Taboo Trades
Taboo Trades
Plasma with Peter Jaworski
Peter makes the case for paid plasma. I commit basketball treason
Peter Jaworski is is an Associate Teaching Professor in Strategy, Ethics, Economics and Public Policy at Georgetown University’s McDonough School of Business. He has published in Ethics, Philosophical Studies, the Canadian Journal of Law and Jurisprudence, and the Journal of Business Ethics, among others.
Helpful links for this podcast:
1. Peter Jaworski, Bloody Well Pay Them: The Case for Voluntary Remunerated Plasma Collections, https://www.niskanencenter.org/bloody-well-pay-them-the-case-for-voluntary-remunerated-plasma-collections/
2. English, William and Jaworski, Peter M., The Introduction of Paid Plasma in Canada and the U.S. Has Not Decreased Unpaid Blood Donations (July 15, 2020). Available at SSRN: https://ssrn.com/abstract=3653432 or http://dx.doi.org/10.2139/ssrn.3653432
3. Peter M. Jaworski, "Not compensating Canadian blood plasma donors means potentially risky reliance on foreign plasma", The Conversation, https://theconversation.com/not-compensating-canadian-blood-plasma-donors-means-potentially-risky-reliance-on-foreign-plasma-143970
4. Peter M. Jaworski, "Canada should not be spending $1 billion on plasma imports; it should be producing enough to export, and for that, we need to pay Canadian donors", Policy Options: https://policyoptions.irpp.org/magazines/august-2020/why-isnt-canada-a-net-contributor-to-the-global-plasma-supply/
Hey, hey, everybody. Welcome to the Taboo Trades podcast, a show about stuff we aren't supposed to sell, but do anyway. I'm your host, Kim Kravick. All right, so thank you for being here today, Peter Jaworski, a philosopher by training, an associate teaching professor in strategy, ethics, economics, and public policy at Georgetown University's McDonough School of Business, an expert in plasma donation who has written a lot about it, and also has been involved in a variety of sort of legal changes and political debates, especially in Canada surrounding plasma. paid plasma donation that hopefully we will talk a little bit about today. So thank you, Peter, for doing this. It's good to see you.
SPEAKER_00:Yeah, thanks very much for having me. I appreciate you letting me talk to your students about this issue.
SPEAKER_01:Yeah, well, students and hopefully others, right? Because we're putting them out into the world. So hopefully, hopefully others as well. Okay, so can we just start, if you don't mind, with some basic information about plasma? Because, you know, it's not an obvious thing to people sort of why we have a shortage of plasma or why there's an issue about providing sufficient amounts of plasma. So why do we need plasma? In other words, why are we even having this discussion?
SPEAKER_00:Okay. So I actually, I bought these on eBay. So I want to show you. These are all the components of your blood. Okay. This is white cells. These are your white cells. These are your red cells, right? This is what makes your blood red, right? So this is for the law students, right?
SPEAKER_01:This is brilliant. I love it.
SPEAKER_00:These are your platelets, okay? And then this is plasma, right? And then this is a protein found in your plasma called an antibody or an immune globulin. So we'll be talking about these two things. So the the white blood cells and the platelets, they make up about 1% of the volume of like the whole blood in your veins, okay? Interestingly, they're called a Buffy layer, right? So if you watch Buffy the Vampire Slayer, I believe that's why her name is Buffy. That's my own theory. I don't know if that's true. Yes. Then 45% of your blood are these red cells and then the remainder, 55%, is plasma. And plasma is this straw colored liquid. It's like yellow. It's mostly water, but it also contains these like really important proteins and i just have this guy here this is immune globulin right or an antibody that's one of the proteins that float around in your plasma but there's also albumin that is in your plasma that's a different protein and a variety of different clotting factors right okay those three different types of proteins there's also other proteins that are important as well what we do is we ask people to donate plasma and there's two different ways to get that plasma which i'll get to in a second. And then we separate out these individual proteins, and we create plasma-derived medicinal products from those proteins. Those proteins are useful against a number of different problems or diseases that people might have. Some people can't produce their own antibodies, and so they rely on intravenous or subcutaneous immune globulin infusions, like regular infusions, and that allows them to go about their day. For most of us, if we have severe burns or we have some kind of trauma, that's when albumin is useful. And then there are people who have rare blood disorders. The most famous one, I guess, would be hemophilia, but also things like von Willebrand disease. It's like when your blood has trouble clotting or your blood doesn't clot at all. And then we use clotting factors to help with that. So
SPEAKER_01:this is something that you actually mentioned in the appendix to your article that people are often confused about. And that seems right to me. And I myself have always had questions about this, which is how much of the demand for plasma is then for these pharmaceuticals, if you will, that are made with the proteins versus the I guess, plasma transfusions. Is there a use for sort of whole plasma? And if so, what percentage is that? Do you know? I
SPEAKER_00:don't know the exact percentage, Kim, but it's tiny. It's tiny. The amount of plasma that we need for transfusion is so small.
SPEAKER_01:Okay.
SPEAKER_00:Got it. The overwhelming majority of the plasma that is used around the world is used for these therapies.
SPEAKER_01:Okay. Perfect. I wanted to know the answer to that. Okay. So I interrupted you. Sorry. Did you have more on the specifics of the proteins?
SPEAKER_00:Yeah. So here's not about the proteins, but about the process whereby we get the plasma. So there are two major ways. One is called recovered. The other kind is called source plasma. Recovered plasma is you go in for a whole blood donation. And then we, after the fact, separate the plasma from the red and white blood cells in the platelets. And then we can use the plasma that way. The second way is called source plasma. And I have another visual example here. So this is a bottle used to collect source plasma. And on it, it indicates different weights because people can donate more or less plasma depending on how much they weigh. So just to give you a sense of how large this bottle is, it's huge, right? It's really large. Source plasma separates the plasma from the red and white blood cells, but it does that while you're sitting in a chair. And then it keeps the plasma and returns everything else back to you. It takes your body about 24 hours to regenerate plasma. Whereas by contrast, it takes your body about 56 days to regenerate the red and white blood cells and the platelets. So you can donate source plasma much more often in the United States than in Canada. You can do it twice a week with 48 hours in between donations. In Europe, it depends on which country in Europe, but it's basically once a week that you can donate. By contrast, you can donate whole blood once every 56 days. And that's true all around the world.
SPEAKER_01:Okay. All right. So one thing, so let's follow up, I guess, on this discussion about the process, because my guess is that most of the people watching or listening to this have not donated plasma. Some will have, but probably most will not have, but probably a lot of them donated blood and probably they didn't get paid or, you know, they maybe got a little gift card or something like that. So why is it then that we are not... I should preface this by saying that you know Nico Lecetra and Mario Machis, and they are also going to be guests on here. So in fact, we will talk about paying for blood. But what's different about these two processes that make the US, among other countries, mostly able to collect the amount of blood that it needs without paying for it and not able to do that with respect for plasma?
SPEAKER_00:Okay. So I should point out that like every once in a while, we do have shortages of like specific types of blood and sometimes there are shortages of blood as well. And in other
SPEAKER_01:countries there are severe shortages, but yes.
SPEAKER_00:Yes. Right. Yes. And the reason why we don't pay for blood is because in order to manufacture the therapies from plasma, we can do certain things to that plasma that we can't do for purposes of transfusion. That's true both for plasma and for blood. When we transfuse plasma or transfuse blood as a whole, we take all of it, we don't process it, we collect it, and then basically one-to-one we transfuse it to another person. When we're making the therapies out of the plasma, we can do a number of things. For example, we can pasteurize or heat treat the plasma. And heat treatment is effective against viruses like HIV, for example. The most important stage in the process of purification and viral inactivation and removal is the use of solvents and detergents. So the same reason why washing your hands with soap and water is effective against coronavirus is the same reason why that process is effective against hepatitis C, for example, hepatitis B, and a number of other viruses. These are viruses that have a lipid envelope or they have like oil around them and when you introduce soap it breaks up that that oily outer layer and exposes the the vulnerable inside to attack right and so we kill those viruses in the process of making plasma therapies but we can't use those steps for purposes of transfusion right and so that's why by the way we don't pay for blood that's also why we don't pay for plasma for purposes of transfusion, but we do pay for plasma only if we're going to turn it into those therapies. How is it possible that the United States collects enough blood without payment? The answer is that the volume of blood that we need for transfusions has been decreasing significantly almost every single year through superior patient blood management. We don't need a unit of blood at every single surgery anymore okay so the demand has decreased
SPEAKER_01:okay so we so part of it is that we don't need as much blood as we need um for plasma and part of it is that we can treat plasma in ways that we can't treat blood that makes it safer um regardless of the source is that reasonably close
SPEAKER_00:um regardless not regardless
SPEAKER_01:maybe that's an overstatement yeah okay
SPEAKER_00:um that makes it strong we do we do have
SPEAKER_01:We do have restrictions. Yes. Okay. So, but it eliminates some of our worries about certain types of bloodborne illnesses in particular that we worry about with respect to blood for transfusion purposes. Is that better? Okay. Okay, good. You know, I didn't, I forgot, but since you brought up coronavirus, I wanted to get you to speak briefly about the new what I assume is a new use of plasma for treating coronavirus patients now. Can you say something about that? I mean, I have a friend, a co-author who is donating his, so.
SPEAKER_00:Are you allowed to say the co-author's name?
SPEAKER_01:Al Roth. He publicly put it on his blog, so yeah. But Al has donated his, yeah, so. And others, yeah.
SPEAKER_00:Yeah, so here's what we know about convalescent plasma. It's a promising treatment, transfusing people who currently have coronavirus with the plasma of someone who has recovered from coronavirus. The reason why it works, if it works, is because the plasma of the people who have recovered from coronavirus contains the antibodies against coronavirus amongst all the other proteins that are inside of that plasma. And we hope and we have some good reason to believe that that's going to be effective, at least for a certain number of people, right? So we would transfuse that convalescent plasma. Interestingly, the pharmaceutical companies that manufacture plasma-derived medicinal products, they are also working on a therapy against coronavirus as well. And it's the same principle. They want to isolate the specific antibody against coronavirus. They want to concentrate that and then create this. It's also experimental at this point, but a treatment. So one interesting issue is that in order to transfuse people with convalescent plasma, we can't pay the donor. So Al Roth, for example, he is not paid for his plasma donation because they're using his plasma to transfuse into people who have coronavirus right now. However, the plasma companies are paying people and they're paying people more for this specialty type of plasma. So the numbers that I've heard, they range from like$100 to$200 per donation. As opposed to
SPEAKER_01:roughly$50 for regular? Yeah.
SPEAKER_00:It's like$30 to$50 in the United States would be the average.
SPEAKER_01:Would be the average. Okay. So All right, so one of the things I wanted to talk to you about are safety issues. I mean, as you know, there are a variety of arguments that are put forward against paying plasma donors, but one of the ones that is front and center has to do with safety. And I guess we could think about safety on two fronts, right? One being the safety of the plasma supply. Do we worry that paid donors are giving us unsafe plasma? That is an argument that is frequently raised. And then the other is safety to donors, which we can talk about as well. I mean, maybe we should start with the second one because I have a feeling we're going to dispense with the first one pretty quickly. But safety to donors seems worth talking about, right? And so in your paper, I actually pulled this quote just to play devil's advocate with you on page 25, where you say, remuneration demonstrably leads to higher donation frequencies per donor. And critics, of course, would say that that is a bad thing, right? That that is It means that the profit imperative is encouraging plasma collectors to disregard donor safety in a way that wouldn't happen if we did not pay donors. And that right there is an argument against paying donors. So I have a feeling you have a response to that.
SPEAKER_00:So I do. And so first, the average American plasma donor donates 21.4 times per year. That's the average. That's the majority of plasma donors will donate. It's about twice a month. At those rates, there is no evidence whatsoever that that's harmful to the donor. In fact, there have been two separate CIPLA studies that looked at high-frequency donations. However, they only tested up to, I think it was 50 donations per year or 60 donations per year. And at those caps, it looks like there is no additional risk from donating that frequently. Now, typically there are tests for the level of proteins in your plasma that are done in the United States. Those tests are done more frequently in Germany than the United States. I do think that's something that they should do in the United States is test the presence of the important proteins more frequently. So up
SPEAKER_01:to about 50%-
SPEAKER_00:Yeah, I think in the United States, those protein levels are tested once every two to three months, whereas in Germany, it's done much more frequently. I think it's like once every two weeks or something
SPEAKER_01:like that. And just to clarify for listeners, Germany pays plasma donors as well. Is that correct? Okay, right. So
SPEAKER_00:there are five countries that pay.
SPEAKER_01:Germany, the US, Austria.
SPEAKER_00:Yeah. The Czech Republic or Chechnya.
SPEAKER_01:Okay.
SPEAKER_00:Right? And Hungary. Those are the five. Okay. And together, they supply 89% of the entire world's plasma used to make these plasma therapies.
SPEAKER_01:Right. Interesting.
SPEAKER_00:At this point, it's probably closer to 90%. Well,
SPEAKER_01:I think it's interesting what you said about Germany testing more frequently, right? Because, I mean, it's evidence that there are many market models, right? I mean, there are... There are different ways that one can structure a marketplace, either to protect donors or not protect donors. And Germany has chosen, at least in this particular regard, to test donors more frequently and therefore, one might argue, pay more attention to their safety and welfare, at least on this one metric than in the US.
SPEAKER_00:And I think I'd be prepared to say that that's true.
SPEAKER_01:Yeah, okay. But, you know, now I'm done playing devil's advocate and I'm going to argue on your
SPEAKER_00:side. Before you do, Kim, let me make what I think is the most powerful argument. Okay, do it. And it has to do with legally the United States and Canada now to permits up to 104 donations per year.
SPEAKER_01:Okay.
SPEAKER_00:So twice a week, every single week. you get up to 104 donations. In the United States, less than 1% of plasma donors donate at that frequency. So we're talking about a small number of people. However, those people are at the border between the United States and Mexico. So the donors are actually Mexicans who cross the border and sell their plasma regularly, twice a week, every single week, And they're the ones that overwhelmingly give 104 times per year. And CSL Plasma is an Australian company and they are expanding and a lot of their plasma centers are being located at the border. And the reason why Mexicans cross the border to do this so frequently is because$20 to$50 in the United States is like, okay, that's not bad. That's pretty good.$300,$400 a month. That's okay. But in some cities in Mexico, you're talking about a middle class income.
SPEAKER_01:Yeah, right. That's amazing. And so have there been any studies on the health of this particular set of donors that are donating much more frequently or no?
SPEAKER_00:No, not yet.
UNKNOWN:Okay.
SPEAKER_00:Not yet. We have followed some of those donors. Nothing that rises to the level of a proper study. I'd like to see those done. So that is actually the space in this entire debate that gives me a bit of pause. And you see something similar at the border between Austria and Slovakia. Slovakia is an interesting case because it's surrounded on three sides. by countries that do pay for
SPEAKER_01:plasma.
SPEAKER_00:And there are plenty of Slovaks that cross the border into Austria and sell their plasma there because of the relative difference in how far that money goes. But in Austria, you can only donate, I think it's 50 to 60 times per year, not up to 104 times. So it's less of a concern there.
SPEAKER_01:Right, right. You may not know the laws of all the countries, but we just compared Germany and the U.S. Is your sense that the U.S. law on frequency of donation is the most lenient of the five countries that permit donation?
SPEAKER_00:If you include Canada, Canada actually very recently adopted the same frequency as the United States. I'm Canadian, by the way, so that's why I'm about to use we to refer to Canadians. We used to allow once a week... frequency, but we changed that in, I think it's April of this year, to match the American system. So I would like to know on what basis Health Canada, that's our regulatory body, why they changed the American model, but I do trust Health Canada, so they probably know something that I don't know.
SPEAKER_01:Right, right. So, I mean, since you brought up Canada, I would like to talk about Canada a little bit. So, and I guess part of where I see these concerns about the safety of the plasma supply from paid donors is in Canada and in connection with the debates that has gone on. I mean, it's been very heated at various times for, has it been maybe five years since the debate first became very heated about paid plasma?
SPEAKER_00:So it started eight years ago in 2012.
SPEAKER_01:Okay. Okay, time goes much faster for me than I think it is going these days. Okay, and so you'll have to inform me of this. It's hard to follow it sometimes as an outsider. I got the sense that there was some past scandal in Canada that people kept referencing that really seemed to motivate critics of paid plasma. Do you know anything? Can you shed some light on that?
SPEAKER_00:Yeah, so the scandal actually happened around the world. It's called the Tainted Blood Scandal. It happened in the United States as well as in Canada and in the United Kingdom. They're going through, what's that called? They're doing like a, right now there's some government body that's looking into the 1980 scandal. So here's in brief what happened. There were blood products and blood that was purchased from the United States. And so a lot of the blood transfusions that were from the United States, they caused people to receive HIV. So in the 1980s, we didn't know about HIV. That was a brand new virus that hit. And so a lot of people contracted HIV from blood transfusions. However, a more sizable number of people were affected by use of plasma-derived medicinal therapies, namely a product called Factor VIII. Factor VIII, so hemophiliacs used Factor VIII in order to be able to live a normal life, and then they contracted Hepatitis B and Hepatitis C from the Factor VIII product. We found out afterwards, by the way, that the plasma was taken, it was paid plasma, but it was taken from primarily the Arkansas prison system. So most of the plasma used to manufacture Factor VIII products came out of the prison system and in particular the Arkansas prison system. And at the time we didn't have the kinds of technologies. We didn't have the like solvents and detergents and heat treatment until, you know, so early on in the eighties, we didn't have it by the mid eighties. We had it, but we didn't always use it. Right. So a lot of people, and we're talking about thousands. So in Canada, a country of back then, it was like 28 million or 30 million people, something like 35,000 people were infected just about every, Every single hemophiliac in Canada, in the United States, in the United Kingdom, and elsewhere contracted hepatitis B, hepatitis C, if they were using the factor VIII product from the United States. As a consequence of this tainted blood scandal, there were inquiries all over the world, and one of the most significant inquiries all over the world was conducted in Canada. It's called the Crever Inquiry. They put justice... Horace Crever in charge of that. He was a Supreme Court justice in Canada. And he came up with a set of criteria to ensure that something like this doesn't happen again. And amongst the criteria was, one, we need one single national blood operator. This actually generated the creation of Canadian blood services. The Canadian Red Cross, by the way, was kicked out of the country. Oh, really? Yes. Oh, and that's the birth of CBS. The birth of CBS happened after we kicked out Canadian Red Cross because, I mean, part of the inquiry also, we discovered that people knew that some of these products were, and yet nevertheless allowed them. It's a huge scandal. The largest health-related scandal in Canadian history, right?
UNKNOWN:Right.
SPEAKER_00:So the Canadian Red Cross was kicked out. Canadian Blood Services took over. Quebec is always weird. Quebec created its own independent system. So in Quebec, it's HEMA Quebec. In the rest of Canada, it's Canadian Blood Services. Canadian Red Cross was kicked out. So that was one recommendation. Another recommendation that opponents of paid plasma highlight is that blood and plasma, regardless of what use you put it to, should not be paid for. We should only have one day. The other things, the things that people on the other side of this debate failed to mention is that Justice Krieger also recommended that we not import plasma therapies. And yet Canada continues to import plasma therapies from the United States primarily, where of course donors are paid.
SPEAKER_01:Right. So that's actually the thing that always gets to me about this debate. I mean, are people who raise that, are they... uninformed, do they not realize that they're buying their plasma from the U.S. where we pay donors? Or are they being disingenuous? You know, they know, but they think others won't know, and this is a good rhetorical device. Or is their concern something else, and nobody's going to listen to the something else, so they jump on this bandwagon? I'm always puzzled by this
SPEAKER_00:argument. Okay, if I have to... guess as to like the motives of the people on the other side, but only because you're asking me and only because I have to, I would say that they're being disingenuous. Everybody who, everybody is informed that like we get, by everybody, I mean everybody who is commenting about this publicly, everybody knows that we get our plasma therapies, almost all of them from the United States where donors are paid. However, the Canadian public they're not really that aware. So people on the other side continue to raise the issue of safety, which is a non-issue. It's a non-issue. These plasma-derived medicinal products, we haven't had anything in over 25 years now, not a single person has contracted any transfusion transmissible infection from any of these products. That's an unbelievable safety track record, right? So they're perfectly safe, but the thought is that it's easier to convince people to be against paying for plasma domestically, that is within Canada, if you raise the specter of this tainted blood scandal and suggest that something similar might happen now. Something similar will not happen now, Right. But like the vast majority of the Canadian public is not aware of that fact.
SPEAKER_01:Right. But
SPEAKER_00:I have to speculate as to their motives. But you'll notice that like their arguments have shifted over time. So back in 2014, the arguments were about safety primarily. Then a few years later, you know, because the CEO of Canadian Blood Services has repeatedly said that it's safe. that it's safe and that it's equally safe, that it's just as safe. What's his name
SPEAKER_01:again? Graham?
SPEAKER_00:Graham Schur. Graham
SPEAKER_01:Schur, right. Yes, he seems very sensible on this issue anyway, from what I've read.
SPEAKER_00:Yeah, when it comes to the safety, he definitely is. But the argument has shifted to this concern about the impact on unpaid blood donations from the presence of paid plasma or parallel paid plasma.
SPEAKER_01:So they shifted from a safety argument to a crowding out argument? Is that... essentially what has happened? Oh, okay. And so can we talk about that then? Explain the crowding out argument that they've shifted to. So the
SPEAKER_00:intuitive claim is pretty simple, right? Suppose you had a choice. You can either give blood for free or you can get paid to deal with plasma, which do you prefer? And actually, this is kind of funny because when I talk to people about it, most people say, well, I would want to be paid. to donate plasma. I would give blood for free. That's what they'll say. But it's all these other people. Like me, I'm pure. I'm an altruist. It's just everybody else. But this is all I hear from everybody. Hardly anybody. Some people have told me that like, oh yeah, sure. I would sell my plasma rather than give blood away for free. That's the intuitive appeal of this argument. And it it just sort of makes sense. You get paid for one, not for the other. Most people are going to choose the paid option rather than the unpaid option, right? So that is basically the concern. That's the intuitive argument undergirding that particular
SPEAKER_01:argument. Is it that intuitive, though? So, I mean, it does not seem intuitive to me, and I can't decide whether that's because I know too much or know too little, and it could be either one. But I mean, they're two completely separate processes, right? You know, giving blood is, you know, you go, you go to school one day and they're like, Hey, come give blood. And you know, all your friends are doing it. And so you go. Whereas donating plasma, my senses, I've, I've never donated plasma, but my senses that, you know, it takes more planning and they're going to do some tests and it's more time consuming and you're going to be tired afterwards. Are you not? So it doesn't, They just don't strike me as being substitutes. But am I mistaken about that? Are they more similar than I realize?
SPEAKER_00:I am glad that those are your intuitions because your intuitions are exactly right and the intuitions of everybody else are exactly wrong. I love that. And it's partly a consequence of what you just said. It takes a lot longer to donate source plasma than it does to donate blood. To donate blood, it takes like, you can do it during your lunch break. It's like 30 minutes, 45 minutes, maybe an hour to donate blood. It takes one and a half to two hours. Right. To give plasma. Right. That's sometimes even longer than that, right? You're sitting in a chair and it's 40 minutes with a needle in your arm.
SPEAKER_01:Right, right. And this seems to mostly affect women. This is anecdote, by the way, just from discussion. Because every year I ask my students, which of the things we're going to discuss for money have they done, right? And plasma is one that some people have. But a number of women were ruled ineligible because of, I guess, the body weight restrictions. So not everybody can give plasma. And it seems that women are excluded more than men but you know I have a sample of you know 10 so is that
SPEAKER_00:I mean you're right there's Yes, that's right. It's also iron deficiency is more prevalent. Would
SPEAKER_01:be more common in women. Yeah, that makes sense. Yeah.
SPEAKER_00:Yeah. But it is, it is a weight issue. So I think, I don't remember off the top of my head how much you have to weigh, but there's a lot of women who fall under the weight restriction. Yes.
SPEAKER_01:Yes. Some of my students did. At least that's what they reported. Okay. So let's get back to the crowding out argument. I mean, presumably this is something we have data on, right? I mean, what is the crowding out argument borne out by the by the data we have or not
SPEAKER_00:okay so I'm so glad you asked because Yes, we now have data thanks to a paper that I wrote with my colleague, William English, which looks at like actual data, not survey data, not aggregate country level data. So before this paper that Bill English and I, Bill English, who's a Duke graduate, by the way. Yeah, I
SPEAKER_01:was going to say, I feel like I know him, but, or have run into him. Yeah.
SPEAKER_00:I've got my Georgetown basketball, 1984. I've got I'm sorry, I
SPEAKER_01:can't support you in that.
SPEAKER_00:Okay, okay. No, I can't support you in your Duke basketball.
SPEAKER_01:No, I actually can't either. I have to confess that I am a Tar Heel fan.
SPEAKER_00:Whoa. I know. Well, we'll have to edit this out. Luckily,
SPEAKER_01:there's editing.
SPEAKER_00:So let me tell you the history. So here's the kind of evidence that we had in the past. We had an instance in Germany where there was like a paid blood center. So Germany does in fact pay for blood, right? But they have both systems. They pay for blood and they also don't pay for blood. They also pay for plasma. That's fascinating to
SPEAKER_01:me, by the way, that whole, that's a conversation for another day, but the dual system in Germany, I find just fascinating.
SPEAKER_00:I do too. And I'm in the middle of trying to get data from Bavaria because I know I'm chatting with a guy who runs the Red Cross in Bavaria and he's slowly giving me some of this data. So in Germany, there was a paid blood company that paid people for blood and then they went under and appeared. And the German Red Cross could only get back like one out of every eight. of those donors. So that was an instance of an argument in favor of the crab and elk hypothesis, okay? They also conducted surveys in places like New Zealand where they asked people like, hey, what if you were offered money? Would you then donate blood more often? And people were like, ew, oh, if you offered me money, then I definitely wouldn't do it. I'd stop donating blood altogether if somebody was being paid for blood. Okay, so that was like a survey. evidence. And then we had evidence from like Czechoslovakia or the Czech Republic, excuse me. They legalized paying for plasma in 2000. What happened is that plasma donations increased sevenfold and whole blood donations also increased, but very little. So there was a sevenfold increase in plasma donations. with basically no impact on blood donations. But this is again, country level. Now I've gotten more specific data because one of my students, she's Slovak and she actually plays basketball for the Slovak National Women's Team. So I'll be following that team. We can at least agree to root for that team. We can agree on
SPEAKER_01:that. We'll both root for her. Okay.
SPEAKER_00:So she wrote to the people in charge of the blood system in the Czech Republic and got me all of this more fine-grained data. And so I'm able to say that this seven-fold increase in plasma donations happened both for the paid plasma sector as well as the unpaid plasma sector. Unpaid plasma... increased increased yeah right and then bill english and i got data for uh canada and the united states and in our in our in the amount of time that like so what we looked at is the period from i think it was uh 2014 until about 2018 or 2019. that's the time frame when in canada three different centers started Paid plasma operations. There was one in Saskatoon, one in Moncton, New Brunswick. And then there was a center that operated in Winnipeg since like 1984, but they used to only collect specialty plasma. But in 2017, they started collecting all plasma types and they paid for plasma. And then, interestingly, in the data that we got from the United States, there were also three cities that saw the introduction of paid plasma in the presence of ongoing unpaid blood donations. And what we found is that in Canada, every additional 100 plasma collections were correlated with eight to 10 additional blood donations. Additional blood donations. In the United States, we saw The direction of the effect was the same, but it was much smaller, meaning that for every 1,000 additional plasma donations, there were an extra, I think, 12 or 16 blood donations.
SPEAKER_01:And so do you guys have an explanation for what might be driving that?
SPEAKER_00:We have a couple of possibilities. Mm-hmm. One is an advertising spillover effect. That's the one that we're going with. So the paper is under review at the moment. It's available publicly on SSRM.com, but it is under review at the moment. One hypothesis that we have, the one that we think has the most going for it, is an advertising spillover effect. And it goes like this. If you allow paid plasma, that company is going to advertise. But the vast majority of people, when you say, hey, donate plasma, they go, yeah, blood. Right. And it's like, well, plasma is different from blood and people go, yeah, isn't plasma a part of blood? Yes, it's a part of blood, but it's different. Right. So if you were on the bus and you see a sign that says, sell your plasma 20 bucks a 50 bucks, whatever, every time you sell your plasma, some people sitting on that bus go, oh yeah, right, there's a Red Cross blood drive, I should probably give blood. That's our hypothesis.
SPEAKER_01:And is that because, so just to try to get to figure out what we think is operating psychologically here, is it just that people are confused, they show up to donate blood thinking they're going to get paid, or is it just that it makes them aware, ah, blood donation, I should do that? I
SPEAKER_00:think it's the latter and not the former.
SPEAKER_01:Okay.
SPEAKER_00:I think confusion plays some role, but I don't think people who go to the Red Cross, I've not heard of people being like, where's my payment? Where's
SPEAKER_01:my money, right?
SPEAKER_00:Yeah, where's my money? I think it's just like raising awareness. Another possibility is like the more people that are giving either blood or plasma in an area, the more likely it is that you'll hear about it. The more likely it is that you'll know somebody who either sells their plasma or gives blood. And then you're just more, your awareness level is raised. Then you go, oh yeah, sure. I'll go do that. I have a different hypothesis, which has to do with fear, which does not appear in our paper, but it's in the back of my mind, which is there are some people who are just afraid of needles. The more people that you know that give blood or plasma, the less afraid you are, I think. And so maybe that'll get you to donate blood. That sounds plausible to me.
SPEAKER_01:Yeah. Yeah.
SPEAKER_00:We have to investigate these things.
SPEAKER_01:Yeah, right, right. Well, interesting. Okay. So I guess I'm trying to think if there was anything else I intended to ask you about the specific case of Canada. Well, maybe can you bring listeners up to date on where Canada is now in terms of this long and winding road regarding paid plasma donation?
SPEAKER_00:Okay, let me give you a bit of the history too. So back in 2012, there was a company called Canadian Plasma Resources, and they announced that they were going to open 10 paid plasma centers across Canada. And that started the debate. People were really, I mean, most people were okay with it, but there was a small group of people who were really not okay with it. And I'll explain why in a bit. So they started operating with three plasma centers in the province of Ontario. But by 2014, the Ontario government introduced the Voluntary Blood Donations Act, which made it illegal for them to operate, which made it illegal for any commercial enterprise to pay people for either blood or plasma donations. By the way, they exempted Canadian blood services. So it's legal for Canadian blood services to pay for
SPEAKER_01:plasma. Okay, okay. But only
SPEAKER_00:them? But only them. So then this company said, okay, we'll go out west. And they opened a plasma center in Saskatoon, Saskatchewan, and then they were going to open in Alberta. But by 2017, the Alberta government passed the same law that Ontario passed, making them illegal. So then they opened a plasma center in Moncton, New Brunswick, and then they were going to open in British Columbia, but the British Columbia government passed the same law that Ontario and Alberta passed in 2018. So we only have three paid plasma centers across all of Canada. Meanwhile, demand for the therapies made from plasma continues to increase at 6% to 10% per year. And Canada has gone from being 30% self-sufficient in the plasma that is used to make these therapies. We are now 13.5% self-sufficient. The rest we get from American paid donors.
SPEAKER_01:Right, right.
SPEAKER_00:Okay, however, Alberta had a change of government, and they, as of in July of this year, a private member named Tani Yao introduced a private member's bill to repeal the Voluntary Blood Donations Act in Alberta. They are now on break. They resume October 27th. It has gone through a second reading in Canada. It has to go through three readings before it becomes law. At this point, I am convinced that it will become law by November or December of this year. So Alberta, it will be legal to pay for
SPEAKER_01:plasma. To pay for plasma. That's great.
SPEAKER_00:And thank goodness.
SPEAKER_01:Yeah, right. So, I mean, when you're in these discussions and debates, I know you've had many with folks over the Canadian position. I mean, what is their reaction when, when you say, but the result of this is that we just buy all of our plasma from the United States where they pay donors. I mean, do they say something like, well, we should stop doing that and try to use less plasma? Or do they just say, yeah, but we don't care about Americans. I mean, which, you know, Kudos to them for being honest about it. I mean, but what is their reaction?
SPEAKER_00:So one reaction is to try to say, oh, well, what happens in America? Like, who knows? That's an American. That's America's business. That's not our business, right? Right. But I'm like, well, if paying people for plasma is exploitative, then we are participating in exploiting Americans, right?
SPEAKER_01:Right.
UNKNOWN:Okay.
SPEAKER_00:They also respond by saying, so Canadian Blood Services has put forward a proposal to open 40 unpaid plasma centers, and they have asked for$855 million in order to be able to do that. And so they say, we need to give Canadian Blood Services time to open those 40 plasma centers. That will, according to Canadian Blood Services, that will hopefully result in 50% self-sufficiency in just one of these therapies, immune globulin, right? So that's the hope. And so they say we need to give them time to do that. How much time is my response. Separately, I say the average unpaid plasma center collects between 10,000 to like 30,000 liters of plasma per year compared to 30,000, excuse me, 20,000. 10 to 20,000 liters per year. The average paid plasma center in the United States collects 60,000 liters per year. The numbers are so different.
SPEAKER_01:Canadian
SPEAKER_00:Blood Services wants to have an ongoing operational budget of$247 million, and they want to collect 600,000 liters of plasma at full maturity. Well, I crunched the numbers. That's$412 per liter collected. The private Canadian company has offered all of its plasma to Canadian blood services at$220 per liter. That's the most recent offer. It's two to four times more expensive. It's less than half as efficient or productive. There's no difference in safety or effectiveness. There is no impact on unpaid blood donations. It just seems absurd to spend twice as much
SPEAKER_01:Right.
SPEAKER_00:We have other healthcare priorities we should be spending money on.
SPEAKER_01:Especially now. Yes. Yes. Okay. So this actually kind of brings me to a similar question about WHO, which I find they're, I mean, do you have any insight into their position? And I mean, let's just assume that it made sense at the time, right? But You know, but now, right? And I mean, they have the same position on blood. I'm going to, you know, as I already said, Nico and Mario will be on and we'll talk about whether that makes sense. But plasma strikes me as being just much less defensible for precisely the reasons that you've laid out, including that if I understand you right, there is no country that is self-sufficient in plasma who doesn't pay. And unlike blood, unlike blood, right? And so it's, what are they thinking?
SPEAKER_00:Okay, I'm speculating again. Of course, yeah. I have much better insight into the motives and the reasons that people who oppose paid plasma in Canada, why they oppose it. I have much less when it comes to the World Health Organization. I haven't spoken with them. Okay, so one... One theory that I have is that this is a theory that I've heard both from American blood clinic operators and Canadian blood clinic operators, which is a story about the fragility of the culture of altruism. So in order to get the enough blood for transfusion or whatever, we need to have a system where we reward and applaud pure altruism. But altruistic culture is so fragile, especially in the face of commodification. And so if we allow a little bit of commodification into the system, we're going to have to commodify the whole thing because the whole culture of altruism is going to fall apart. So I think the World Health Organization believes that. By the way, there is a condition where some people have too much iron in their blood. I forget what it's called, hemochromatosis or something like
SPEAKER_01:that. Yeah, I forget it too, but I have read about it, yeah.
SPEAKER_00:So the American Red Cross, if they find out you have that condition, will not allow you to donate blood. One thing that you can do if you have this condition, to fix this condition, is to donate blood. It's good for you. It's a win-win, right? But the American Red Cross is like, but if you donate blood, then it's not pure altruism. You're doing it for this like medical... This is, to me, this is such extremism. It just kind of points to this, like the concern about the culture of altruism that it's so fragile that we can't have people benefit from donating blood. Okay, so that's one thing. Here's another theory that somebody has told me about with respect to the World Health Organization, which is this. If they allow paid plasma or if they augment their position with respect to paid plasma, then the low and middle income countries where I would not recommend a paid plasma system because they do not have the safety technology, they do not have the advanced testing, and they don't have those procedures in place, then they're just going to be like, well, then we can pay for blood and we can pay for plasma. And so in order to keep some of the poorer countries from changing those policies, the World Health Organization has adopted, as though like everybody listens to the World Health Organization, which not everybody does, but they have adopted this extreme position to prevent what they imagine would be a repeat of the tainted blood scandal. Right, right, right. So those are... The culture of altruism is super fragile, theory number one. Theory number two is like if you allow paid plasma in advanced countries, then developing nations will respond by paying for blood.
SPEAKER_01:Both of those sound plausible to me and consistent with WHO positions with respect to organ donation and organ trafficking, for example, right? Which is... not to get too much into it but there's there is definitely this notion that that things have to be resisted, not because they are in and of themselves dangerous, but because they might lead to organ trafficking. In particular, it might lead to poor countries saying, hey, well, you know, if the U.S. can do this thing and it's, you know, kind of just like a market, then why can't we just have a market here? And it resonates with sort of their position on organ donation and, again, the preservation of altruism and then also organ traffic This worry that other countries will copy the developed countries but do it badly, essentially, and that that motivates much of what seemed like extreme positions, as you say. Even though we're just speculating, it does sound consistent to me with what one sees in regards to organ donation as well.
SPEAKER_00:I'm trying to have a conversation with somebody at the World Health Organization about this, but they are a kind of distant, non-transparent kind of organization. I have no idea how to even begin to talk to them. As compared to Canadian Blood Services, I've had conversations with Graham Schur. I can talk to people at the American Red Cross, but the World Health Organization is an impenetrable... They might as well be on Mars as far as I'm concerned.
UNKNOWN:Right.
SPEAKER_01:Okay. So, I mean, this is most of what I wanted to talk to you about. Have I forgotten some big thing that we should have discussed and we failed to? I mean,
SPEAKER_00:there's one thing that is worth asking about, which is why is it that in the United States, there is no like organized opposition? the paid plasma? That's a great question. I wish I had thought of that. How come in America, people are like, paid plasma? Yeah, of course.
SPEAKER_01:Yeah, right.
SPEAKER_00:Yeah. But in Canada, there is this organized opposition to it. So why is there this difference? So the first thing that I will say is, there have been three separate public opinion surveys of Canadians at large about payment for plasma. And all three of them find that overwhelming majorities of Canadians are A-OK with like paying for plasma. One of those surveys was conducted by Nico Lachiterra. Nico and
SPEAKER_01:Mario, yeah. I haven't seen the other two, I don't think. Were they?
SPEAKER_00:The other one was conducted by Canadian Blood Services. And the only thing that they will release publicly is that majorities and seven out of 10 young people were in favor of payment for plasma. And then the third one was conducted by myself. So I did a survey of Canadians and we found that like 63% of Canadians are okay. I think that paying for plasma is morally appropriate. That's the question, morally
SPEAKER_01:appropriate.
SPEAKER_00:You can see those at donationethics.com. So why is there this difference between the US and Canada? The answer is that in Canada, the employees of Canadian Blood Services are represented by public sector employees unions. Okay. And private commercial paid plasma centers represent competition to Canadian Blood Services. If we allow a commercial sector, then there will be less pressure on provincial governments to give money to Canadian Blood Services to open more unpaid plasma collection centers. And back in 2012, Canadian Blood Services shuttered a plasma collection center in Thunder Bay because they were collecting like 6,000 liters of plasma per year. But that meant that these people lost their jobs. So the public sector unions are the ones that have pushed this opposition. They fund all of the major organizations that oppose paid plasma in Canada. I have found no organization that isn't funded by them.
SPEAKER_01:You're kidding. I did not. I didn't know that. I did not know that.
SPEAKER_00:Some of them are not secret. Like Canadian Health Coalition is founded and funded by public sector unions. Friends of Medicare, also funded by public sector unions. And then Bloodwatch. Bloodwatch is like the major organization. And they're super secret about where they get their funding. But if you Google, quote, contribution to Bloodwatch, end quote, you'll find like meetings of the Ontario Public Service Employees Union where they're like, we're gonna give$20,000 to Bloodwatch, we're gonna give$10,000 to Bloodwatch and so on. So they fund, So that's where the opposition- For people who
SPEAKER_01:are listening and not watching, I'm sitting here with my mouth hanging open because I'm in shock by this. I mean, that's amazing. So is it all just hand-waving, all the safety and commodification and crowding out? I mean, is it all fake?
SPEAKER_00:Is it all fake? I want to be as charitable as possible. So I will say that for a lot of participants in this debate, They believe it. And I mean, like, so the president of the Ontario Public Service Employees Union keeps saying, they're like, oh, safety. That guy doesn't know what he's talking about. That guy clearly is just interested in preserving jobs. He's doing his job, right? He represents the union. Right, right. He wants to increase the number of people that they represent. So he's, okay. There are, however... at least a few people who are sincere. I've had conversations with them. We have good, healthy back and forths. There are professors who are on the other side of this debate. It took them a while. So I should say, I have never been paid by anyone in the plasma industry. I have never received, I don't own any shares in any of these companies, even though I wish I did. Whether Canada legalizes it or not, it has no impact on my financial... I have no financial stake in this whatsoever. However, in this debate, publicly, people are often just saying that I get paid by the plasma industry or whatever. This is actually what led me to look into... I'm like, even like, who cares that Bloodwatch gets its money from the unions? If the argument is good, the argument stands on its own. But I noticed that like the arguments were not that good.
SPEAKER_01:Yeah, right.
SPEAKER_00:And then the ones that I'm like, oh, well, this is false. Like the CEO of Canadian Blood Services said this is false. Why do you keep saying it? And then they kept accusing me of taking money from them. So I was like, okay, well, you know, let's look under that rock.
UNKNOWN:Right.
SPEAKER_00:That's what I've done. But there are plenty of people on the other side of this debate who are very sincere, who believe in the fragility of the culture of altruism, who believe that the way we shouldn't get this product is altruistically. They think that, well, what about the space for altruism? If we get rid of this space, we'll have fewer opportunities for altruistic expression, although you can always just hug more people. Not in coronavirus. Not now, but yeah.
UNKNOWN:Yeah.
SPEAKER_00:They have some genuine worries about like really poor people
SPEAKER_01:are
SPEAKER_00:going to do this. So there are plenty of people who have good
SPEAKER_01:objections. So I guess I should clarify that I was not suggesting that there aren't genuine arguments that one can make on the other side and that all the people that make them don't believe them, but that the specific actors within the debate overpaying in Canada were perhaps being disingenuous. And if that's the case, I find it less mysterious. I mean, actually, because I mean, now I understand it.
SPEAKER_00:There's a good bootleggers and Baptists story here.
SPEAKER_01:Yeah, right, right, right. Well, thank you so much, Peter, for being on today. I learned a lot and I'm glad we finally got to have this conversation because we talk on email and Twitter, but it's been a few years since I got to talk to you in person and this is what passes for in person now.
SPEAKER_00:Well, I want to thank you very much for having me on, for giving me an opportunity to talk about this really important issue. I did want to close by saying that we are anticipating a shortage of plasma therapies by the end of this year or early next year because there was a 15 to 20% decrease in the amount of plasma donations in the United States. I think that's something that a lot of us should be concerned about. I suspect at least one of your students has a condition that either Either they themselves use plasma therapies or they have friends who use plasma therapies. So I think it's really important for other countries to step up and start collecting plasma before something really bad happens. But anyways, Kim, thank you very much for having me.
SPEAKER_01:Thank
SPEAKER_00:you. The last time we saw each other in person was at Georgetown University. I also want to end with Cleo Saxa.
SPEAKER_01:That's
SPEAKER_00:the basketball
SPEAKER_01:thing. Go Heels!
