x Abu Dhabi, UAETuesday 25 July 2017

Blood and treasure

In Texas plasma collection facilities are attracting a steady stream of impoverished Mexicans with nothing to sell but their blood.

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The United States is the world's number one supplier of blood plasma - a precious substance that enables medical miracles. Aram Roston reports from Brownsville, Texas, one of a handful of border towns where plasma collection facilities are attracting a steady stream of impoverished Mexicans with nothing to sell but their blood

One Friday morning earlier this month, Geraldo Castillo climbed off the bus in Matamoros, Mexico, near the bridge that crosses the Rio Grande and leads into the United States. Just months ago Castillo, 46, lived a solidly middle class life in Mexico with his wife and two teenagers, but now he was impoverished and desperate. Last year, when he heard a report on a Matamoros radio station about companies on the US side of the border willing to pay Mexicans for donating blood plasma, he thought he'd never have to do such a thing. In December, however, he was laid off from his job supervising data entry operations at a construction company, another casualty of Mexico's economic collapse. He's been looking for work ever since. "I look and I look and I look," he said. "There is nothing. But we have to eat." Castillo is a heavy man who moves slowly, and his small wire-rim glasses contrast with his bulk. He pushed his way through the metal turnstile on the Mexican side of the border, then walked across the bridge, high over the sluggish brown waters of the Rio Grande. On the American side of the bridge, he entered the sterile, air-conditioned indoor facility, where pedestrians formed a single-file line. A border agent examined his visa, which allowed Castillo to enter the US briefly for business or tourism, and then he stepped out into the sleepy town of Brownsville, Texas - the most impoverished city in America, according to the US Census Bureau. After entering the United States, Castillo didn't have to walk far to sell his plasma. A few hundred feet up International Boulevard from the border, the IBR Plasma building sits on Washington Street, across from a Duty Free shop. The plasma centre still looks very much like the bulk second-hand clothing store it used to be, though long white vertical blinds now hide what goes on behind its windows. Inside, the waiting room is divided into two sections marked by sheets of paper taped to the wall: one for "new donors" and another for "return donors". This was Castillo's first visit, which meant he could make $30 - about 400 Mexican pesos. Signs in Spanish and English offered an additional $10 to those who recruited other donors. The United States is the world's leading exporter of human plasma - providing about 70 per cent of global supplies, the biggest player in what is now a multibillion dollar business. In recent years, nondescript plasma collection centres have sprung up in dusty towns all along the US-Mexico border: in Laredo, Texas, across the border from the drug-war battlefield of Nuevo Laredo; in Eagle Pass, Texas; in Yuma, Arizona. Here, giant for-profit companies pump blood plasma from the veins of paid donors - many of them poor Mexicans with nothing left to sell but their blood.

Human plasma is the transparent yellowish liquid component of blood - what is left behind when the blood cells that float in it are stripped away. "Plasma contains all these proteins which make life possible. It is incredibly important," explained Dr Harvey G Klein, who heads the department of transfusion medicine at Johns Hopkins. It is used to manufacture a series of incredible life-saving products, critical to the treatment of haemophilia, immune deficiencies, burns and other illnesses. After it is collected from donors, plasma is processed - "fractionated", in the jargon of the trade: massive vats, sloshing with 30,000 litres of the stuff, are used to separate the liquid into distinct proteins. Fractionated plasma products are used to treat familiar ailments like tetanus, rabies and chickenpox. Intravenous immunoglobulin (IVIG), which is prescribed to treat a variety of immune deficiencies, as well as neurological diseases like multiple sclerosis, is currently being tested as a treatment for Alzheimer's disease. IVIG currently costs about $70 per gram - twice its weight in gold. No one doubts the utility of blood plasma in modern medicine, but critics of the plasma industry are quick to point to the uncertain ethics involved in harvesting blood from impoverished donors who cross the border to sell their plasma. "We have ethical issues with them bleeding Latin Americans," says Corey Dubin, an outspoken US activist and a frequent critic of the blood banks and plasma companies. Dubin, who has haemophilia, must inject Factor VIII - a blood-clotting agent derived from plasma - once or twice a week. (One month's supply can cost about $40,000.) But bad injections infected him with HIV and hepatitis - back in the days before plasma was treated to kill these viruses - and he now heads a group called the Committee of Ten Thousand, named for the estimated number of those infected by contaminated blood products. "They are collecting plasma basically in the free trade zone, one of the poorest and most polluted strips of the land in North America," he told me, with aggravation in his voice. "They are a captive, poverty-stricken population. And we have real issues with that. To me it says a lot about captive populations. You've got poverty. You've got health issues, and you are bleeding them. I mean: it kind of boggles our minds."

Castillo told me that, when his name was finally called, he was taken to a private room, where a female technician took his medical history and told him they would test his urine and his blood for sugar levels, HIV and hepatitis. She told him how it would be perfectly safe for him: as long as he drank plenty of fluids and ate well, he could give two times a week. He would, as promised, get $30 for this visit, and $40 the next time, so long as he came back within seven days. The human body, scientists say, can replenish its plasma much more quickly than its red blood cells, and plasma collection companies encourage repeat visits, since those donors have already been tested and screened. Castillo lay in the big soft chair, he said, while they inserted the needle and his blood started pumping out. It was cycled into a machine that spun the red cells from the liquid, as if squeezing whey from curds. The whey, the watery plasma, was stored in a big plastic bag, while the red blood cells were periodically reinjected into his arm. While he laid there, he later told me, he wondered about what his plasma was really worth - and where it would end up. Castillo is an educated man with a degree in business administration; before coming to Brownsville he had done some research and found, among other things, that in Mexico donating plasma for money is illegal - as is the case in much of the rest of the world. Business these days in Brownsville is especially grim: the general recession has taken its toll, but so have reports of continued drug-war violence just over the border and the outbreak of swine flu: the first person killed by the flu in the United States was a Mexican toddler who had come to visit relatives in Brownsville. Leaving the IBR centre where Castillo sold his plasma, I walked a block and a half to the east - past stores selling used clothing in bulk - to another clinic equally close to the border. This facility is run by a company called Biomat, a subsidiary of a massive Spanish multinational firm called Grifols. (Slogan: "What matters most: People.") Inside the waiting room, a comfortably air-conditioned area with two-toned walls, a uniformed security guard stood watch as about 60 people waited in rows of chairs. Almost all were Mexicans from across the border, but few wanted to talk. Fernando Martinez, a 32-year-old Mexican national who still had a bandage on his arm as he left the centre, told me he had been a semi-skilled worker - operating an injection-moulding machine - at a maquiladora, one of some 3,000 factories located just over the border in Mexico, until he was laid off abruptly in October 2008. Martinez, who is married with two children, has been selling his plasma ever since. He has a short wiry build and the erect posture of a horseman. He came dressed for his donation that day in a somewhat flashy striped shirt and tan slacks, and he listened to music on an MP3 player. Martinez says by now he's quite comfortable donating his plasma - he's been doing it weekly for eight months. He explained the maths to me, holding one finger after another to make his point. He makes $70 a month at Biomat, enough to support his family. Recently, he was offered work at another maquiladora, but at a salary equivalent to about $50. The contrast is a stark one: for a Mexican factory worker, selling plasma across the border is a more profitable trade than working - if you can even find a job to begin with.

When I called Grifols to learn more about the collection centre, I talked to a spokesman for the company, Chris Healey. "The health profile of those centres is on par with or better than the health profile of other centres in the country," he said. He told me the site had been open since at least 2003, when his company bought it, and that they were "absolutely not" targeting Mexican nationals who needed the money. "We do not target any specific geography," he said. Was it coincidence that the site was just a short walk from the border? I asked. "Coincidence is your word," he said. "It's not my word."

On June 2, the executives of the plasma industry gathered far from the Mexican border - in the plush lobby of a Marriott hotel in Washington, DC. Men in dark suits huddled for consultations around coffee tables, and then took the escalator up to the conference, sponsored by the Plasma Protein Therapeutics Association, or PPTA. The organisers handed out printed name badges as well as gift bags, flash drives, pens, notepads and breath mints labelled PPTA. Companies in the specialised blood industry laid out their wares: a company called Hemocue hawked its testing equipment; Medical Supplies of America gave away free bandages and antiseptic napkins; a Japanese company advertised its "Pore Diffusion Membrane Separator". The day's first panel of doctors and experts was called "Donor Epidemiology: The Cornerstone of Safety?" In other words: how critical is the health of a donor population to the safe supply of plasma? There was no mention of the collection sites on the Mexican border, but this is precisely the concern that has been raised by some experts and activists. The panelists seemed unworried: one speaker announced confidently that "there's been no case of confirmed transmission of viral load in 15 years". A heavyset executive from Biolife, a major plasma company that operates collection centres including ones along the border in Laredo and Eagle Pass, Texas, gave a presentation that suggested epidemiology was one leg of a "safety tripod" that relied on testing plasma and using hi-tech methods to render any viruses harmless. Plasma is big business, and in fact it is one of the few industries still booming amid the worldwide economic crisis. "Plasma is one of the strongest end-markets in medical technology," an analyst for Morgan Stanley wrote happily earlier this year, advising increased investment in plasma firms. For the plasma companies, the problem is not selling products - it is obtaining enough plasma. "Demand is strong and collections remain a bottleneck in the production process," according to the Morgan Stanley report, "as players are selling everything they can collect." There are not more than a handful of big players in the field: the industry, according to a recent filing by the US Federal Trade Commission, "operates as a tight oligopoly". A few of the biggest firms are European, but all of the companies collect the majority of their plasma in the United States. The big reason for doing so is that America still permits payments to plasma donors. The industry is tight-lipped about its statistics, but this year, according to Morgan Stanley's report, companies worldwide will collect about 20 million litres of plasma - 14 million litres of which come from America, or enough to fill five or six Olympic-sized swimming pools. The journal of the PPTA wrote in 2007 that there were 10 centres on the border, collecting more than a half million litres of plasma per year. The companies argues that the border sites are just as safe as those elsewhere in the country, and the US Food and Drug Administration, which regulates the industry, generally agrees. But even within the industry there have been other questions about the practice of operating facilities on the border. The National has obtained a 2007 letter to the PPTA from one huge company, complaining that border plasma collection "compromises the fundamental ethics of our business and negatively impacts donors, patients and the industry itself". The company even threatened to quit the trade association - but since then the internal debate has quietly subsided.

One issue that was not broached at the PPTA conference was the health and safety of using paid donors. In the US, as mentioned above, paying for plasma is taken for granted. Whole blood donations are generally collected by non-profit organisations like blood banks, while "source plasma" - the kind manufactured into medicines - is collected by for-profit firms. In decades past, American college students in need of quick cash would trudge off to the local plasma centre, textbook in hand. But Corey Dubin, of the Committee of Ten Thousand, notes that other aspects of the industry's past haven't been so idyllic: plasma companies, he says, routinely set up operations in the poorest areas of towns. "The history of paid donors," he pointed out, "is not a good one. The Los Angeles plasma centre used to be right on Los Angeles Street, right on skid row." Since the early 1990s, plasma has been treated to kill known viruses, and the industry says screening, testing and technology makes plasma products safe. But around the world there has been a vigorous campaign in the past few years against remunerating plasma donors, in line with the goals of the World Heath Organization, which in 2005 approved a push against paid donations. "The provision of blood, blood components and plasma derivatives from voluntary, non-remunerated donors should be the aim of all countries," it said. Harvey Klein, the transfusion specialist, explains there are two concerns at work: the first is the ethical issue of paying for any body part or tissue, even if no harm is done. The second, he said, is safety of the blood or plasma products. "Going back from three decades or more we know that volunteer donors are statistically the safest in terms of exposure to contagious agents. There really is good data. The fact is that paid donors are less safe." According to a 1998 report to congress by the US General Accounting Office, "paid plasma donors are over one and a half times more likely to donate potentially infectious units". But that disparity could be reduced considerably, the report noted, by using only repeat paid donors, whose blood could be tested with each visit. Why are paid donors more likely to provide contaminated blood? There are various theories, but the predominant one suggests that if someone is desperate for money, they will be less likely to reveal their medical history, or any high-risk behaviours, than a volunteer donor. Many European countries don't permit paid plasma donations at all. In England there are basically no plasma donors at all, because of the potential risk of mad cow disease; in 2002, Britain's National Health Service spent roughly 50 million pounds to purchase an American plasma collection company, DCI Biologicals, to ensure no interruption to the country's future supply of plasma products. The United Arab Emirates recently became the first country in the Gulf region to ban paid donations - chiefly for safety purposes, according to Dr Amin al Amiri, who oversees the Sharjah Blood Transfusion and Research Centre. In a telephone interview, he says that there is indisputable evidence that donations from volunteers are safer. "We say: 'Safe donors will give you safer blood and safe plasma. And the safe plasma will give you a safe plasma product.'" Back in Washington at the PPTA conference, right before the lunch break, I sat down with two officials from the trade organisation in the corner of the meeting room, to ask them about the ethical and safety issues associated with compensation for plasma donors. Gordon Naylor is an executive of CSL, the Australian plasma giant, and is a PPTA official too. "I think ethics is very much in the eye of the beholder," he told me. "It's about people's own value systems. In all cases of the donors we work with, they are remunerated, but it is an entirely voluntary process. These people are making a free choice as to what they do. The question as to whether its unethical is something you would have to ask them!" he pointed out, with a slight laugh. The PPTA also makes a semantic distinction: companies do not actually pay for the plasma, but for the commitment of time required from the donor. Joshua Penrod, an earnest looking man with a goatee, is vice president of the PPTA. "You have a significant commitment of time. We are talking hours and hours. And that is what the donors are compensated for. It is because of their time." But Harvey Klein says that can be "a convenient fiction", particularly when it comes to Mexican donors. "When a developed country is paying citizens of a developing country for their plasma," he said, "I think people don't see it as compensating them for their time." Dr Robert Dracker has a practice in upstate New York that involves quite a bit of infusion therapy for patients who need plasma products. He is a strong supporter of compensating donors for their travel expenses and time, but he remains sceptical about the motives of collecting plasma at the border. "I could see that this whole thing was initiated by the fact that they thought they could go across the border, bring people over, pay them next to nothing, and get a lot of service," he said. "And we could make up any scenario we want, but that is the reason." He raises other concerns: how much responsibility are plasma companies willing to take for their non-US donors, who may need follow up care? "You are really taking advantage of these people. I mean you can say you've got their consent, they've been informed of what they are doing, et cetera, but they need the money! These are people coming from Mexico who may have problems with access to physicians or poor health care, you have to make sure that they are getting fluids, eating properly, and have to make sure they get access to health care." The binational United States-Mexico Health Commission, established in 2000, contends that rapid population growth in the border region has put "further pressure on an already inadequate medical care infrastructure, which further decreases access to health care.... The large and diverse migrant population increases the incidence of communicable diseases such as HIV/Aids and tuberculosis, as well as chronic illnesses such as diabetes, certain cancers and hypertension." But there is a certain irony in the international campaign to end paid plasma donations: as Klein points out, almost all of the countries that ban paid donors still buy plasma products from the United States. "The irony," he told me, "is you can have a policy or a law that prohibits paid donors but they will purchase plasma that is from paid donors. They buy finished product that comes from paid donors. In countries like the Emirates, where paying for plasma is illegal, demand still requires the purchase of blood products harvested from the veins of people like Geraldo Castillo and Fernando Martinez. "We are buying the fractionated products," said Dr al Amiri, who oversees the blood supply in the UAE. "There is no choice. This is what's available in the world."

For now the collection centres in Brownsville - and elsewhere along the 3,000 kilometre US-Mexico border - carry on, and the steady stream of Mexican donors shows no signs of diminishing so long as the economic situation makes blood donation more profitable than paid labour. Julio, a young man I met in Brownsville, asked that I not use his last name so that his middle-class parents in Mexico don't learn that he survives solely by selling plasma. He has no other job and, he says, no other way to make a living, but selling plasma covers his expenses in Matamoros, where he shares the cost of renting an apartment with his sister. He's a fairly tall gangly lad of 25, slightly stooped and thoughtful. He is fully aware of the odd nature of his current "occupation" - which began more than a year ago, when he was in his last semester of a bachelor's degree in business at the Instituto de Ciencias y Estudios Superiores in Matamoros. He couldn't pay his tuition or buy books, he says, and he was about to quit school when a friend told him about a "good chance for making money" across the border. For Julio, however, this was not easy money: he'd had a phobia since childhood about the sight of blood. "It really freaked me out," he told me, standing in front of the IBR collection centre. "Maybe that's why I didn't study medicine," he said with a grin. But he needed the money desperately - for school, for food, for rent - so he began to research plasma donation. "I Googled everything," he said. "I Googled the risk. I tried to learn everything. I have a phobia for blood so I checked everything." And then, one Friday, he swallowed his disgust, walked the 10 short blocks from his apartment to the border crossing, and went straight to IBR. He'd been to Brownsville plenty of times, but he had never noticed the plasma centres. "I looked down," he said, "but I had to look away. You lie there; the blood comes out of your arm. There's a machine. The plasma leaves and the red blood comes back to you." Julio graduated from college in May. He hasn't found a job since, so he continues to cross the border to sell his plasma. "I'd rather be working," he told me, with a somewhat sad smile.


Aram Roston is the author of The Man Who Pushed America to War: The Extraordinary Life, Adventures, and Obsessions of Ahmad Chalabi.