in.
ARONCZYK: The amount you get paid for donating actually goes up the more times you come in each month. On top of that, you hit a certain threshold, and you become eligible for even more money.
RUDER: This month, if you come six times, you're entered into a raffle to win 200 bucks.
ROMER: Robert, the plasma donator I talked to, said coming into the center was pretty routine for him at this point.
MATTHEWS: I come twice a week. Actually, I come on Tuesdays and Fridays.
ROMER: Just like clockwork. It's part of your schedule.
MATTHEWS: Yeah, yeah. It's just like clockwork. It's just like a job. When I get off, if I'm - if I work during the day, I come in the evening.
ROMER: When I asked Robert why he gave plasma, he said he liked the idea that his plasma was helping other people, but he was pretty open about money being the bigger motivator.
Do you think, like, if they stopped paying people to come in here, would you come in as often?
MATTHEWS: Honestly, no, I wouldn't. No, I wouldn't.
ARONCZYK: Today there is still only five countries that fully allow payment for plasma - the U.S., Germany, Hungary, Austria and the Czech Republic. The rest of the world, including my home country of Canada, largely does not allow it. Some countries had always been opposed to paying for plasma. The rest, they got on board after that big WHO declaration back in 1975.
ROMER: To try to figure out why, we called up the head of the non-profit in charge of blood and plasma collection and distribution for Canada.
GRAHAM SHER: I'm Dr. Graham Sher, and I'm the chief executive officer at Canadian Blood Services.
ARONCZYK: Technically, some of the less populated provinces in Canada do allow paying for plasma. But in the big provinces where the vast majority of Canadians live, not OK.
SHER: Certainly all the plasma that we collect from donors is done on a non-remunerated basis. There is no payment by Canadian Blood Services to its plasma donors.
ROMER: There were three basic components to those 1970s arguments against paying for plasma. First, there was a concern that the people being offered money for their plasma might be being taken advantage of somehow.
ARONCZYK: Graham says that sort of moral angle is not really a concern he has about the American plasma that Canada ends up buying.
SHER: As long as there is no exploitation, as long as there is no perverse incentive to bring a donor in and diminish their health, it's an individual's free choice. And it's not for me to judge that person's action or the industry that supports it.
ROMER: The FDA regulates the American industry, and Graham largely trusts the FDA to do a good job of keeping an eye on things.
ARONCZYK: The second piece of the old argument was a concern that plasma from paid donors might be more likely to contain disease. And that was a real thing. In the 1970s, hepatitis was an issue. Then in the '80s and '90s, in Canada and around the world, HIV did spread through blood and plasma supplies.
ROMER: People worried that money might incentivize donors to lie, to hide their diseases to make sure they got paid for plasma. But Graham says scientists ultimately came up with a solution for this concern. They figured out that the right combination of freezing and heating and washing plasma with detergent actually kills all the diseases in plasma, including HIV. Plasma products have been disease-free for decades.
SHER: The plasma sector has done a remarkable job of implementing standards that make plasma from paid donors inordinately safe, so we don't have an objection on a safety basis, either.
ARONCZYK: The last piece of the argument from the 1970s is in some ways the most complicated. This piece says that if you start paying people for their plasma, they might stop being willing to do other things for free, like donating blood during a blood drive - what you normally think of as a blood donation.
ROMER: And Graham takes that concern seriously, so he's trying to thread this needle where he figures out how to collect as much plasma as possible without resorting to paying people. Canadian Blood Services has started expanding the number of unpaid-for plasma centers it operates with a goal of eventually supplying as much as 50% of Canada's plasma needs.
SHER: So as long as we can do it and meet the collection targets, then I don't think it becomes an essential requirement that we pay donors.
ARONCZYK: But Canada is nowhere near meeting its goals.
ROMER: At this point in 2021, where is Canada in terms of self-sufficiency around plasma products?
SHER: The current measure - the correct number would be 14 - one, four - percent.
ROMER: The remaining 86%, Canada buys abroad, almost entirely from plasma that was collected and paid for in the United States.
ARONCZYK: Canada got here by making a set of choices decades and decades ago. Those choices are part of why it is so dependent on American plasma now.
ROMER: If you were reinventing the system from scratch today, in Canada, do you think that remunerated plasma collection would be part of that system? Or is it simply a historical legacy that it's not allowed?
SHER: I think it is largely a historical legacy. Correct.
ARONCZYK: Canada has never really been forced to change its no-paying-for-plasma position because they've always been able to buy their way out of the problem. But that approach does not and kind of cannot work for every country around the world.
ROMER: After the break, we look a little more closely at the world's reliance on America's paid plasma donors and who is being left behind by that system.
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ARONCZYK: So for years, there has been talk in the blood plasma industry about the possibility of a looming plasma shortage. That's because new medical treatments keep being developed using medicine derived from plasma, and the use of those treatments keeps expanding around the world. The worry is at some point, the supply of plasma from the U.S. just will not be able to keep up.
ROMER: And when I talked with Ben Ruder, the CEO of B Positive Plasma, he said that shortage had maybe finally arrived, for a reason no one had really anticipated - COVID.
RUDER: The pandemic has certainly done a huge toll to this industry. Nationwide, collections are down, with some centers experiencing a much worse drop-off.
ROMER: According to the Plasma Proteins Therapeutics Association, a big trade group, plasma collection fell by about 20% in the U.S. last year.
RUDER: You know, there are a few factors, right? So one is child care.
ARONCZYK: If your kid isn't going to school, you might not be able to find time to come in and donate.
RUDER: And then just, you know, generally speaking, I mean, I think people are just - we're scared.
ARONCZYK: It was a pandemic. People didn't want to sit in a room for an hour with a bunch of strangers.
ROMER: But Ben says he thinks there's a third reason the pandemic hurt his business, and that is the government's response to the pandemic - specifically, all the government money that started flowing to people in the form of stimulus checks or enhanced unemployment benefits.
RUDER: You know, most donors are getting $500 to $700, $800 a month. If that's supplemented elsewhere, then plasma donation might not necessarily be on your - the top of your to-do list. So you kind of see when the federal money comes in, donations go down. And as people go through that money, donations rise. And then - (laughter) yeah.
ARONCZYK: Also worth mentioning, the U.S. largely closed the border with Mexico during the pandemic, so the really productive collection centers down there saw huge drop-offs because so many of their donors, in fact, live in Mexico.
ROMER: And regardless of how you weight these different factors, all of a sudden, the supply of American plasma that the world has always counted on has started to seem a lot less reliable.
ARONCZYK: And if countries like Canada have had to dial back their plasma medicine consumption around the edges, other countries have it way worse.
ROMER: We called up a doctor in Brazil who specializes in treating the kinds of patients who need plasma treatments the most.
ANTONIO CONDINO-NETO: I am Antonio Condino-Neto, professor of immunology at University of Sao Paulo, Brazil.
ARONCZYK: Antonio treats patients with a variety of immune deficiencies. Their bodies can't produce the kinds of antibodies they need to protect themselves, so they require injections of these proteins, immunoglobulins, that are only found in blood plasma.
ROMER: And so a patient who doesn't get this treatment, what are their symptoms?
CONDINO-NETO: They get recurrent infections, generally pulmonary infections like pneumonias, chronic sinusitis, chronic otitis, chronic tonsillitis, and diarrhea, as well. They will stay sick and will have a very bad quality of life, both children and adults.
ARONCZYK: There's a rule in Brazil that requires pharmaceutical companies to inform doctors if a shortage is getting so bad that they think they might not be able to keep supplying the doctors with treatments their patients require. In the last few weeks, Antonio says he's started getting these kinds of letters.
CONDINO-NETO: Dear Dr. Condino, this is to let you know that we have now a world problem in plasma shortage. And very soon, there will be a shortage of immunoglobulin products made by us (ph) because we don't have the plasma to make the products.
ROMER: How long do you think until you run out of supplies of immunoglobulin?
CONDINO-NETO: In two or three months.
ROMER: And what will happen to your patients?
CONDINO-NETO: Those medications are not optional. The patients must receive immunoglobulin replacement therapy because otherwise, they will get back the recurrent infections that may be severe and may kill them. So there is a high risk of dying because of infection.
ROMER: Antonio does not have a lot of patience for discussions about who has the moral high ground between countries that pay for plasma and those that don't.
CONDINO-NETO: If you are going to pay or not, I can tell you, I'm really not concerned about this. This is the least important topic to discuss.
ARONCZYK: Whatever societal harm or moral fraughtness we might feel about the imperfect way Americans collect plasma has to be considered in the balance with the very, very real harm that happens to patients when there is not enough plasma to go around.
ROMER: Even after the pandemic passes, it's not like the supply problem is just going to go away. Every year, more and more people are diagnosed with one of these rare diseases and told that their lives could be radically improved by plasma therapy.
ARONCZYK: And in the last decade or so, researchers have started looking at whether immunoglobulins or other proteins in blood plasma might somehow help other patients, people who have far more common diseases than the ones that afflict Antonio's patients.
ROMER: There's been some research about using proteins from plasma to treat things like Alzheimer's disease. So far, there have not been any huge breakthroughs. But if plasma proteins turn out to be helpful for a common condition, the supply chain is not at all equipped to deal with some huge jump in demand.
CONDINO-NETO: There is not enough plasma in order to produce medications for the entire world. It is now time to change the legislation of the other countries in the world that will allow them to start collecting plasma and produce their own medications.
ROMER: As it stands now, the only countries in the world that are even close to being sustainably self-sufficient in plasma production are the ones that allow companies to pay people for that plasma. All the others, including Canada and Brazil, are left to buy what they can on the international market, mostly from the United States.
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ROMER: Are you a teacher? We make it easy to use PLANET MONEY for lessons in your classroom. Go to npr.org/teachplanetmoney. You can write us. We are planetmoney@npr.org. We are also on Facebook, TikTok, Twitter, Instagram - @planetmoney. Special thanks today to Matthew Hotchko at the Marketing Research Bureau and Peter Jaworski from Georgetown University.
ARONCZYK: Today's episode was produced by Dan Girma and Alexi Horowitz-Ghazi. Our supervising producer is Alex Goldmark, and our show editor is Bryant Urstadt. This episode was edited by Adriene Hill. I'm Amanda Aronczyk.
ROMER: And I'm Keith Romer. This is NPR. Thanks for listening.
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