Nine Pints: A Journey Through the Money, Medicine, and Mysteries of Blood

by Rose George

We fear blood, still, despite our science and understanding, and we look to blood to tell us who we should fear. In 1144, the death of a young man named William of Norwich was attributed to Jews who had crucified him in order to use his blood as a sacrifice. This was the first documented case of what became known as blood libel, and it was enduring and lethal: for centuries, blood libel was used as a reason to massacre Jews and steal their property, across northern Europe, again and again.8 In 2015, a Hamas leader in Gaza declared that Jews were still killing children and using their blood to knead into special Passover bread. The Times of Israel headlined this MEDIEVAL MINDSET.

The Nazis, obsessed with the purity of blood, decided A was Aryan; B was inferior.23 The Japanese even now believe that blood type involves far more than what antigens are on the outside of each blood cell. A types are perfectionist, kind, calm even in an emergency, and safe drivers; Bs are eccentric and selfish, but cheery. Os are both vigorous and cautious while ABs, obviously, are complicated.24 A book on blood types in beautiful women was a bestseller, along with the author’s follow-up, a book on blood types relating to lunch boxes.25 Blood typing has serious consequences: people are denied jobs because of it and it is thought necessary to making a good dating choice. In 2011, when government minister Ryu Matsumoto resigned a week after taking office, having offended survivors of Fukushima and the earthquake, he blamed his blood type. “My blood is type B,” he told reporters, “which means I can be irritable and impetuous […] My wife called me earlier to point that out.”26 Blood type discrimination somehow nicely slots in with perceptions of inferior minorities: AB and B, more common in Taiwanese and Ainu people, are thought to be violent, backward, and cruel.

More than half the 37.5 million people living with HIV worldwide are female. Every week 7,500 young women are infected, and globally HIV/AIDS is the leading cause of death of women aged fifteen to forty-four.4 In sub-Saharan Africa, young women between fifteen and twenty-four are twice as likely to be infected with HIV as young men.5 In some parts of KwaZulu-Natal, an eastern province of South Africa, a fifteen-year-old girl has an 80 percent chance of being infected with HIV.6 Eighty percent! To be interested in HIV is to be pulled to the bottom of the African continent as if by a tractor beam, and to want to know why in 2017 being a black young woman is a death sentence.

him? In the 1990s, Uganda launched a highly successful behavior modification program with the slogan Zero Grazing.36 Grazing was having more than one partner. Uganda wanted people to stick to main meals. It worked; condom use increased dramatically and Uganda’s HIV prevalence dropped. Then conservative Christian ideology arrived from the United States along with PEPFAR money and found a receptive home in President Museveni and his wife, and condoms were burned, and HIV came back.

Plasma companies collect it from paid donors using aphaeresis machines, which spin whole blood, retain the plasma, and return the rest to the recipient. This is source plasma, and it is purified for its components such as immunoglobulins, which boost immune deficiencies, or albumin, the most common plasma protein, which can maintain blood volume and pressure. These components have come to be known as plasma protein therapeutics. A unit of FFP is cheap: the NHS sells one for under £30 ($42).2 A fraction of source plasma is not. The most popular, intravenous immunoglobulin (IVIG), often costs more than gold (the NHS buys it for about £35 [$49] a gram),3 and one plasma donation can reap medicines worth ten times what a donor is paid (usually about $30). Human and animal blood is the thirteenth most traded commodity in the world, worth $252 billion. Most of that is products derived from plasma, and most of it is coming from the United States, the largest exporter of plasma. In 2016, the category of “human and animal blood”—actually mostly blood fractions such as plasma products—earned the United States $19 billion, close to what it got from selling medium-size cars or soybeans.4 The chief of America’s Blood Centers, an association of blood banks, has called it the OPEC of plasma.5 Half of Europe’s plasma for medicinal products comes from American veins.

Although the new variety of hepatitis was poorly understood and there was no test for it, by the early 1980s it was known that both hepatitis and HIV could be dealt with by good screening of donors, and with heat. But this was costly: the clotting factors weren’t destroyed but they were reduced so that more plasma was needed. Also, companies had lots of inventory of untreated factor on the shelves. They decided that it had to go somewhere. At a 1984 conference at the Centers for Disease Control in Washington, DC, a minority argued strongly that all non-heat-treated product should be discarded. The majority disagreed: it should be a matter for local medical personnel.28 A report by Justice Horace Krever into the contamination by US products of the Canadian blood supply titled one section “The Sorry Story of Blood Product Withdrawals.”29 It was sorry because it didn’t happen. An editorial in the Lancet, while recognizing the benefits of heat treatment, concluded an editorial with the reminder that “by far the commonest cause of haemophiliac death is bleeding.”30 By the mid-1980s, heat treatment was adopted as standard, but some companies continued to export their old, unheated inventory. Cutter sold it to Taiwan, Malaysia, Hong Kong, Argentina, Japan, and Indonesia, exporting more than one hundred thousand vials of unsafe, unheated concentrate—even though by then it produced heated product, too—and earned more than $4 million. In response, Bayer officials told the New York T...

In the UK, hemophiliacs were used as guinea pigs. Or chimps, actually. In a 1982 letter, Professor Arthur Bloom, a hematologist at the Oxford hemophilia center where Neil Weller was treated, proposed testing the new heat-treated product on hemophiliacs. It had been tested previously on chimpanzees, but animal testing was expensive. Bloom decided that quality controls would be better—and less costly—if they were carried out on hemophiliacs who had not yet been exposed to large pooled products.35 The candidates were called PUPs, for previously untreated patients. Most were children. No PUPs were told that they were a human experiment. One was Colin Smith, treated by Bloom. He died of AIDS at the age of seven. In the months before Colin’s death, his parents had to pick him up in two sheepskins because he couldn’t tolerate the pain of being touched.36 Later it was discovered that a product called Factorate, produced by Armour, was heat-treated with a process inferior to the other companies. Armour was told in 1985 of cases of HIV infection in people using Factorate. It did not modify its process until two years later.37 Tainted blood activists today say that they are “cheaper than chimps.” But bleeders are also used to being told how expensive they are, because of how costly factor is. In 1985, a junior minister named Kenneth Clarke wrote that he was skeptical of heat-treating UK-produced factor. After all, “only hemophiliacs have died.” It’s an extraordinary memo. “Of course,...

The river now is not the only thing dividing Saskatoon: health and poverty statistics do the same. The city has some of the highest rates of HIV and hepatitis C in Canada, as does the province. On some reserves where Saskatchewan’s First Nations people live, HIV rates are eleven times higher than in the rest of the country and equivalent to Nigeria’s.39 An assessment of Saskatoon’s health disparities found that residents from six low-income neighborhoods, all in the west of the city, are 3,360 percent more likely to have hepatitis C than higher-income Saskatoon residents. An infant born in these neighborhoods is 448 percent more likely to die in its first year of life. This mortality rate, wrote the authors of the report, a senior epidemiologist and the city’s chief medical officer, “is worse than [in] war torn nations like Bosnia.”

Location matters in the plasma business, and the biggest plasma business in the world is just over the border. More than forty years after J. Garrott Allen castigated the use of skid row sellers, the plasma industry in the neighboring United States still had a reputation for locating its clinics in poor areas populated by vulnerable people. Grifols, the global leader in plasma protein therapeutics, has nearly 150 clinics in the United States. Thirteen are along the Mexican border. There are four clinics in El Paso.43 A paper coauthored by someone with one of the best names in epidemiology, Cameron A. Mustard, examined the location of plasma clinics in the United States between 1980 and 1995 and found that the number of source plasma clinics operating in extreme poverty areas grew from 77 to 136. Commercial plasma clinics were five to eight times more likely to be located in areas considered high-risk than would be expected by chance. What was surprising was that “such clinics continued to operate in these areas well after the epidemiologies of HIV and HCV [hepatitis C virus] and the links between drug use, infection and blood product infection were established.” This, in dry science language, “is inconsistent with epidemiologic evidence that locating of commercial source plasma clinics—which provide cash compensation for plasma donation—in the midst of active drug markets and poverty represents a risk to blood system safety.”

The number of people donating plasma had risen as dramatically as the number of Americans living in extreme poverty, according to Kathryn J. Edin and H. Luke Shaefer, two sociologists who published $2.00 a Day, a book about modern American poverty. Over ten years from 2006, the number of people selling plasma grew threefold, to 32.6 million.45 According to figures from the Plasma Protein Therapeutics Association, an industry body, they were donating more frequently. Today, according to the $2.00 a Day blog, “there are over 500 commercial plasma donation centers scattered across the country, most of which are disproportionately positioned in or around poor areas, where the most likely donors, the impoverished, reside. Of these centers, 100 opened their doors during the Great Recession and almost 200 have opened within the last decade.”

It makes economic sense: the FDA allows Americans to sell their plasma up to twice a week (because plasma contains no cells, the body can replace it within forty-eight hours) and the payment is usually $30 to $50.47 Nowhere else in the world allows people to sell their plasma as frequently as in the United States. European regulations limit plasma sales to twenty-four a year, with at least two weeks between donations.

A 2010 government survey found that up to 58 percent of women in Nepal’s far west regions reported having to live in a shed while they were menstruating.

Anyone writing about menstruation or, as I may call it from now on, the noxious catamenial flow, starts with Pliny. Gaius Plinius Secundus was known as Pliny the Elder and for his multivolume Natural History. There are many wonders in the thirty-seven volumes, but even Pliny admitted that it is difficult to think of “anything which is more productive of more marvelous effects than the menstrual discharge.”14 Human females, he wrote, are the only “animated beings” to have a monthly discharge. He was wrong about that. He was wrong in abundance. On the approach of a menstruating woman, he wrote, nature would cringe and submit. “Seeds which are touched by her become sterile, grafts wither away, garden plants are parched up, and the fruit will fall from the tree beneath which she sits.” Her look, also, is formidable, because it will “dim the brightness of mirrors, blunt the edge of steel and take away the polish from ivory.” She can kill a swarm of bees, turn iron and brass rusty. She can scare away hailstorms and lightning, as long as she is both bleeding and naked. At sea, she doesn’t even need to bleed: a storm will flee before the sight of her unclothed body. What a useful creature. Farmers must employ their menstruating wives with great joy, because “if a woman strips herself naked while she is menstruating, and walks round a field of wheat, the caterpillars, worms, beetles and other vermin will fall from off the ears of corn.”

Over 70 percent of the 747 women and girls surveyed during the Yatra’s travels had known nothing about periods before they began them because their mothers and grandmothers had told them nothing.27 During one of the Yatra stops, I meet Neelam, a fourteen-year-old girl whose mother had died of breast cancer. (She calls it “something rotten in the breast.”) When she started menstruating, she thought it was cancer, because who was there to tell her differently? Nearly a quarter of the MHM tent visitors also said that menstrual blood was dirty. This belief is not unusual. A survey by WaterAid in Iran found that nearly half of Iranian girls and women think that menstruation is a disease.28 In some cultures—Afghanistan, some Jewish traditions—the acceptable reaction to a girl’s first period is to slap her across the face, either as a punishment, because the blood is interpreted as a sign that the girl has had sex, or as a discouragement, so that a slapped girl will not immediately go and have sex with a boy, propelled by her powerful puberty like a jet stream toward sin.

In the Yatra survey, 99 percent of respondents said they faced some kind of restriction when they were menstruating. In the schoolyard in Uttar Pradesh where Khushi and Ankita tell me about periods, they also say this: when we are bleeding, we are not allowed to touch pickles, because we will rot them. This is such a powerful belief in India it inspired Whisper, a commercial sanitary pad company owned by Procter & Gamble, to launch a Touch the Pickle campaign, encouraging girls to break boundaries, smash taboos, and buy Whisper sanitary pads.

To establish whether black bears were attracted to period blood, they hooked used tampons onto fishing lines and cast them past ursine noses, then dragged them back again. The working hypothesis was that bears would be as interested by the tampons as by garbage and other control substances. So would I be, if a fishing line holding a used tampon had come sailing past my nose while I was minding my own business. They also exposed human-socialized bears to menstruating women by having them hang out together. After six experiments in various conditions over several years with different tampons, different women, and different bears, the scientists came to a conclusion. “No bear showed appreciable interest in menstrual odors regardless of the bear’s age, sex, reproductive status or time of year.”

Béla Schick was a Hungarian pediatrician who in 1910–11 devised the Schick test, still used to detect immunity to diphtheria. For that, we are grateful. He was also convinced that menstruating women made flowers wilt. This revelation came to him when he asked his maid to put some red roses in water and was shocked that by the next morning they had withered. She told him she was menstruating. Schick experimented further, giving flowers to menstruating women. The flowers died, quickly. He expanded into dough, getting several women to prepare some and noting that the dough prepared by the sole menstruating woman in the group rose 22 percent less than the others.39 Obviously, he concluded, a woman on her period was expelling not just blood and tissue but some potent chemical that had an abominable effect on botany and bacteria. It was, he declared, “menotoxin.” This also conveniently aligned with old-fashioned superstition and taboos. Pliny was right along with every other vividly absurd and usually male commentator on the corrupting superpowers of the bleeding woman. Women really could slay rodents with what a recent TV writer called our “menses badness.”40 Menotoxin was an attractive idea and an instance of ingenious branding, and it bore much academic fruit. In 1940, the anthropologist M. F. Ashley-Montagu wrote “Physiology and the Origins of Menstrual Prohibitions,” which explored recent research on menotoxin. His list of references was unsettlingly long and predominantly ...

A tampon, as the eminent disgustologist Paul Rozin found, sets off all the disgust alarms: when his research team asked men and women to put the tip of an unused tampon—unwrapped in front of them—into their mouths, 69 percent refused. Three percent wouldn’t even touch it.

Ancient gynecologists decided that hysteria was caused by a uterus moving around a woman’s body.49 How preposterous and old-fashioned. Except it is not. Katharine Switzer, the first woman to run the Boston Marathon, wrote in her memoir that her high school coach—a woman—told her that if women played basketball, an “excessive number of jump balls could displace the uterus.” In 2010, Gian-Franco Kasper, president of the International Ski Federation, said on television (publicly!) that a ski jump could cause a woman’s uterus to burst.50 Women were allowed a competitive ski-jumping event only in 2014. A post on the Public Library of Science (PLoS) blog was headlined, OLYMPIC SKI JUMPING COMPETITION COMPLETED WITHOUT A SINGLE UTERUS EXPLOSION. Unlike men, wrote Dr. Travis Saunders, women’s gynecology is safely contained inside the body.

Today, the average woman in an industrialized country with access to a wide variety of sanitary choices for her menstrual period might use 11,000 to 16,000 sanitary products in her lifetime. Persuasive data on how many women use what are scanty, but a Euromonitor survey of American women aged twelve to fifty-four found they bought on average 116 pads a year, but only 66 tampons.23 Worldwide the absorbent device of choice is definitely external. Insertion taboos stop many women from using tampons: the only thing you insert in there should belong to your husband, and it’s not a tampon. The choices, then, are cloth or a sanitary pad, or towel, or napkin, or whatever we are supposed to call them. Feminine protection (from what?). Feminine hygiene (are we dirty?). Feminine Needs. Feminine Care. Feminine Accessories, as if tampons were earrings. I’d love to see a shop or supermarket that dared have an aisle called Menstrual Products. Blood Absorbers. Plugs and Wads. But plain speaking and feminine hygiene have never been comfortable companions. The advertising of sanitary products on TV and radio in the United States was banned until 1972. Despite one letter writer asking the agony aunt Dear Abby in 1984, “Please tell me what can be done to stop the advertising of personal feminine products on television,” the word period wasn’t spoken on American television until the following year, when a young Courtney Cox starred in an ad for Tampax. The company used the scandalous word, its...

Tampax consistently used the tagline “approved for advertising in the American Medical Journal” as if it meant something other than that someone picked up the phone to the ad sales department. It boasted that Tampax was “perfected by a physician” (not an osteopath). I don’t find any advertising mentioning a letter to the British Medical Journal in 1942 by a female family doctor from Oldham. Shopkeepers had informed her, wrote Mary G. Cardwell, that young girls of eleven, twelve, and thirteen, and young women in general, were asking for these “internal sanitary towels.” She had medical misgivings. Some were using them as a preventive “in conditions of promiscuous intercourse.” But also, these internal towels entailed “undesirable handling of the vulval area.” Many young girls, she wrote, “insert the tampons by the aid of a looking glass. The psychological ill-effects are obvious.”

A single sanitary pad is a luxury item, let alone a box of tampons. I read accounts of girls who have sex with older men in order to earn money for essential items like sanitary napkins. It’s called “sex for pads,” and though it is hidden, it is common. A field officer for one NGO called Freedom for Girls in Nairobi reported that 50 percent of girls she encountered in the slum of Mathare had turned to prostitution to afford sanitary pads.57 When researchers surveyed 3,418 menstruating girls and women in rural western Kenya, one in ten of the fifteen-year-olds reported selling sex for sanitary pads.58 In Ghana, the Girls’ Education Unit of the Ghana Education Service reported that 414 teenage girls in twenty-six districts in the eastern region “were impregnated in the last two years while exchanging sex for sanitary pads.”

In the United States, tampons merit sales tax though condoms, hair-growth products, and lip balm do not.

How different things would be if men had periods. This is an old idea, and never better expressed than by Gloria Steinem in her peerless and perfect 1978 essay “If Men Could Menstruate.” In this alternate world, Men would brag about how long and how much. Young boys would talk about it as the envied beginning of manhood. Gifts, religious ceremonies, family dinners, and stag parties would mark the day. To prevent monthly work loss among the powerful, Congress would fund a National Institute of Dysmenorrhea. Sanitary supplies would be federally funded and free. Of course, some men would still pay for the prestige of such commercial brands as Paul Newman Tampons, Muhammad Ali’s Rope-a-Dope Pads, John Wayne Maxi Pads, and Joe Namath Jock Shields “For Those Light Bachelor Days.” Street guys would invent slang (“He’s a three-pad man”) and “give fives” on the corner with some exchange like, “Man you lookin’ good!” “Yeah, man, I’m on the rag!”