The Trouble With Plasma

Remunerated Plasma Donation Remains a Moral Quandary

An email notification pops up on my phone from our department chair, with a photo of him smiling alongside two bagged units of packed red blood cells with a large bore IV in his forearm: “I’m scheduled for my routine every four- to six-week donation and just want to remind everybody that if they can, please try to donate!”

We are three years deep into the COVID pandemic, and along with myriad other supply chain issues, blood and blood products continue to be scarce. I think back to a year-and-a-half ago…

I was a fourth-year medical student, engaged to my now co-resident, with time on my hands and trying to scrape together some money for a wedding. I had heard about plasma donation as a side gig from a seasonal outdoor guide and decided to give it a go.

The nearest plasma donation site was just 10 minutes away from my house, and I began donating every week, raking in a respectable $200 weekly on the prepaid debit card that I was provided. On top of it all, I was granted a $40-per-donation boost because I qualified as a convalescent plasma donor, being fully vaccinated and having contracted COVID during my anesthesia rotation.

After several weeks of regular donation, I began to notice trends. Frequently, when I arrived for the appointments, I was the only one in the room who was not a person of color. And more often than not, one or two shopping carts filled with personal belongings were situated at the front entrance, suggesting that an unhoused person had recently arrived for their donation appointment.

We were a group of folks that had sought out a supplemental revenue stream, and it happened to be the sale of our bodily fluids.

A month after becoming a certified convalescent plasma donor, I again contracted COVID and was forced to take several weeks’ hiatus from the plasma side hustle. This break gave me a chance to reflect: Is this conscionable? What rules are in place to assure for-profit blood-product companies do not take advantage of vulnerable populations?

It turns out the U.S. Food and Drug Administration (FDA) has quite a few rules when it comes to source plasma establishments (SPEs).1 There are regulations limiting the frequency of donations, and donors are required to pass an extensive medical screening questionnaire, as well as undergo a physical exam and evaluation of their hemoglobin and cholesterol. SPEs are required to advise donors about the possibility of immunosuppression2 as part and parcel of the donation process, though for the life of me I cannot remember this being emphasized during my own consenting process. Reading through the FDA guide, it seems there are far fewer safety stipulations protecting donors than there are benefitting recipients.

The United States is one of the few countries that allows for remuneration of plasma donations. After an international scandal involving the exploitation of Nicaraguan citizens by dictator Somoza via the sponsoring of a giant plasma center — termed Casa de Vampiros, or House of Vampires — to provide a source for the highly profitable global plasma market,3 the World Health Organization (WHO) released a statement in 1975 to ban such practices and contract the globalization of plasma sales. Many countries, including Nicaragua, were on board at the time. However, countries such as the United States, Brazil, Germany, and the Czech Republic declined to adhere to the WHO guidelines and went on to corner the blossoming multibillion-dollar market.

The U.S. now provides roughly 38 percent of the plasma supply for the European Union. A majority of plasma centers in the U.S. are located in zip codes with higher-than-average poverty rates. Many of the most productive centers are situated in counties that line the U.S.-Mexico border.4

Platelets and whole blood products in the U.S. continue to be sourced from volunteers on four- to six-week donation cycles. The COVID-19 pandemic tamped down the supply of donated products; fortunately, after a concerted marketing effort revealing this decrease, many communities responded in a heartwarming turn.6

Although it is legal to remunerate platelet and whole blood donors, the FDA requires these products to be identified as coming from volunteer or paid donations. After studies from California demonstrated higher rates of HIV-positive samples from paid donors,7 many hospitals began to refuse these products.

Because plasma requires more complex purification and reconstitution processes to be incorporated into resultant medication therapies, it has less stringent labeling practices, and thus SPEs continue to benefit from philanthropic or enterprising efforts of volunteers — many of whom hail from lower socioeconomic status.

Is the remunerated exchange symbiotic or predatory? The situation seems to buck categorization. Wiser minds have dedicated extensive efforts to make the relationship more favorable toward both parties. A World Health Assembly (WHA) declaration from 2010 acknowledges the pitfalls of remunerated blood product sources, but also acknowledges the severe shortage of plasma and prioritizes the development of self-sustaining practices.8 After all, the only countries that can claim to be self-sufficient in plasma production are those that allow companies to pay plasma donors.4 Nowhere in its declaration does the WHA urge member countries or request the director-general for movement to a volunteer-only system.

Remunerated plasma donation remains a necessary unpleasantry. In response, we can bolster the voluntary systems that uphold our country’s current blood product supply by signing up for regularly scheduled appointments.

Take-home Points


  1. “Guide to Inspections of Source Plasma Establishments - Section 2.” Fda.gov, U.S. Food and Drug Administration Office of Regulatory Affairs, 2014, https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/inspection-guides/section-2#INFORMED.
  2. Zhao, J., Gabriel, E., Norda, R., Höglund, P., Baden, L., Diedrich, B. A., ... & Edgren, G. (2021). Frequent platelet donation is associated with lymphopenia and risk of infections: A nationwide cohort study. Transfusion61(2), 464-473.
  3. Starr, D. (2012). Blood: an epic history of medicine and commerce. Knopf.
  4. Romer, K. (Host). (2021, May 14). Blood money [Audio podcast episode]. In Planet money. National Public Radio. https://www.npr.org/transcripts/996921658.
  5. US Trade Numbers WorldCity, “EXPORTS: PLASMA, VACCINES, BLOOD” https://ustradenumbers.com/export/Plasma-vaccines-blood.
  6. Thomas, Khrista. “Why blood donation is unpaid: a global perspective.” 2021, May 6. Stanford Blood Center. https://stanfordbloodcenter.org/pulse-volunteer-donations/#_ftn7.
  7. General Accounting, Blood plasma safety: Plasma product risks are low if good manufacturing practices are followed. 11–12 (1998). Washington, D.C. (P.O. Box 37050, Washington, D.C. 20013); United States General Accounting Office. https://www.gao.gov/assets/hehs-98-205.pdf.
  8. Integrated Service Delivery, Availability, safety and quality of blood products (WHA63.12). (2010, May 26). Sixty-third world health assembly. World Health Organization. https://www.who.int/publications/i/item/WHA63.12.
  9. Swaminathan, A (Host), and Weingart, S. (July 2022). Critical care transfusions [Audio podcast episode]. In Critical care mailbag. EM:RAP. https://www.emrap.org/episode/emrap2022july/criticalcare.

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