Nine Pints

by Rose George

  Graham Sher’s testimony to the Ontario legislature was not what I’d expect from a man who runs an organization set up to deliver a blood service based on voluntary donations of blood products. He did not condemn the practice of paying for plasma. It was something for provinces and territories to determine. “Decades of evidence have proven that drugs made from plasma derivatives today are inordinately safe and just as safe as those made from volunteer donors. This is not the 1980s.” In this, he was aligned with Bahardoust, who believes the protests were fueled by Canadian Plasma Resources’ mistakes. A misunderstanding. Negotiations had been going on with Health Canada for four years before the clinics arrived, but CPR had not done any public relations. “We very much underestimated the sensibility of this issue,” Bahardoust says. “We didn’t do any public relations or any government relations apart from meeting with bureaucrats in Health Canada. That was, looking back, a very big mistake on our end.”

  It was also costly. When the Ontario legislature disagreed and passed the Voluntary Blood Donations Act, the clinics were told to shut down. When they carried on operating anyway, the police were sent in.58 Canadian Plasma Resources, unbowed but poorer—it’s estimated it lost several million dollars in its Ontario ventures—went looking elsewhere. CPR needed a provincial government that was conservative and free market and could stand up to unions scared of privatization. It found one in the province where Canada’s socialized medicine system had begun.

  * * *

  My guide around Canadian Plasma Resources’ clinic in Saskatoon is a tall, fair man called Jason. He is a project manager, not an academic or medic. “A jack-of-all-trades, really.” He grew up in a small town in Calgary and spent most of his career in oil. This is, then, an appropriate switch, as his experience of dealing with a highly lucrative liquid will be useful in the plasma industry. Trapping the volatile prices of oil barrels to give a stable comparison is tricky, but in a 2012 paper for the William and Mary Business Law Review, Sophia Chase gave a persuasive example from 1998, when a barrel of crude oil was worth $13 a barrel, but a barrel of blood would have cost $20,000. Blood separated into its derivative products would have been worth $67,000, while the barrel of oil, even including its derivatives, was worth only $42.59.59 Yes, Jason says. “There aren’t going to be many downs in this business.”

  None of these calculations appear in any of CPR’s literature or online. The slogan is “Give plasma, give life,” and the language is that of donation and gift and good, not profit and potential. It is no different from the marketing of voluntary blood donation, until you get to the page on Donor Compensation. But that is for later. First, a tour. Jason fetches me a white coat, more for theater than hygiene, as there are no other requirements such as hand gel or hairnets. The first step for what he calls donors and what I call sellers is an ID test: they must prove that they live within sixty miles of the clinic and not in a shelter or dubious hotel. Local donors, Bahardoust tells me, are more likely to be committed donors. A fixed address is a requirement. They keep a database, says Jason, and update the list of dodgy accommodations as best they can. As for the location limitations, they use Google.

  With the right ID and the right answers on the questionnaire, the donor-vendors are screened by a nurse, then go through to the giving room. It’s an impressive space, as is the clinic: white, shiny, new. It’s not new: when the Toronto clinics were closed down, they simply moved the clinic, cots and all, to Saskatoon. The other clinic is in storage, waiting to be transported to Moncton, New Hampshire, where CPR is planning a second clinic.

  There are sixteen cots. Currently the clinic sees about thirty-five donors a day, which is far fewer than CPR would like. Bahardoust would like to see an increase to one thousand appointments a week. That is a reach: business is modest but steady. I ask to interview some people attached to the plasmapheresis machine. Sure, says Jason. He is remarkably casual and open. It’s nothing like a later visit I make to Saskatoon’s blood donation clinic. It had taken me three weeks of asking a Canada Blood Services PR rep to be allowed to visit. Eventual permission was accompanied by strict instructions. “One of the supervisors will give you an operational tour. But you can’t talk to anyone. If you want pictures, we will send you pictures. If you want commentary we will send you commentary.” The PR rep finishes with a flourish. “The woman you are meeting is Karina with a K, and she will not give you her opinion on anything.” By the time I do get to the clinic and take a picture of the clinic sign, I almost hide behind a parked car in case they see me and drag me into the blood services prison for having taken a picture. There’s none of that here at CPR. If Jason doesn’t answer something, it’s because he doesn’t know it. I’d asked Bahardoust for a tour only the day before and been given no restrictions. It is in CPR’s interest to be open and apparently transparent. They remember the bad press and want better. But when Graham Sher of Canadian Blood Services later says that they are losing donors to CPR, I wonder whether it’s because CBS needs a lesson in getting good press.

  The first seller I talk to is Gail Wittig. She’s watching something on her phone while the machine takes her whole blood, spins it, retains about 800 milliliters of her plasma, and returns her red and white blood cells. She is exactly the kind of person whom Graham Sher is worried about, because she has given whole blood forty times, and now she gives plasma. She used to do plasmapheresis when Canada’s blood was run by the Red Cross. “When I found out about this place, I thought, I’d like to do that again, I think. So I’ve come over to this side I guess. You can’t really do both.” Studies have shown that once a voluntary donor switches to being paid, either for plasma or whole blood, they rarely return. When a German company began paying for blood donations, then quickly shut down its business, the local Red Cross blood centers could get back only one in six of the donors they had lost.60

  Gail works in a lab and knows that this plasma is going to make medication. She says, “They have their little thing out there,” meaning a display cabinet in the lobby that holds a few medicine bottles and empty IVIG vials. She’s not here for the money, she says, but because she thinks that giving plasma, even when it becomes a product with a huge profit margin, is a good thing. It helps people.

  The next seller is also a lost blood donor. He’s a twenty-two-year-old student who last gave blood a year ago. Now he’s going to sell plasma instead. Why? “Well, one, you get paid. Two, I did blood before, and I felt good. Plus I’m a student.” I ask him if he knows what happens to his plasma and he is vague. “Kind of. Like, pharmaceutical companies? I don’t know. Not much.” I feel like turning a screw, a little. You know this place is controversial? He doesn’t. I tell him about Krever and tainted blood, waiting for Jason or the clinic nurse to stop me. They don’t. I tell him that people are worried that this clinic is the beginning of something rotten. He is pleasingly concerned, though probably just polite. “I’ll definitely go and research it.” And he will definitely come back for his money. First-time donor sellers don’t get paid until their plasma is quarantined and screened. Seven to ten days after the first plasma donation, they get a Visa card in the post, loaded with $70: $45 for the first lot, $25 for the second. If they sell five lots within three months, they get $50 for their fifth, and $100 for their tenth.

  Plasma can be stored for up to three years. At the time of my visit, and probably for a long time after, Canadian Plasma Resources had no market for its plasma. It can’t sell it to Canadian Blood Services because it has no contract to do so, and there is no fractionating facility in Canada. What is not set out in the leaflets and advertising is that this plasma sold by Canadians is currently going no farther than a fridge in the back room overseen by a man called Innocent. The IVIG in those now-empty bottles on display in the lobby was made from American plasma, like 85 percent of Canada’s source plasma, or fractionated outside the country, like all of Canada’s plasma.61

  This is the case in plenty of European countries whose residents would not countena
nce the selling of blood but who use medicines derived from paid American plasma donors. Britons have been using foreign plasma for decades, since vCJD—mad cow disease—infected the blood supply (its prions travel in plasma). In 2002, the government bought a US plasma company to supply enough plasma for protein therapeutics (it buys plasma from Austria when stocks fall) that is fractionated by Plasma Resources UK.62 It quietly sold it off in 2013 to Bain Capital, which in turn sold it to a Chinese conglomerate for a large profit.63 British people who would be horrified at being paid for blood are now receiving plasma products sold by Americans and governed by the Chinese. On its website, BPL claims that it is regularly audited by government inspectors. When I wrote to ask who would inspect it now that it had been liberated into the private sector, no one replied.

  Dr. Ryan Meili is a Saskatoon doctor who has worked for many years in an inner-city clinic. During my visit, he was also fighting a campaign for election to the provincial government. When we meet in a downtown café, I recognize him easily as the man whose face I’ve been seeing, billboard-size, all over town. He speaks quietly and fluently. His worry about the new clinic is on two fronts. The politician in him is disturbed by the language of donation, which “gives the impression that this is a benevolent operation, a nonprofit whose main concern is the public good. Whereas it’s clearly a for-profit organization that is selling these products for the development of drugs.” The other worry is medical. The literature into long-term health effects of frequent plasma selling is “not rich,” he says, but the people in his clinic have high rates of diabetes, hepatitis C, and HIV. They have poor diets and food insecurity. “So adding this literal drain on their bodies is something that I think should not be done without significant further investigation, and really should not be done at all.” I ask him whether his medical or moral concerns are uppermost, and he gives an answer that, if I were from Saskatoon, would have got my vote. “The practice of medicine is a political act however you choose to do it.”

  Don Davies is the health spokesperson for the opposition National Democratic Party. He objects on the grounds of “two S’s.” Science and safety. “When you introduce a profit margin, you’ve now introduced a competing value to safety.” Anyone who reads the Krever Report understands that, because of its finding that dangerous inventory was given to people only to cut costs. “We don’t think anything should compete with the safety of blood.”

  For Kat Lanteigne, creeping privatization is what concerns her most about Canadian Plasma Resources. It is not the safety of the product that concerns her but the safety of the system. A private clinic is not linked to the public health care system, so if something did go wrong, it would be harder to trace. “When you go to a Canadian Blood Services donor clinic, you are under the umbrella of our health care service, so a nurse taking care of you is a Canadian public health care nurse, and if something shows up in your blood you get a phone call immediately from a Canadian blood services nurse, and you go to your doctor and it’s integrated.” She tells me of an artist several years ago who used a bag of blood in an artwork. “A journalist asked him where he got the blood, and he made a joke and said Canadian Blood Services. The agency flipped. But they were able to find that it wasn’t from them, that nothing was missing.” She thinks this kind of scrutiny will be diluted by privatization. Graham Sher of Canadian Blood Services has said differently. “We may have moral objections and philosophical objections to paying,” he told the Toronto Star. “But let’s not make it an issue about safety when it’s not about safety.”64

  * * *

  In 1987, Ann Hume, living in Shetland with a new partner, was pregnant again. By now there was AIDS in the news, and she thought of this and remembered her terrifying hemorrhages all over her kitchen floor. She asked her hematologist to test her for HIV. “And oh, she went off her head. She said I would never get any viruses out of Scottish blood products.” She got the test and she was negative, but only for HIV. “I went ahead with the pregnancy not knowing I had the hep C. I had got hep C in 1982.” She sends me her medical records, mostly correspondence between the hematologist and Ann’s Shetland GP. Typewritten, first, then computerized. Ann has added handwritten Post-it notes here and there. On a letter dated August 18, 1982, the hematologist wrote that Ann’s Factor VIII level “was totally normal.” Ann’s Post-it: “Yet she still gave me Factor 8?”

  She carried on. She was busy with three children and attributed her backaches and joint pains to life or aging. One day she was at the hospital for physiotherapy and saw something in a magazine about the Hemophilia Society. “I wrote to them and got back a letter on leaflets and hepatitis C. I read it and said to my partner, this is what I’ve got. I’ve got all the symptoms.” When she got her positive test result, she was given another leaflet that informed her that 80 percent of people with hepatitis C would get cancer. Her partner said, We can’t tell anyone. The Hemophilia Society said, Don’t tell anyone. The stigma of having a blood-borne virus, in the days of AIDS, was high. “You’ve got this illness but you can’t tell people what it is in case it goes all around the town, and everybody is pointing their finger at you.” And sometimes they don’t believe you. In a letter that Ann sends me from her doctor, the hematologist described this young woman as arriving on crutches and having a vivid imagination. The connection between the two is clear.

  Ann hasn’t had cancer yet, just persistent joint pain, osteoarthritis, and overwhelming fatigue. She struggled to look after her children. She couldn’t work. She got a new hematologist, who had to hunt for her medical records because they had disappeared. Disappearance of documents is something tainted blood campaigners get used to. When Lord David Owen tried to access his records from his time as health minister, he was told they had been shredded according to “a ten-year rule.” There is no such thing. But nor are there any records. Ann’s new hematologist, a Mr. Watson, also hunted for something else: in her dossier, there are letters to Watson from the Aberdeen and North East Scotland Blood Transfusion Service, assuring him that Ann had not received any blood products—Factor VIII—from their stocks. A few weeks later, another letter, from the director of the Scottish National Blood Transfusion Service Protein Fractionation Centre, who remembered that hemophilia doctors had used American Factor in the early 1980s. Other letters, other official forgetfulness. Another Post-it note: “This Factor 8 bottle brand name was never found.” She did finally get a diagnosis, of a platelet clotting disorder. And after taking a drug called Arvon, she has been cleared of the hepatitis virus. But she is not symptom-free. Walking is exhausting and painful. Her joints ache. She blames her first hematologist more than the authorities. “I suppose I blame them for taking it into Britain in the first place. If it was American stuff I got, I don’t know, I’ll never know. But the genotype of the hepatitis C I had was called 1A and it’s prevalent in North America. So that’s what makes me think mine was American. But nobody will tell me.”

  Other victims of contaminated blood were more successful in their efforts at tracing the source of their infection. But when Jason Evans, whose father Jonathan was killed by AIDS at the age of thirty-two, tried to seek his dad’s medical notes, he was told they had disappeared. In an interview for the BBC, he said, “Had I not met other people in the tainted blood community, I wouldn’t have thought anything of it. But they all said the same thing.” Papers had vanished. “I don’t think you can help but be suspicious.” Evans has now launched another lawsuit—there have been many before, but none successful—using new documents he has found in archives. In early 2017, the English MP Andy Burnham, in his last speech in the House of Commons, said that the contaminated blood issue, usually described as a “tragedy,” with the implication of happenstance and accident, was worse. It was, he said, “a criminal cover-up on an industrial scale.” Medical records had been doctored. Pages were missing. In 2016, a Conservative MP named Peter Bottomley participated in a debate about tainted blood in Parliament. His mother, he said, had had an HIV test af
ter receiving a blood transfusion, and he supported greater transparency and investigation. He said, of people whose blood was tainted, “People should go out of their way to put arms around them, act not just like a two-armed human being, but like an octopus and get right around them and try to meet all their needs in a way that they find acceptable.”65 This was a rare example of warmth toward a community of people who feel mostly discarded and treated with abominable disdain. These people who were “only hemophiliacs.” “We weren’t hearts, we weren’t cancers,” said David Watters, formerly head of the UK’s Hemophilia Society.66

  In Canada, Alberta has become the latest province to introduce legislation to ban the sale of blood, even when it’s called “plasma.” But the Canadian Plasma Resources clinic in Moncton is now open for business after months of opposition. The plasma protein therapeutics industry is predicted to grow 10 percent a year, with no recession in sight.

  Plasma products are as safe as biological products can be. And accusations that the industry targets poor people are unfounded, according to the Plasma Protein Therapeutics Association. “Plasma donors,” it wrote in a recent press release (not “plasma sellers”), “deserve our gratitude and respect, not sweeping negative characterizations.” To say otherwise is “unfair to plasma donors as well as to individuals living with rare, genetic and chronic disease who rely on access to plasma protein therapies.”67 Perhaps it is also unfair to wonder about the safety of an industry run by only four companies, when conglomerates and monopolies dominate business (the US petroleum industry is in the hands of a handful of corporations; so is its bottled water industry). Pathogen inactivation techniques are sophisticated and widespread. But population growth, deforestation, and climate change are all pushing humans and wild animals closer together. Viruses like that; they like to jump. We can inactivate only the pathogens we know about. Scientists such as Jonathan Quick of the Harvard Medical School believe there will be another major outbreak of something—in our air, food, or blood—in the next fifty years. Since 1975, twenty-five new pathogens have been discovered for which there is no vaccine or treatment. In 2012, a Chinese team detected parvovirus B19, a pathogen discovered in 1974, in more than half of Chinese plasma pools. H7N9, a flu usually confined to chickens, has begun to cross into humans and kill them. China has the largest plasma industry in the world after the United States. How safe is safe? The unhysterical Lancet Haematology wrote a recent editorial on “the big business of blood plasma.” The financial incentive, it read, “can encourage lying during medical screening and could adversely affect the health of some of the donors as well. With some companies pooling hundreds of thousands of donations together for processing, this can be an important safety risk.”68 We can’t protect ourselves fully from what we don’t know is coming.