The news in the fall of 1976 from a small township in the Democratic Republic of the Congo was that villagers were suffering from high fevers, bone-rattling chills, and agonizing head and chest pains.1 The gruesome details of the death of the town’s headmaster, only a week after he fell ill, had spread fear throughout the remote region. Those tending to him reported how blood had filled the whites of his eyes, disfiguring blisters spread across his face and chest, and that he spasmed between coughing and vomiting. What they did not know was that a pathogen had ravaged his immune system and caused it to turn on him. The microbial invader had liquefied his organs. An autopsy revealed they had turned into a black liquid. No one then knew that the blood that poured from his mouth and nose when he died was packed with the lethal microbe, ready to infect its next victims. Within a month, 280 of the 318 villagers were dead (a nearly 90 percent mortality rate). For a backwater hamlet just across the border in South Sudan, a second outbreak had a 50 percent death rate.2
Blood samples of the dead were sent to Antwerp’s Institute of Tropical Medicine.3 Researchers there identified the microscopic culprit, a long wormlike virus. Its shape resembled the Marburg germ, a hemorrhagic fever virus discovered nine years earlier. Not certain if it was a new strain, the Belgians sent samples to both a British military lab and the American Centers for Disease Control. Epidemiologists at the CDC concluded that what was killing Africans so quickly and savagely was a “new organism… different than anything else we have seen.”4
A team of physicians, epidemiologists, and microbiologists from the CDC, Antwerp, South Africa, and France traveled to the Congo.5 The Congolese government had declared martial law and the military enforced a wide quarantine. Scientists and physicians in hazmat suits were soon the only ones visible in the ghost towns dubbed the “hot zones.” Virologists narrowed the pathogen to a family of six related viruses native to fruit bats but that had spread over time to gorillas, chimpanzees, and monkeys.6 The medical team thought it likely that the microorganism had jumped species from humans eating infected bush meat.7 It was also possible that it passed to people from hunters who handled the raw meat when they had open cuts or scratches.8
An airborne virus would have a much higher infection rate. Their working assumption was that humans passed it by exchanging bodily fluids. That meant everything from sex to infected blood or perspiration penetrating an open wound or entering the mucous membranes in the nose, mouth, or eyes.9 Local burial customs, it turned out, spread the pathogen since it put survivors in close contact with plague-ridden corpses.10 Researchers did not know it then, but later determined that the virus that decimated those two African villages remained active in the blood and semen of survivors for up to forty days.11
The medical sleuths eventually solved how the outbreak had its quite accidental start. Belgian nuns at a local mission had been giving pregnant women vitamin shots. When they ran low on supplies, instead of stopping the injections, the nuns just kept reusing the same set of syringes and needles.12 Once a woman carrying the deadly virus got an injection, every patient who followed got the bug.
One night, over a couple of bottles of Kentucky bourbon, the medical team that had been dispatched to Africa decided they should name the new microbial killer.13 A French microbiologist from the Pasteur Institute suggested the Yambuku Virus, after the Congolese village it had wiped out. Others disagreed, saying that would forever stigmatize that village. That had happened before. In 1969 a virus struck Lassa, Nigeria. Later named the Lassa virus, it caused an exodus by many locals who mistakenly thought it was more likely to break out there than anywhere else.14 A CDC researcher suggested that if they named it after something like a local river, that would make it geographically generic. Everyone liked that. The obvious choice was the continent’s second-biggest river, the Congo, which snaked through the country. The problem was that a few years earlier a tick-borne viral disease had been designated Crimean-Congo hemorrhagic fever.15 One of the doctors pulled a map from the wall and looked for the river that ran nearest to Yambuku. It was Ebola River, which in the local language meant “Black River.”16
Ebola was not the only new deadly virus passed by sex and blood. A handful of people in Europe who had worked in or visited Central Africa were turning up at hospitals or clinics afflicted with a range of opportunistic infections. A Portuguese man who had returned after several years of managing a restaurant in the small West African nation of Guinea-Bissau was admitted in late 1976 to a London hospital. He was suffering from dehydration caused by chronic diarrhea. Tests revealed an intestinal infection caused by the microscopic Cryptosporidium parasite, common to tourists who drank untreated water or ate contaminated food.17 Traveler’s diarrhea passed, though, in a few days. That none of the antidiarrheal meds worked puzzled doctors.
A few months later, a Lisbon-born cabdriver who had served in the Portuguese navy in Angola and Guinea-Bissau was admitted to a Paris hospital complaining of chest pains and difficulty breathing. The diagnosis? Pneumocystis carinii, a rare but not lethal fungal lung infection that had jumped species in the 1940s from sewer rats to immunocompromised children who were Holocaust survivors at a Polish orphanage.18 Again, physicians were stumped as to why antifungals did not clear it.
At the same time, a Greek fisherman showed up at an Antwerp hospital with Cryptococcal meningitis, caused by fungus found in soil and bird excrement that rarely affects humans. When the doctors learned he had worked at a commercial fishery at the Congo’s Lake Tanganyika, they called Peter Piot, a twenty-seven-year-old microbiologist who had been one of the researchers dispatched to the Congo. He was a co-discoverer of the Ebola virus. The Antwerp physicians hoped that his experience might help diagnose what was wrong. Piot knew the fungus that had infected the patient’s brain and spinal cord only flourished in people with compromised immune systems. Those were usually cancer patients undergoing chemotherapy or transplant surgeries in which doctors had weakened the body’s immune response so it would not reject a donor’s organ. That was not the case with the fisherman; Piot was perplexed that none of the antifungals slowed the infection.19
A few months later, Dr. Margrethe Rask, a Danish surgeon, returned to Copenhagen after five years at two Congolese clinics. She admitted herself to a hospital with trouble breathing and told the physicians she had battled fatigue, chronic diarrhea, and swollen lymph glands for a year. She tested negative for parasites but positive for oral thrush, a yeast contamination of the throat. Staph infections were multiplying in her blood. Tests revealed her body’s natural disease-fighting T cells were almost depleted. The forty-seven-year-old physician was soon fighting the same rare Pneumocystis carinii pneumonia that had infected the Portuguese cabdriver in Paris.20
A German concert violinist checked in to a Cologne medical clinic because he was alarmed by dark purple lesions that had broken out across his chest and arms. It took doctors a week to diagnose Kaposi sarcoma (KS), a cancer so infrequent that one physician had to look it up in a textbook. It was generally benign and affected mostly older Italian and Jewish men. The same disease afflicted the sole survivor of a Canadian transport plane that had crashed in the Congo in 1976. He had required two units of locally sourced blood. A year later he developed some of the same immune problems encountered by the others, including Kaposi sarcoma. It took almost a decade for a husband-and-wife team of virologists at Columbia University to discover that the version of Kaposi affecting younger patients like the concert violinist was a new strain of herpes. As with hepatitis and Ebola, it passed from one person to another through exchanges of semen or blood.21 I 22
It was unfortunate serendipity that a surging demand in the United States and Europe for blood by-products was setting the groundwork for escalating the spread of any infectious agent. The culprit was the industry that had been built around plasma, a pale yellowish liquid that is about half a person’s blood supply. It is packed with vital proteins, has excellent clotting components, and carries blood cells throughout the body. Doctors who understood why plasma was so vital also were aware of the dangers it posed when prepared or distributed improperly.
Plasma had become important during World War II because of the advantages it had over whole blood for emergencies. Not only did it keep longer without refrigeration, but it did not degrade when transported. Most important, it could treat shock and help wounds clot without worrying about matching blood type. There was no time in wartime field hospitals to check blood types and start searching for a match among the whole blood bags. Plasma not only made it much faster but in situations where a standard transfusion could not be administered, it could be injected into muscles or even rubbed into the skin.
Before the war, it was difficult to separate plasma from blood. Charles Richard Drew, a thirty-five-year-old who was the only African American physician with a senior position in the wartime blood program, solved that problem in 1938. (After having earned an MD specializing in transfusion medicine, he was the first African American to earn a medical doctorate at Columbia. The “father of the blood bank,” his doctoral thesis was “Banked Blood: A Study in Blood Preservation,” and after the war he organized America’s first national blood collection centers.)II
Drew’s method for extracting plasma from blood was slow but effective. It involved spinning the blood to separate the sediment and then a series of steps applying ultraviolet light and sterile solutions.23 The government wanted a crash program to use plasma as a blood substitute at the front lines. The Committee on Blood Substitutes was formed under the National Academy of Sciences. Millions of units of liquid plasma were shipped abroad in kits that included everything ready for battlefield infusion. The unintended consequence was that soldiers who got transfusions were fourteen times more likely to return home with hepatitis. In order to manufacture plasma in large enough quantities, it had been pooled from multiple donors.
When the Army realized it had a hepatitis problem, it ordered the pools to be no more than six donors and barred drawing blood from anyone with a history of jaundice. Still, the hepatitis infection rate stayed high. Laboratory efforts to kill the virus by heating or freezing plasma sometimes succeeded but invariably reduced its healing and clotting properties.
As opposed to penicillin, which was the dominant drug in the postwar pharmaceutical industry, plasma emerged from the war as a medical breakthrough that held great promise but had too many risks to justify widespread medical use. By the Korean War in 1950, the government tried again to rid the plasma supplies of hepatitis, this time with a new process that relied on intense ultraviolet light. Its failure was measured in the postwar statistic that one in five soldiers who received plasma during the Korean conflict contracted hepatitis. That was three times the World War II infection rate.24
The civilian population in the U.S. was not faring much better. In the 1950s, almost a third of the blood supply was from prisoners. The rest came from nonprofit blood collection centers around the country. Three pharmaceutical firms had a monopoly on producing plasma from that collected blood (Cutter Laboratories, Hyland Labs, and Merck’s Sharp & Dohme).25 The overall hepatitis infection rate in six major cities grew in proportion to how much pooled plasma was used.26
Technology revolutionized plasma collection in the mid-1960s. The National Cancer Institute adapted the know-how used in dairy creamer separators for a much speedier, mechanized method for obtaining it (called modern plasmapheresis).27 A needle or catheter drew whole blood from donors that was then put into a centrifuge machine that separated the plasma. That plasma was frozen while the red blood cells were reinjected into the donor.28 The entire process took two to three hours, a fraction of the time it had taken to isolate plasma from harvested blood. Before plasmapheresis, men had waited a minimum of twelve weeks between blood draws and women sixteen weeks. Red blood cells needed time to rebuild. Giving blood too frequently raised the risk for anemia, a chronic and potentially debilitating illness. By reinjecting the donors with their own red blood cells, the body regenerated plasma much faster. Donors could give blood twice a week, a rate that resulted in a liter of plasma.29
There were some unexpected consequences from the scientific breakthroughs. Since donors could give blood more frequently there was considerably more money to be made by the faster turnaround. The blood industry was flooded, according to medical historian Douglass Starr, with “new classes of people… shadier buyers, more desperate sellers.”30
European countries mostly banned paying for blood fearing that compensating donors attracted unhealthy ones, including alcoholics and drug addicts. The U.S. allowed the collection of “paid blood.” Hundreds of independently owned plasma centers opened and offered anywhere from $4 to $8 a visit. Those clinics knew that people down on their luck were the ones most likely to be induced to donate blood for a few dollars. As a result, the plasma centers proliferated near big-city skid rows. They distributed tens of thousands of flyers in New York, Los Angeles, and Chicago to drug addicts, alcoholics, the homeless and destitute, telling them about the easy-to-be-had money.31 A few clinics, led by the huge Doctors Blood Bank in Los Angeles, were more blatant in their pitch: donors received coupons redeemable at a local liquor store. The long lines desperate for cash or a drink formed early every day.III
Demand for plasma outstripped the supply. That was a result of scientific advances in the specialized blood products made from plasma. In 1965, for instance, a Stanford professor made a significant discovery about plasma’s clotting components. She had examined the sludge that remained after thawing frozen plasma. That residue, at the bottom of each bag after transfusion, was considered useless waste material and blood banks had always discarded it. The professor found it was a dense, rich concentrate of Factor VIII, the name given to the set of proteins required for blood to clot. That residual slush became the key ingredient in a slew of new products for hemophiliacs who needed emergency or elective surgery.32 It was not long before a concentrated white crystalline powdered form of Factor VIII transformed health care for hemophiliacs.33 It was one hundred times more effective at clotting than regular plasma. In that way, the nation’s ten thousand hemophiliacs no longer had to visit clinics or hospitals to get their plasma transferred from a bag.34 The powdered concentrate in a salt-shaker-sized vial cost 11 cents a unit for a pharma company to produce.35
Beyond blood products for hemophiliacs, doctors and hospitals had begun relying on specialized plasma components to fight autoimmune illnesses, infections, and even as an aid in transplant surgeries. Fractionation, a process for extracting individual proteins such as albumin and gamma globulin from plasma, had been streamlined. Those proteins became concentrated derivatives and were in huge demand. Obtaining enough for therapeutic doses required larger supplies of plasma.36
The plasma centers delivered the raw material for the specialized blood products. As more medical treatments became plasma intensive, demand exploded, requiring millions of liters a year. They could not process it fast enough unless they pooled all the donors. The plasma collection centers now mixed hundreds, even thousands of units from different donors. They sold it at 300 percent to 400 percent profit to hospitals and pharma manufacturers that then created the specialized products of clotting factors, gamma globulin, albumin, and others.
There was concern at the NIH and among some leading hematologists about the risks inherent in failing to screen the blood from “remunerated donors.” Although a rudimentary test to spot hepatitis B antibodies was developed in 1964, the blood lobby had prevailed in stopping the FDA from requiring it. America’s Blood Centers, the American Blood Resources Association, and the American Association of Blood Banks, national organizations that represented the country’s for-profit and nonprofit blood centers, hospitals, and community blood banks, argued that the extra cost of the screening would be burdensome for the mom-and-pop blood collectors.37
The blood lobbyists contended, without any supporting evidence, that an infected single donor would be diluted by all the healthy donors in the pool. With that logic, the larger the pool, the better. It reduced the risk of any transmissible virus. Years later that was proven wrong. Researchers confirmed that a single patient with hepatitis could infect a pool of more than a million donors.38
Hepatitis infection rates across the country spiked starting in the mid-1960s. A 1968 study in JAMA reported that when the donors were “suspected narcotics addicts,” it was seventy times more likely that a single transfusion resulted in a hepatitis infection.39 In 1968 the federal government revoked all licenses for consumer sales of whole plasma from multiple donors (the FDA required hepatitis screening on blood and plasma supplies in 1972, but the test was only 15 percent effective).40 A lot of the independent collection centers closed. Many of the remaining ones were bought by the four pharmaceutical firms that dominated the blood trade.41
It was a mistake to expect that eliminating most of the small operators might tamp the cowboy flavor of the American blood industry. The pharma firms now oversaw the plasma collection as well as processing it into a range of therapeutic products. Their incentive was to keep costs as low as possible. As a result they did not spend anything on making their products safer. Courtland and Hyland continued using skid row donors in large plasma pools. Hyland also set up plasma centers at U.S.-Mexico border towns, hoping to attract poor migrant donors. Cutter got into a fight with some hospitals over the right “to bleed prisoners.”42 A congressional investigation later obtained confidential documents from those companies, and from private blood collectors, that proved that for the next twenty years they often ignored, or at least delayed, readily available safety tests.43 That only changed in the 1990s when AIDS made blood transfusions a matter of life and death.
Consolidating the plasma collection of the American blood industry under a handful of drug companies did not even result in more supply. They had not figured out how to induce more Americans to donate blood so demand continued to significantly outstrip production. The country’s three largest blood organizations—the American Association of Blood Banks, the American Red Cross, and the Council of Community Blood Centers—had launched a promotion campaign to encourage more people to donate. It had a negligible effect.44
The gap in the supply of plasma was met by collection centers that opened in some of the poorest and most downtrodden urban slums in a dozen countries. The owners of the shuttered U.S. clinics ran some of them. By the end of the 1960s, blood centers in Costa Rica, El Salvador, the Dominican Republic, Mexico, Belize, Colombia, Haiti, and Nicaragua fed the American plasma market. The two largest collectors operated from Nicaragua and Haiti: Compañía Centroamericana de Plasmaféresis in Managua and Hemo-Caribbean in Port-au-Prince. They were in a class of their own, far outselling all offshore competitors in how much they sold monthly to the U.S.
There was, however, something unique about the Haiti center. It was the only one of the Third World collection operations with a link to the Democratic Republic of the Congo at a time when HIV was developing there. After the Congo declared independence from Belgium in 1960, a civil war wracked the country for four years. The U.N. secretary-general launched an ambitious project intended to recruit French-speaking engineers, physicians, nurses, teachers, and technicians to help stabilize the fledgling nation.45 Although a lot of Belgian professionals had stayed in the country, the United Nations Educational, Scientific and Cultural Organization, UNESCO, wanted other nationalities than the one responsible for colonial rule. UNESCO offered housing and generous compensation packages and required a one- to four-year commitment. The largest contingent of French-speaking foreign professionals that arrived were between 4,500 and 6,000 Haitians.46 They stayed on average twenty-four to thirty-six months before returning to Haiti. As they returned home, a few unknowingly were among the first people in the Western Hemisphere to have contracted HIV.47
The Hemo-Caribbean plasmapheresis center had opened in late 1970 in a two-story building in Rue des Remparts, a squalid street on the edge of the capital’s infamous portside slums. An American stockbroker based in Miami, Joseph Gorinsteen, put up $250,000 to build it. An Austrian biochemist was its technical director.48 Luckner Cambronne, the former head of the notorious Tonton Macoute police militia who had become the interior minister, had a secret stake. Aside from the island’s autocratic president, François “Papa Doc” Duvalier, Cambronne was the most powerful man in Haiti.49
With Duvalier’s blessing, Cambronne bypassed the country’s minister of health and personally negotiated the contract that granted Hemo-Caribbean an exclusive ten-year contract for “plasma farming.”50 The center paid impoverished Haitians $3 per liter of plasma (2.1 pints). Those who queued before the doors opened daily at 6:30 were among the island nation’s poorest, overwhelmingly illiterate and mostly unemployed. They could double or triple their average annual income of $75 by regularly giving blood.51
The Rue des Remparts center processed an average of 350 donors daily. There were usually some still waiting at its 8 p.m. closing. So many wanted to give blood that Hemo-Caribbean started building a second collection center in the capital capable of processing an additional five hundred daily.52
Although some hematologists criticized the center’s poor hygiene and haphazard testing, it sold between five thousand to six thousand liters of plasma monthly to the American pharmaceutical companies licensed by the National Institute of Health’s Division of Biologics Standards.53 The frozen plasma, which returned a 500 percent profit, was flown to Miami on Air Haiti transports, an airline partly owned by Cambronne. Hemo-Caribbean’s widespread plasma ventures had earned Cambronne a nickname in Port-au-Prince: “The Vampire of the Caribbean.”54 Once in Miami, the drug companies took the plasma and processed it into a lucrative range of therapeutic blood products.55
Werner Thill, Hemo-Caribbean’s technical director, told a reporter that the blood center rejected 1 to 2 percent of its six thousand donors, judging them too weak or their hemoglobin count too low. What about donors who might be infected with hepatitis, malaria, or venereal diseases? Thill contended that it was foolish to worry about blood they collected since “Haiti has no drug-addict problem.… [and] most active blood sellers in the United States are drug addicts, many of whom have hepatitis.”56 As for anyone in Haiti “who may slip through the screening process,” Thill claimed that Hemo-Caribbean had a unique freezing technique that “kills those bacteria” (that was wrong).57IV
Even if the plasma it sold was contaminated, Thill asserted, “the companies that buy the plasma… are ultimately responsible for the product.” The U.S. pharma and biologic companies were instead depending on the NIH’s Division of Biologics Standards to randomly inspect blood products collected from paid donors in poor offshore countries with few stringent medical standards. When a Los Angeles Times investigation in 1972 raised troubling concerns about the safety procedures at Hemo-Caribbean, a California congressman, Victor Veysey, queried the Biologics Division. Federal regulators told him that “no imported plasma is being transfused directly into human beings.” When pressed, they admitted that no one in the Biologics Division had verified that.58 Instead, they relied on the assurances of the pharma companies distributing the Haitian plasma. Biologics also initially claimed there was no danger of the plasma transmitting hepatitis (HIV/AIDS was not yet identified) since it was broken into “its component fractions” for specialized treatments. When pushed by Veysey, the oversight agency admitted that the risk of passing on hepatitis or other infectious diseases “is not completely eliminated by this procedure.”59
The author uncovered that one of Hemo-Caribbean’s most dangerous cost-cutting measures was to reuse unsterile needles and sometimes catheters.60 That is almost certainly why the clinic’s donors had a high rate of injection site infections. In at least one instance, a worker became infected with hepatitis from handling the blood.61 A former Hemo-Caribbean lab technician (there were twenty-two at the company’s peak of two hundred employees) later recounted there were some instances in which a donor’s artery was mistakenly punctured instead of a vein, and others in which patients became sick to their stomach or short of breath. None of those was reported to the Ministry of Health.62 Other times, in the lab, there were worries at the end of a second shift that the technicians and nurses were so tired that red blood cells taken from one donor had been “returned” to the wrong person. That could cause serious kidney and breathing problems as the body attacked the foreign cells as if they were invaders.
A sizable percentage of Hemo-Caribbean’s weekly donors were sex workers, including men who regularly had sex with male tourists for pay, and ex-prisoners who had moved back to the neighborhood after their release from jail.63 WHO and epidemiological studies later demonstrated that nearly three quarters of all sexually transmitted diseases in Haiti were then concentrated in those same demographic groups.64
By coincidence, eighteen months before Hemo-Caribbean opened its doors in Port-au-Prince there had been a medical breakthrough in the production of a highly concentrated form of Factor VIII. When the federal government had banned consumer sales of pooled plasma in 1968 over hepatitis fears, it exempted Factor VIII since there was no alternative for the nation’s hemophiliacs. The thousands of monthly liters of pooled plasma that Hemo-Caribbean sold in the U.S. were distributed widely from California to New York to Indiana as finished Factor VIII.
In 1979 and 1980, a dozen men in Haiti were the first to be diagnosed with Kaposi sarcoma. The author was unable to confirm a report that ten of them had been Hemo-Caribbean donors.65 A French geologist had his arm amputated after a car accident in 1979 while working in Port-au-Prince. He received eight pints of blood during surgery and eighteen months later developed Kaposi sarcoma (the first case of the new virus passing through a blood transfusion in the U.S. was that same year, 1979, to an eighteen-year-old hemophiliac in Pittsburgh).66
Expectant mothers started turning up with another herpes-related virus, cytomegalovirus (CMV). The symptoms—fatigue, fever, swollen lymph glands, and vision loss—created serious pregnancy complications. A thirty-four-year-old secretary for Air Zaïre checked in to a health clinic in Louvain, Belgium. She was ill with a severe CMV infection and toxoplasmosis, a parasitic disease normally found only in cats. Two of her daughters had died at six months of age from respiratory infections, and her three-month-old surviving daughter had oral candida, an opportunistic yeast throat infection. No medications helped. Against her doctors’ advice, the secretary traveled to Zaire to visit her family. The doctors intended to perform additional testing when she returned to Belgium; she never did. There was no urgency or any follow-up; they considered her a puzzling medical anomaly.
No one could yet be expected to connect all the inexplicable reports in obscure journals about the cluster of young patients who had turned up at doctor’s offices or emergency rooms with rare illnesses resistant to all traditional treatments. No one could imagine they were the harbinger of AIDS, the most lethal modern-day epidemic.V67
I. In all the early instances that baffled doctors, the patients had died by 1979. In most cases, tissue samples were preserved for later study. In the 1980s, all were confirmed as positive for human immunodeficiency virus (HIV).
II. Although Drew’s work was instrumental in establishing the technology that made the American Red Cross flourish, he was barred as a black man from giving blood. That had been the segregated blood policy that Arthur Sackler railed against in the late 1940s.
III. Eventually, the FDA required blood centers to label their supplies as “volunteer” or “paid.” That 1978 change eliminated the market for “paid blood” since American hospitals and clinics wanted only “volunteer” blood. They feared the consequences of buying riskier remunerated blood. However, the author learned that there was suspicion at some hospitals that what happened was that many of the less reputable blood clinics had merely marked all collected blood as “volunteer.” That meant that some hospitals were still buying “paid” blood but paying the higher “volunteer” prices.
IV. In fact, the only way to possibly kill such infectious viruses was the opposite, concentrated dry heat combined with solvent-detergents. After an advanced technology to heat plasma became available in the 1980s, the FDA pulled earlier versions from the U.S. market. Baxter International and Bayer continued to sell the recalled plasma to Asian, Latin American, and some European countries, despite an explicit FDA warning that those blood products might be contaminated with HIV.
V. Efforts to wean plasmapheresis centers off paying the poorest people for donating blood have failed repeatedly. The current demand for plasma, for which there is no synthetic substitute, is several times greater than it was in 1970. An investigation in 2018 in The Atlantic reported, “Americans are flooding into the country’s blood-plasma donation centers in greater numbers than ever before, seeking to make up for low wages or small benefits checks, or even as their only source of cash income during a spell of extreme poverty. Their blood plasma—which historically has been collected disproportionately in the country’s poorest communities—is fueling a multibillion-dollar worldwide industry.”