The US supplies two-thirds of the world's plasma, and it's one of the few countries where donors get paid.
In fact, thousands of Americans rely on plasma donation as a main source of income.
The pandemic has increased demand for plasma, and desperate volunteers may be putting themselves at risk to continue giving.
For thousands of Americans, donating plasma is a lifeline. In the 90 minutes it takes to donate, they make five times the federal minimum wage.
Americans supply two-thirds of the world's blood plasma. The industry is worth over $24 billion today, according to the Marketing Research Bureau, and that number could nearly double by 2027, as global demand for plasma-derived medicine rises by 6% to 8% each year.
Plasma is the yellowish liquid that makes up more than half of blood volume. Hospitals use it in transfusions to treat burns and liver failure, relying on unpaid donors. Biopharmaceutical companies also use it to manufacture life-saving drugs. Unlike those going toward transfusions, plasma donations destined for medication do not need to be labeled as voluntary or paid.
That's led to a boom in private, for-profit plasma centers across the US, with the number of centers tripling over the past 15 years. According to analysts at Fortune Business Insights, two-thirds of these centers are owned by one of three companies: CSL Plasma, Grifols, and BioLife.
Even before the pandemic hit, global demand for plasma far outpaced supply. That gap only worsened in 2020, as a mix of social distancing, cleaning requirements, and donor reluctance caused global donations to drop 15%, according to the Marketing Research Bureau. Meanwhile, plasma has been in high demand, as antibody transfusions show promising results in treating COVID-19 and private companies use plasma from COVID patients to develop potential drugs.
With no synthetic substitute for plasma, drug manufacturers rely on a steady stream of human donors to make up their supply. Treating just one patient with plasma therapies for a year takes between 130 and 1,300 donations.
"The bottom line is if the US didn't compensate donors, there would not be enough plasma and lives would be lost globally," the president of the Immune Deficiency Foundation wrote in a February 2019 statement.
But the burden is falling on vulnerable donors, many of whom rely on plasma compensation as a source of income.
"There's nothing wrong with giving plasma," said researcher Analidis Ochoa. "There is a problem when you feel that there's no other option."
Plasma centers attract donors in need of money.
Liz Savage visits a CSL Plasma center in Glen Burnie, Maryland, twice a week.
"I could pretend that I do it because it helps people and I'm glad that it does help people," she said. "But I only found out about it because it pays you money, and I only find myself doing it when I need money."
Savage has used plasma money to supplement her income throughout her life - as a college student in Idaho, a young adult in Tennessee, and now, as a mother in Maryland - to pay for family expenses like her children's new school clothes.
"I've tried DoorDash, I've tried, you know, little things here and there, but this is consistent. There is a need for it," she said.
Savage's story is a common one. A study from the Center for Health Care Research and Policy found that 57% of donors at one Cleveland center reported at least a third of their income that month would come from donating plasma. Researchers like Ochoa have found that plasma centers tend to be concentrated in states with lower minimum wages and cities with more people living under the poverty line.
"These are the areas where people who are most in need of income live," she said.
According to CSL Plasma, the company selects new locations "based on population density, availability of property, and local zoning laws." BioLife said it "looks for areas with a large population where it doesn't have a presence, real estate availability, and the amount of skilled staff nearby." Grifols declined to comment.
Regular donors told Insider they spend their plasma money on gas, rent, phone bills, food, and student loans. While some expressed a desire to help others as a motivating factor, many confessed that compensation was their primary influence. Even for those with other means of income, plasma donations are a popular way to make cash quick.
"There is at least a third of our church who donate," said Raquel Marruffo, who lives in Arizona. "All of them have jobs. It's just extra income."
Incentives to donate have only grown during the pandemic. Centers that usually offer between $35 to $50 per visit have paid an average of $65 per donation, according to the Marketing Research Bureau. That's in addition to referral bonuses, rewards programs, and incentives for those who donate twice a week or eight times a month.
Demand for plasma from recovered COVID-19 patients was so great that at times, they could make as much as $200 in a single visit. That inspired students at Brigham Young University-Idaho to intentionally try to contract the virus "with the hope of getting the disease and being paid for plasma that contains COVID-19 antibodies," according to an official notice released by the school.
BioLife Plasma said it "compensates individuals who donate plasma in recognition of the time, commitment, and effort required," and CSL Plasma emphasized that donating is a choice donors make freely, regardless of motivating factors. "In some instances, the compensation provided to donors provides a much-needed supplement to other sources of income," a CSL representative told Insider.
Paying donors increases the world's plasma supply.
The ethics debate is so involved, Georgetown associate teaching professor Peter Jaworski has focused his career on it. He falls firmly on the side of paying donors.
"There is no country in the world that is self-sufficient in plasma for plasma therapies unless it pays donors," Jaworski said.
In the Czech Republic, legalizing paid donation led to a sevenfold increase in liters donated in three years. In 2017, Italy - where donors can take a paid day off work, but are not compensated - needed 545,000 more liters of plasma than it collected, whereas Germany - which allows paid donation - had a surplus of 704,000 liters.
But the American system still outpaces that of its pay-for-plasma peers because of its comparatively lenient restrictions on donation.
Through a process called plasmapheresis, only the liquid plasma is removed from a donor's body, and since the human body replenishes plasma within 48 hours, that allows for much more frequent donation. That means while US donors have to wait eight weeks between blood donations, plasma can be given up to twice a week.
According to the Plasma Protein Therapeutics Association, only 14% of US donors made over 50 donations in 2017. Still, without much research on the health effects of donating 104 times a year - the US legal limit - researchers like Ochoa worry that the American system could put donors at risk.
"Our concern is that people who are vulnerable are giving their plasma to make ends meet," said Ochoa. "And we don't actually know what the long-term repercussions of this is."
Patients who rely on plasma-based therapies are bracing for a shortage.
When Christina Brown was in college, she got sick a lot.
"I had 15 UTIs in one year," she said. "Five bouts of bronchitis, two different pneumonias, a bunch of sinus infections."
She was diagnosed with common variable immunodeficiency, meaning her body doesn't make antibodies it needs to protect her from illness. Now, she injects herself with 100 milliliters of a plasma-derived drug each week.
"It's literally saved my life in every single way," Brown said. "I'm able to have a life and to be alive."
When she read the Immune Deficiency Foundation's warning of an impending plasma shortage, Brown's heart sank.
"I knew this meant people were going to die and I could be one of them," she said.
It takes seven to 12 months for plasma to go from a donor to the drug store shelf, so as the pandemic's drop in plasma supply catches up with production, patients like Brown are bracing themselves.
"I'm getting refills the day that I can get a refill, so maybe I can have an extra bottle or two on hand, because this is going to happen," Brown said. "It's not an 'if,' but a 'when' and 'to what extent' are we going to have this shortage."
For patients like Brown to access the life-saving drugs they need, global plasma donations have to rapidly increase. But as the system currently exists, that can't happen without drug companies relying on the desperation of some donors.
"The fact that they are providing a need to low-income Americans, I think is undeniable," said Ochoa, who believes both private industry and public policy can do more to protect donors. "That is the government that can step in to provide a safety net that is more adequate to the needs of Americans, particularly during difficult times."
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