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Blood Basics > The Blood Supply

Bad Blood

The following is excerpted from BLOOD: A HISTORY OF MEDICINE AND COMMERCE (ISBN 0-688-17649-6) by Douglas Starr (pgs. 207-212).

Chapter 12: Bad Blood

The blood business boomed in the 1960s and '70s. The enterprise had become so decentralized by now that no one knew how much was collected, although most estimates put it well above six million pints a year in the U.S. alone, easily surpassing peak collections during the war. The liquid's uses multiplied as well, as Cohn's dream of component therapy approached realization. Rather than using whole-blood transfusions, doctors increasingly administered individual components such as red cells, white cells, platelets, and plasma. Plasma itself was giving way to an increasing number of fractionation products, including albumin, gamma globulins, blood-typing sera, and clotting factors for people with hemophilia. Doctors used more blood in more ways than ever before.

At this point the blood business divided. Hospitals and blood banks continued collecting whole blood, but plasma became an industrial affair. A new process called plasmapheresis propelled the separation. The system involved removing blood from the donor, centrifuging it to separate the plasma, and then re-infusing the red cells. The procedure was uncomfortable and could take a couple of hours (at least until it was automated in the mid-1980s), which made it necessary to pay the donors.

Plasmapheresis proved invaluable to the drug industry, allowing manufacturers to harvest greater volumes of the raw plasma they desired. The process was safer than harvesting whole blood, since removing only plasma did not lead to anemia. Furthermore, while it takes weeks for the body to regenerate red cells, plasma can be replenished in a couple of days. All this meant that drug firms could collect more often than before: Previously they had had to wait a couple of months between purchases of blood from a given donor; now they could buy from him twice a week--104 times a year instead of 6.

What happened next can best be envisioned by imagining that someone invented a very fast and cheap way of drilling for oil at the same time that the industry discovered petrochemicals. Almost overnight, the collection business boomed. Hundreds of new plasma centers sprang up to meet the demands of the burgeoning "biologics" industry, as it came to be called. Some belonged to the drug firms that had pioneered fractionation under Cohn; others belonged to small independents, specializing in collecting and selling the raw material. Like drilling rigs at an oil field, they sprouted wherever the resource seemed promising--around army bases and college campuses, in downtrodden neighborhoods, and along the Mexican-American border. From there the "source plasma" was sent to the nation's biologics manufacturers, who, in order to process it economically, pooled it in vats containing thousands of pints.

New classes of people became involved--shadier buyers, more desperate sellers. Experts had warned about the potential for abuse. During a 1966 conference at Cohn's Protein Foundation, Dr. Tibor Greenwalt, a leader in nonprofit blood banking, cautioned against "exploiting for its proteins a population which is least able to donate them"--yet that gave little pause to commercial entrepreneurs. Tom Asher, a fifty-year veteran of the plasma industry who worked as a manager for the Hyland division of Baxter Laboratories, ruefully recalled that his company set up its first center at Fourth and Town streets in Los Angeles--"absolute dead center, Skid Row. We'd immunize donors with tetanus to increase their antibodies for tetanus gamma globulin. When hurried, our doctor, who was also the bouncer, would occasionally give them shots of tetanus antigen right through their trousers." Later the company took to "bankrolling all sorts of characters" to meet the booming demand for source plasma, many with questionable ethics. Another Los Angeles center, called Doctors Blood Bank and run by two local pathologists, paid donors in chits redeemable at a local liquor store.

Stuart Bauer, a writer for New York magazine, investigated the world of down-and-out plasma sellers by becoming one himself. After a loved one died of transfusion-related hepatitis, Bauer went undercover, donning old clothes and selling his plasma thirteen times over a period of seven weeks. His tale was a bleak one of hardened collectors and avaricious doctors, and of the winos, addicts, malnourished, and destitute whose plasma they "farmed" at the center in Times Square. Among the chilling scenes in his article is one about the experience of donation:
The pain of insertion comes in three overlapping waves. The first two waves--the puncturing of the skin and the piercing of the radial vein--are dicey enough, but stubbing a toe or biting the tongue are really worse. It is the third wave, the least painful part, that carries the freight. For when the body of the catheter is fitted inside the vein, distending it, it catches you--of all places--in the heart, which registers the intrusion with a chilly ping. When the next beat comes the heart's resumption has a choked rhythm . . . and you resolve from here on in to cater to your heart. But the only favor it occurs to you you can do is not to breathe too deeply. So you take in air in miserly little sniffs. And root for your heart as you would for a long-distance runner who had stumbled. ...

"Ever wonder what it's like?" [he asks the nurse].

"... Wonder what what's like?"

"Being on the other end of a hollow needle the size of a swizzle stick? ... It's like being impaled on the antenna of a car radio, that's what it's like."
Later he describes a scene in which the doctor at the center finds an elderly donor lying quite still with his mouth and eyes open. "How are we today, Sydney?" he asks the old man. But Sydney is dead. After the body is removed, the doctor remarks that during his years of association with the center the man had donated almost half a million cubic centimeters of blood. " 'One always hates to lose a veteran donor with a gamma globulin like his. ...'"

Not all those who sold their plasma were exploited. Some donors, with rare blood types or immunity factors, could sell their plasma at a premium. This was especially true of women who had developed a sensitivity to the Rh factor, the condition in which a baby with Rh-positive blood triggers an immune reaction in its Rh-negative mother. Two disciples of Karl Landsteiner, Drs. Philip Levine and Alexander Weiner, had shown that an Rh-negative woman could be immunized against the disease by injecting her with Rh antibodies immediately after the birth of her first Rh-positive child, and by the late 1960s this injection became commercially available. The source of this rare antibody--called "Big D" in blood-banking circles--was other Rh-negative mothers who had given birth to an Rh-positive child. The women most prized for plasma donation were "high-titre" mothers whose antibody concentrations were unusually high. A woman with such a rare combination of biology and circumstance could become wealthy from selling her plasma several times a month. One such woman, Dorothy Garber of Miami, Florida, had such a high concentration of the Big D antibody that she was able to earn more than $80,000 a year.

For every Dorothy Garber, however, there were thousands of less fortunate sellers--the unemployed, indigent, and substance-addicted--who would line up outside the centers in ragged neighborhoods to sell their plasma for $10 a pint. A "high percentage of our donors are either illiterate or functionally illiterate," the director of a South Carolina plasma center run by Cutter Laboratories wrote in an undated memo. "They have great difficulties reading words with more than two syllables and even more trouble understanding the meaning [of] those words. I am fairly sure most of the other Plasmacenters have the same problems."

The most disenfranchised group of donors was prisoners, who became an important source of plasma-derived products, mainly gamma globulin. Gamma globulins can be fractionated from anybody's plasma, but the best way to gather them is to find someone who has been exposed to a disease and has produced a high concentration of the antibodies in question. One way to collect gamma globulins would be to comb the population for survivors of diseases such as rabies or tetanus. A far more practical method is to inject a donor with a light dose of the pathogen and wait a few days for his immune system to gear up. This "hyperimmune" plasma can be fractionated to produce a highly concentrated and specific gamma globulin.

Prisoners proved ideal for this procedure. They were desperate enough to need the money (or furlough time, the reward in some prisons) but not likely to disappear, as were the transients from Skid Row. Soon prisons became an important source of gamma globulins for pharmaceutical firms such as Cutter and Hyland and the subcontractors who served them. Unfortunately, they operated in a regulatory vacuum. Under so-called short-supply provisions governing vital resources, drug companies could buy certain materials from unlicensed, uninspected vendors. Plasma was one such vital material. So, although federal health and safety rules covered the drug companies that processed the plasma, they exempted the smaller firms that merely collected it. A dangerous situation developed in which drug companies maintained reasonably safe and hygienic prison centers but the subcontractors who supplied them often did not.

The most notorious of these cases involved a chain of prison facilities owned by an Oklahoma physician named Austin R. Stough. Stough was a prison doctor for the Oklahoma State Penitentiary when he became aware of the emerging market for plasma. He opened a plasma center in the penitentiary, then expanded to institutions in Arkansas and Alabama. There he injected volunteer prisoners with the antigens for several diseases, collected their hyperimmune plasma, and sold it as raw material to the major biologics firms. By the mid-1960s, Stough had set up centers in five prisons in the South and was supplying the raw material for a quarter of the nation's hyperimmune gamma globulin.

Soon the prison donors started getting sick. One man nearly died when a technician reinfused him with someone else's red cells; another expired after a series of injections designed to boost his antibodies to whooping cough. Hepatitis rates jumped at several of the prisons. Five months after Stough's center opened in Kilby Prison in Alabama, the hepatitis rate among inmates soared from zero or one case a month to fifteen, then entered a sustained rate of twenty to thirty cases a month, including four deaths. Then forty-two men became sick at two other prisons in Alabama. "They're dropping like flies out here," said a penciled note from an inmate at Kilby. By the time the epidemic had run its course, the National Communicable Disease Center in Atlanta (the forerunner to the Centers for Disease Control) reported that 544 cases could firmly be linked to Stough's operation and that the real number probably approached a thousand. They could not make an exact estimate, because many health records had been lost or destroyed.

There was no doubt as to the cause of the infections. Stough ran a sloppy operation, with poorly trained technicians and unsanitary equipment. Even his customers knew it--an inspector for Cutter Laboratories reported that he was "appalled" by the conditions. Yet, right until the time that Stough was forced to abandon his plasma business, the major drug firms remained a loyal clientele. To them it was a question of supply. Having cultivated corrections officials with generous retainers, Stough had gained unparalleled access to the resource. Besides, reasoned the companies and federal officials, gamma globulins did not transmit hepatitis--as far as they could tell, the products derived from prison plasma were safe. Coldly and legally speaking, what happened to the prisoners was not really their concern.

Such indifference could not last for long. Dark stories were emerging about commercial blood and plasma in America, about a system that was poorly regulated and out of control. It also became evident that American blood products were not entirely safe. They had become tainted by a virus that, spread through transfusions and contaminated plasma, was killing hundreds, perhaps thousands, per year.

Reprinted by permission of the author from BLOOD: A HISTORY OF MEDICINE AND COMMERCE by Douglas Starr. Copyright © 1998 by Douglas Starr. New York: Alfred A. Knopf, Inc.