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

by Rose George

But they had not thought it necessary to prepare any blood. In 1937, the secretary of state for war had been asked what the nation proposed to do about a mass blood supply. He said, “It is more satisfactory to keep our stores of blood on the hoof.”95 He meant that the best way to store blood was how nature intended: inside a human body. By the beginning of 1939, a single emergency blood depot had been set up in a bombproof building in the outer London suburb of Cheam. It was a depot in name only, with a capacity to store 1,000 pints, but empty. Planners expected it could be stocked within seven days of hostilities. Until then, the actual emergency blood supply for a city of several million people consisted of the stock kept by four London county hospitals for urgent maternity use: eight pints.96

But even now, in a year that felt like war was coming, there were no government plans to store blood. She thought this dangerous. She would not be exaggerating, she said later, to say that blood transfusion in war was as important as bandages.

No other military facing war had such a plan, and no other military in the war had anything as successful as the Army Blood Transfusion Service. For a logo, the army chose a vampire bat.

The drivers were anyone willing to drive Wall’s ice-cream vans full of blood through bombs and blacked-out streets. Most were women.

She fought to have women’s colleges accepted as full Oxford colleges, and she increased the intake of science and medical undergraduates at Somerville. Early on, she made sure to employ women as her research assistants and, going flagrantly against custom but forcefully in the direction of fairness, kept their jobs for them if they had children. She served on great and good councils, but also, when flu broke out, carried trays of food to sickly students.

She was establishment, but a socialist to the end.

It was not granted to Percy Oliver, nor was much recognition. Perhaps medical eyebrows continued to be lifted at the truth: that the modern blood supply system was built on the shoulders of a layman and a very naughty little girl.

MSF arrived in Khayelitsha without intending to stay, fourteen years ago, to set up a clinic to deal with HIV. It is still here because so is HIV. The virus is believed tamed in the richer northern countries of Europe and North America, but outside those places the epidemic thrives. Only now it is an epidemic of women.

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!

That he has come back makes him unusual: men are notoriously difficult to get into health care clinics, anywhere.

The state of Texas has laws that have been used to jail people for transmitting HIV by spitting, something that is biologically implausible.

Adults are getting tired of taking drugs, especially when they feel well. Children who grew up with HIV who become adolescents do what teenagers do: they rebel. They stop taking their drugs. It is horribly easy, as MSF pediatrician Ann Moore explains to me later, to create resistance. To protect against resistance, anyone on ARVs must take them 95 percent of the time. I ask her to translate this into doses. Does that mean missing a few doses? No, she says. It means you can risk missing only one a month. This is chilling. Who has never cut short a course of antibiotics or skipped some tablets? Missing one dose a week is a reduction of 12 percent, so a definite danger zone. She tries to explain how this works biologically—it has to do with how the virus mutates—but if I find it taxing, I wonder how they convey that to a teenager. Probably this is why the message to the newly HIV-positive can perhaps seem blunt: take your ARVs, every day, always and forever.

For some reason ARVs make them want spicy food, chocolate, all the bad good things. And they want them all the time. An MSF doctor tries to explain this to me: it’s about calories not working as they should and about what antiretrovirals do to the metabolism. What Eric and Lisa know is that ARVs make you really, really hungry.

South Africa had the highest prevalence of HIV in the world and he assumed that its government would be desperate to find a solution and a treatment. He expected open arms and he got a fist instead. Because this was the time of Comrade Undertaker and Doctor Beetroot. Comrade Undertaker was President Thabo Mbeki. “Comrade” because of his stern demeanor and the Communist leanings of the African National Congress (ANC), the governing party of South Africa, and “Undertaker” because Harvard academics have calculated that Mbeki’s refusal to believe that HIV caused AIDS and to provide antiretrovirals has led to the deaths of at least three hundred thousand South Africans. Doctor Beetroot was Dr. Manto Tshabalala-Msimang, Mbeki’s health minister, a woman who told South Africans dying in their hundreds of thousands—including the president’s spokesperson—that antiretrovirals were toxic and that they would do better to treat HIV with diet. At the huge AIDS conference in Durban in 2000, the government stall displayed beetroot, garlic, and African potatoes because this is what Tshabalala-Msimang proposed to treat HIV. It was a shock. Mbeki as vice president had shown no signs that he believed HIV was not related to AIDS, or that ARVs were toxic, or that AIDS was nothing more than a disease of poverty. In 1999 he became president, and—so the tale goes—was on the Internet late one night and found a quack denialist site and made it truth. The government began to support the use of multivi...

The vacuum of ignorance has plenty of room for quackery. Any pandemic unleashes the same mixture of terror and ingenuity.

In 2001, Andrew Natsios of the US Agency for International Development told a US government committee that rural Africans would not be able to take ARVs because they “do not know what watches and clocks are. They use the sun.”25 (Later studies showed that sub-Saharan Africans were better at taking their medicine than Americans.)26 Strict patents prevented the use of generics. TAC launched a Defiance Campaign against Patient Abuse and AIDS Profiteering, and activists flew to Thailand to bring back cheap generic antiretrovirals in their luggage, their hand baggage, and their pockets. TAC launched a court case against the pharmaceutical industry’s punitive pricing of AIDS drugs, and won.

SIV-cpz became HIV-1 Group M, the source of the deadliest pandemic in history.

The way the virus works in younger people makes matters worse. An adult who goes off medication, says Bernheimer, will “kind of get sick, kind of get sick, get sick, get sick, and then die. Children are fine, fine, fine, fine, fine, fine, fine and adolescents fine, fine, fine, fine, fine, fine, fine, and then they fall off a cliff and they get really sick really quickly.” There is very little time to pull them back. The mortality rate for all other age groups with HIV has decreased by about 30 percent over the last ten, fifteen years, he says. “But in the same time period, the mortality rate for adolescents has increased by about fifty percent.”

I expected more hope and optimism in South Africa. I was fooled by the cheerful version of HIV, the one presented in northern Europe and America. In this version, stigma has been banished (this is untrue). Hardly anyone is infectious (mostly true). Monogamous people, men and women, can take PrEP, a magic pill that will prevent infection. Everything is under control.

There are more than thirty antiretroviral drugs available. But there are more than a quadrillion HIV genomes on the planet, in Racaniello’s estimation. How much is a quadrillion? Too many zeros to understand, so it is shortened to 1015. The math doesn’t really matter as much as this: that among that quadrillion are genomes resistant to every drug we currently have, and HIV continues to mutate.

But Goemaere is dismayed nonetheless by what he calls “a sort of benign neglect.” When he attended the high-profile AIDS conference in Paris in 2017, he was shocked that the French president “didn’t even show up.”

For Eric Goemaere, there will be no true solution for years. “No pandemic has ever been solved without a vaccine,” he says. That is years away. As long as girls have blessers and older boyfriends, and boyfriends have many girlfriends, and men rape, there will be new infections, and prevention and treatment are like pouring water into a sink with an open drain.

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.

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.

hemophiliacs are still rare enough that most people are unlikely to encounter one. A hundred years ago, they would have been rarer because they died young.

Hemophiliacs are born with a genetic abnormality inherited from their mothers that prevents blood from clotting. It used to be accepted that women only carried and passed on the faulty gene responsible. But now we know that women can be bleeders: either mild hemophiliacs, with a chromosomal abnormality that means they lack necessary clotting factors; or with genetic abnormalities such as von Willebrand disease, which cause clotting derangement.

How do you make blood safe? According to the World Health Organization, you take it from volunteer donors who are not paid and who have no reason to lie about their health. Plenty of studies show that when donors are paid, they are more likely to lie about it. Obviously they do: they want to keep getting paid. Paid donors are also more likely to come from sections of society that have poor health to begin with. But the US blood supply has always rested on commerce and transaction. After the Second World War, countries such as the UK, France, and the Netherlands developed a non-remunerated blood supply, often run by a single government entity. The United States did not.

it was only in 1978 that the FDA required all blood to be labeled as paid or voluntary donation, and payment for blood died out.17 But payment for plasma did not.

During the war, more than seventy thousand American inmates gave blood to the Prisoners’ Blood Bank for Defense.19 For the next two decades, there were enterprising efforts to rehabilitate or coerce or coax prisoners into better behavior by using their blood. In the 1950s, writes Susan E. Lederer in Flesh and Blood, “prisoners in the Virginia State penitentiary received days off their sentence for each pint of blood donated.” Prisons in Massachusetts, South Carolina, Mississippi, and Virginia offered prisoners five days off their sentence for each pint of blood given.20 Prisoners were used to giving up body fluids for profit; they would be a rich pool for plasma.

They also harvested plasma from poor countries. As Douglas Starr writes in Blood, the Nicaraguan dictator Anastasio Somoza had shares in Plasmafaresis, a plasma harvesting company in Nicaragua, which sold plasma to the United States. Locals called the facility “the house of vampires.”

New York Times reporter Richard Severo, who exposed the unpleasant trade in poor people’s plasma, wrote in 1972 that the company was shipping 6,000 liters a month, and looking to expand. Haitian sellers had the motivation of being desperately poor. They also had one of the lowest caloric intakes in Latin America, as well as alarming rates of tuberculosis, tetanus, gastrointestinal diseases, and malnutrition. Hemo Caribbean’s technical director, a Mr. Thill, said that “few if any diseased persons slip through,” and even if they did, even if they had venereal diseases or malaria, he was confident that the freezing process killed such bacteria.

By 1980 in the US, payment for blood had come to be seen as unethical. But 70 percent of the country’s plasma came from paid sellers and no one saw anything wrong with it. BPL did not act upon Dr. Allen’s warnings. Hemophiliacs had no intention of giving up Factor and going back to endless hospital stays. They wanted it for three reasons: It gave them a life. They didn’t know about hepatitis C. And no one had told them about HIV, insidiously making its way to being a global pandemic.

By 1983, the UK government knew that there was HIV in the blood supply. So did the plasma industry: memos discovered by hemophiliacs suing the giant pharmaceutical company Bayer, which owned the plasma fractionator Cutter Biological, show Cutter managers acknowledging in 1983 that “there is strong evidence to suggest that HIV is passed on to other people through … plasma products.” Later in the year, Cutter staff predicted a “gigantic epidemic” among hemophiliacs.27

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.

By the mid-1980s, heat treatment was adopted as standard, but some companies continued to export their old, unheated inventory.

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.

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,” wrote an unnamed civil servant in the Department of Health’s Finance Department a few months later, “the maintenance of the life of a hemophiliac is itself expensive, and I am very much afraid that those who are already doomed will generate savings which more than cover the cost of testing blood donations.”38 Cheaper than chimps, cheaper when dead.

Nowhere else in the world allows people to sell their plasma as frequently as in the United States.

The literature into long-term health effects of frequent plasma selling is “not rich,” he says,

“The practice of medicine is a political act however you choose to do it.”

Pathogen inactivation techniques are sophisticated and widespread. But population growth, deforestation, and climate change are all pushing humans and wild animals closer together. Viruses like that; they like to jump. We can inactivate only the pathogens we know about.

The unhysterical Lancet Haematology wrote a recent editorial on “the big business of blood plasma.” The financial incentive, it read, “can encourage lying during medical screening and could adversely affect the health of some of the donors as well. With some companies pooling hundreds of thousands of donations together for processing, this can be an important safety risk.”

Only 250 of the 1,500 British hemophiliacs infected with HIV are alive.

I understand why hemophiliacs call themselves the “shut up and die” community: wait long enough, as some governments have, and probably there will be no one left to complain.

He is sure that the British authorities who gave tainted factor to hemophiliacs without telling them and when they knew it wasn’t safe are stalling. They just have to wait sixteen more years and all the infected will be dead, of hep C or complications from HIV, of tainted plasma protein products or what he calls “manky blood.” It’s just math now. But they’re not gone yet. And they’re not done with wanting to know why something that was supposed to be safe, and that was supposed to give them life, gave them death instead. So “for that last little bit,” says Bruce, in his unsettlingly quiet tones, “we’re going to scream blue murder.”

Other species don’t bother menstruating because they retain their womb lining. We are in a minority among species, and among mammals, to bleed every month. The only other animals known to menstruate are apes, Old World monkeys, the elephant shrew, and four varieties of bat including Desmodus rotundus9 (which I cite because it is a vampire bat, and its name means “two-thirds of the way around”).

The editor of one edition of the Natural History adds a footnote to say that Pliny’s accounts are “entirely without foundation.” But they were built upon centuries of belief about the power of the menstrual woman and others built upon them in turn. It’s telling how many of the Pliny powers were judged to be witchcraft. Menstruation must have been unsettling. How could women bleed and not die, when men bled and did?

In 2005, the Supreme Court of Nepal made chaupadi illegal, without providing any mechanism to prosecute people who continue it.24 So it thrives regardless and in enough accessible places for Western media to have become enthralled by it in recent years. They seem less enthralled by the fact that Nepal’s menstrual taboos are so far from being eradicated, they are celebrated with a national holiday.

Rishi Panchami enrages many educated Nepali women. It’s not so much the superstition but the legitimacy that the government gives it by providing a holiday that declares women to be dirty and polluting. Why can’t the festival simply celebrate women instead? Privately, female Nepali sanitation activists tell me that their male colleagues—even in NGOs that campaign against menstrual taboo—see no need to object to chaupadi or Rishi Panchami because it is tradition.

(Anyway, female astronauts usually opt to suppress their periods in space. You would, wouldn’t you?)