International Paying for blood (1) Thicker than water Prejudice and misconception leave the huge global market for life blood-plasma products dangerouslyrelianton America AntiNGbuyerinamarer wath pen ty of wilingsellets, Baran Bahardovst is finding life surprisingly hard. For years he has been tying o pay Canadians for their blood plasma~the viscous straw

52 (international England has dropped from 2m a year 35 yearsagotoLam now. Pharmaceutical plasma is different. tis heat treated or bathed in chemicals to ste- rilise it, reducing associated risks. rhas all ‘manner of uses. If blood fails to clot prop- erly,asinhaemophiliaes,a plasma product helps. A plasma product can restore anim: ‘mune system weakened, for example, by chemotherapy. A complication known as Rhesus disease, in which the blood type of a fetus is incompatible with the mother's ‘was responsible for 10% of stillbirths in America as recently as the 2960s, These days plasma products can save the child Historically, these products were de- rived fiom plasma collected when volun- teers donated whole blood. But demand hhas outpaced donation. So the proportion, ‘of plasma products derived from whole blood has declined from 40% in1990 1013% {in 205, Plasma today is mostly collected ‘via apheresis, a process where whole blood is extracted, spun in a centrifuge, and the plasma is skimmed off. Red blood= cellsare then mixed with an anticoagulant and transfused backinto the donor. Blood donation can take just 205 minutes. Apheresis usually takes atleast an hour. Plasma zeplenishes more quickly than red blood-cells. So donorscan give more at ‘one session, and far more frequently. In ‘most countries whole-blood donors can give around sooml of blood, which yields just 50m! of plasma, at most once every ‘wo months. Plasma donorscan give up t0 Soom of plasma~and in America are al: lowed to do so twice a week. This quickly adds up. In a year a plasma donor could tive over ao litres of the stuff, compared ‘with just u6 litres from a whole-blood do- ‘nor. Mr Bult says paid repeat donors, who hhave been intensively screened, help keep plasma products safe. Buta stigma about paying fr blood lin gers. Sue Lederer, of the University of Wis: Consin, dates it to 1970, when Richard Tit ‘muss published “The Gift Relationship”, 2 ‘book suggesting paid blood was both ethi- cally wrongand less effective thana volun- tary system. Often American’ donors would be compensated not in cash butin chits redeemable at nearby liquor stores, an insalubrious practice nicknamed “ooze for booze" Prisoners could also trade plas- ‘ma or days of their sentences. ‘Then, in the 2980s, half of the world’s tens of thousands of haemophiliacs were infected with rv or hepatitis by contami- nated plasma products. Thousands died from ips elated illnesses. Many argued that paying for blood had encouraged do- rors to lie about dangerous behaviour such asrisky sexor druguse. Official inqui ries took place in Canada and treland. In France and Japan, health officialsand busi nessmen were jailed. In America, pharma ceutical companies. settled class-action lawsuits. The scandal has cast long shad- Paying for blood (2) ig ee eee ‘The Economist May i2th 2038 American exceptionalism ‘Where paying forplasma works TropayDerekttom sasuessfl lawyerin Canada. Twelve years ag0, hhe was roughing tin Arizona, tryingto breakinto the recording industry.Sohe started sellinghisblood plasma. Twicea ‘week, hesatforanhour ina Grifols ‘Biomatcentre,as an apheresis machine swhided, siphoning the plasma out of his blood. Forthis he took home $as."Asa poor person” atthe time, he found that “a huge economic benefit’ Ttwasalso part ofa thrivingindusty. Blood products made up aremarkable -Us%of American exports in 2016. Since 2005 bloodplasma collections have nearly quadrupled. To critics this is ‘evidence of arapaciousindustry coere ing he poor to auctionbits of themselves, tomakeendsmeet In fact, plasma, 90% cof which is water, is quickly replenished. T cepeing pot asta Peper ee tala Eetcige fon ‘d ne oo » a 0 a0 oor aoe) SED ~ Sacrum Pte Tees son ‘ow The British governmentannounced an independentinquiry last November Teremains legal to pay for whole-blood donation in America today. But hospitals. refuse to accept it, Today's plasma, how: ever, is safe from the contamination risks ofthe past. Modern screening and sanitise tion are extremely effective. Graham Sher, chief executive of Canadian Blood Ser vices, a non-profit, says plasma products from paid danorsare “assafe as thosefrom ourunpaid donors Other prejudices against pay-forplas: ‘maare equally deep-seated, Some data, for ‘example, lend weight o the suspicion that itpreys on the poor. American plasma cen: tres are concentrated in less well-off bitsof the country Typically they are in postal dis: tricts where 274% of the population are ‘poor according to The Ecoriomst'sanalysis, ff census data. This is much higher than theaverage American poverty rate of165% The other worry, shared by Dr Sher, is Givingithas no obvious negativehealth cffects-though the longeiermeconse- ‘quences of repeated siphoninghave not ‘been fully studied Stic testing andlater ‘heat-treating ofthe extracted plasma ‘ensures that those with communicable diseases who mightlie abouttisky be- haviour forcash—like drugaddicts—are quickly discovered, and the tainted blood products arenotshared, ‘To focus on the perceived hardship of plasma donors, moreover, istoignore the needs of the patientsithelps. Consider Jim Crone, who asa25 ear oldman ssdieniy ell with GuillainBarré syndiome,an autoimmune disorder where the body besinsattackingits own ‘nerves. Within das, he wasconfined to hospital breathing through a ventilator and neaiy completely paralysed—able0 communicate only by linking, He was treated with invavenousimmunoglobu lin,and nearly a decade later isnow in remission. “Withoutit, would be lad up {na hospital bed in intensive careand fightingformy life quiteffankly” hesays. ‘The World Health Organisation ists immunoglobulinsand coagulation fac ‘ors-both plasma-derived products=as essential medicines. Yet poor countries ate often desperateforthemandrich counties ely on American imports Without financial incentives, supplies are hardto comeby.“I's notin people's nature”, says MrFrom, “to letaphlebo- tomistpoke aneedle in yourarmand suckyourblood out” thatpaying for plasmamay lead toaredue- tion in whole-blood donation. But, if that weretrue, the problem would be intensify ing, as pay for plasma centres have nearly doubled worldwide in the past five years. But Peter Jaworski, of Georgetown Univer- sityis sceptical, suggesting that, anecdotes aside, the evidence shows paid plasma do- nation “does not crowd out voluntary bblood-donation’ Americans, for example, continue to donate as much voluntary blood perhead as do Canadians. ‘The aversion to paid-for plasma carries its own risks. According o Grifols, the geo: ¢graphicimbalance puts suppliesof plasma products at risk. At the plasma industry's ‘main anual conference, held this year in Budapest in March, over-eliance on im: ports from America wasa hot topic. Repre: sentatives from several countries (inciud- ing Canada) recognised they mustdo more to diversify their supplies. Making it legal topay for plasmaisan obvious fist step.The woes of Argentina Tango tantrum Argentina has much in common with yesterday's emerging markets, but ittle in common with today's "AWNING deficits, stubborn inflation, a plunging curren cy, spiking interest rates, dwin- dling reserves and a humbling tum to the IMP. Argentina seemstobe goingthrough adlas sic emerging market crisis, cul- rminating in the government's decision this week to seek a precautionary loan from the fund-an institution that fears Argentina almostas much as Ar gentina fearsit. ‘The country isnot quite repeating its own crisis-ridden his: tory. Argentina today has a reformist government largely in tenton doing the right thing, rather than the populist adminis- trations that blighted its recent past (see Finance section). But its roubles are real. Many wonder if they will spread to other ‘emerging markets, Several economies share one or {wo of its vulnerabilities. Mereiully few share all of them, ‘Argentina's rate of inflation, which exceeds 25%, seems to belong to a Jost world, Only in Egypt, Nigeria and Turkey (amongnotable economies; Venevuela ison different planet) is inflation even in double digits tisnow comfortably below ‘the government's target in Brazil, China and Russia (among, other places) and uncomfortably below it in Thailand, These countries’ monetary authorities have already won the batde forprice stability that Argentina isstill waging, {Inseveral emerging economies, including Brazil, Faypt and India, the government finances are, if anything, worse than in, Argentina. Brazil's fiscal deficit isprojectedtoexceed 8% of GDP. this year, according to the rte, compared with an overall def- icit of 53% for Argentina. But even as these other countries’ governments live farbeyond theirmeans, thei private sectors, are living well within them. For that reason, their large fiscal, deficits have not translated into equally large current account Peay neta deficits with the rest of the world. ‘And although many emerging markets have heavy debts, they donot share Argentina's old-fashioned need to borrow in other countries’ currencies. Almost 64% of Argentina's com- bined government and corporate debt is denominated in dol- lars and other foreign monies, according to the Institute of In- ternational Finance. Among the big emerging markets, only ‘Turkey compares, with 56%. The equivalent figure for Thailand isn, for Brazil only 26%. Letitgo Low inflation, modest current account deficits and limited for eign-curreney debt thus distinguish many of today’semerging markets from the peso~and from their own past. These atti ‘butes do not render them immune from the global financial forces that have rocked the peso. All emerging economies, even the biggest, must still watch the Federal Reserve, rising ‘American bond yieldsand the strengthening dollar with trepi- dation. In many cases their long-term interest rates seem as sensitive to America's central bankasto their own, But their new virtues do give emerging economies more room for manoeuvre. They can ease their own interest rates if borrowing cos ise too much. And if capita flees they can al- low theircurrenciesto fall without the economy faltering. That, {s because they need not worry that a one-off rise in import prices will translate into ongoing inflation or that a weaker ex: change rate will render dollar debts impossible to service. ‘The distinctions between Argentina and the broader group cof emerging markets have not gone unnoticed. In 2008 the country was even reclassified asa “frontier” market by msc, an index provider. But in its struggles with inflation, deficits, dollar debt and depreciation, Argentina’s economy resembles ‘a classic emerging market more faithfully than many econo: ‘miesthatstillarry the label. m Compensating blood donors Blood money ely, “Many countries ban payment for blood plasma. This is mistaken Tres year marks the sooth anniversary of the first suc: cessful human-to-human blood transfusion, conducted by James Blundell, an English ob: stetrician working just across the ‘Thames from The Econ mists offices. Today blood is big business-with global exports worth more, in 2016, than global exports of aeroplanes. But that trade is distorted by the refusal of most governmenisto allow payment to people who sive plasma, blood’s yellowish liquid component. ‘The blood trade today consists mostly not of blood for transfusion, demand for whichis falling as medical techniques improve, butof plasma (see international section). Most of this comes from plasma-collection centres, where it is extracted from whole blood and the platelets and bloo¢-cells are tans- fused back into the donor. Plasma is used to make drugs such as factor VIM, which helps haemophiliacs’ blood to clot, and vaccines forrabies, tetanusand Rhesus disease. Almost5om li tres of it were used in 2015, enough to fill 20 Olympic swim- ming pools. America, the orc of plasma, producesis of those swimming pool equivalents. Forget steel and cars: plasma ‘makes up 1.6% of America's total goods exports. ‘The secret of this success is simple: America lets companies pay people for their plasma, So do the few other countries that »> are good atcollecting the stuf, ncluding Germany and Hunga- ry. Others don't. Big importers such as Australia, France and Belgium have banned payment. In Canada, where the issue is alive debate, the lone company trying to collect paid plasma hhas recently been banned in two provinces and tisks the same inathird. Blood and treasure ‘The aversion to paid plasma rests on three reasonable-sound- ingbutlargely groundless propositions. Thefististhatitis un- safe. Payment might encourage donors to conceal dangerous behaviour-such as intravenous drug use. In the 1980s and 19908, tainted blood productsinfected half he world'shaemo- philiaes with mrv,along with tens of thousands of plasma do- norsin China. But modern plasma products do not carry such risks. They are heat-treated and bathed in chemicals to sanitise them (an impossibility for blood for transfusion). Since the adoption ofthese techniques there has not been a single case of transmission of pv or hepatitis via plasma products. Doc- {rs agtee that plaima products from paid donors are just as safeas those rom unpaid ones. ‘Asecond argument is that, if people are paid for their plas ‘ma, fewer will volunteer to donate whole blood for transfu sions. (Paying for whole blood would be unwise since it can not be sterilised as plasma can.) But there is no evidence that, paying for plasma diminishes the supply of donated blood. ‘Thatis why, in Canada, more than 30 economistsand philoso phers wrote an open letter arguing against bans on paid plas- ‘ma, Americans voluntarily donate as much blood per person, asdo Canadians. ‘A third argument is that paying for plasma preys on the poor. Itis possible that those selling plasma need the money and therefore might give too often. In America plasma donors, can give twice a week; those in Europe can give just once a Se ee aera ane oe oie i ‘ase, but more long-term study would be prudent. ‘Those against allowing payment suggest using voluntary donors instead, Yet every country that does not pay ends up, importingplasma, And the fact that America isby fr the dom: inant supplier carries risks of its own, The dependence on a single source leaves the rest of the world vulnerable to an in terruption of supply To protect their people, therefore, other governments need to diversify their supplies of plasma. Pay- ing forit would make a big difference. m Iran and America Anew deal? ‘Donald Trump's withdrawal from the Iran dealis unlikely to do anyone any good i Fp uo ocala Xam nuclear deal, President Do | nald Trump is counting on rene tion orregime change. Heis more likely o end up with war, (On May 8th Mr Trump did not cut America's ties with the Iran deal so much as take an axe toit, The Joint Comprehensive Plan of Action, asitis known, curtails an's nuclear programme for a number of years and permanently subjects it to intrusive inspections, in exchange for the lifting of sanctions. Mr Trump's withdrawal from the “decaying and rotten” agreement honoured a campaign pro: mise. However, the president was unexpectedly harsh in vow: ing to extend sanctions, not just restore them, and to punish any firm doing business with Iran whereveritis based, Since the UN says that Iran was honouring the agreement, as even its cites allow, Mr Trump has strengthened the argu: ‘ments of foes that America cannot be trusted and thatthe glo: balrulesit claims to uphold are made to be broken. The ques- tion for the other partes io the deal (Russia, China, Germany, Britain, France and the European Union) is: what next? The question for the world as a whole, especially the Middle East, is:what does thismean for Iran’sabiliy to getthe bomb? Em, 4 First tragedy, then Farsi In Tuesday's announcement Mr Trump offered his own an: swers. Hesaid thatheis “ready, willingandable” tonegotiatea ‘new deal that limitslran’s regional aggression as well sits nu- lear weapons, though he offered no plan for bringing that, about. He also issued a veiled appeal to the Iranian people, ‘who he said are being held “hostage” by theirgovernment, to rise up against their oppressors. ‘Avits heart, Mr Trump's plan is based on a hunch about sanctions First it assumes that, with heavier sanctions, iran's, economy will beless able to finance warfare in Iraq, Syria, Leb- anonand Yemen. Yetlran’sbelligerenceisnotthe outcomeofa book keeping exercise. Notwithstanding last year’s street prot: ests, which called for more spending at home, iran finances, tuoops, militias and terrorists because t craves influence and it, perceives threats. Mr Trump set out to intimidate Iran this, ‘weekshe may have leftitmore determined, ‘Second, Mr Trump assumes that economic pain from new sanctions could force Iran to the negotiating table, as it did North Korea. Heavy sanctions can indeed lead regimes to ne- gotiate, as Iran showed in the deal that Mr Trump has now te= jected, But Mr Trump displayslittle sense of how the very ead: ers he has just welched on can surrender wholesale to his, demands and survive. Perhaps that is the point, and his real bet is that sanctions -will bring about economic agonies that topple the regime. The ‘mullahs will not rule Tran for ever. But the Castros in Cuba have withstood sanctions for decades. Iran's theocrats have proved perfectly willingtokeep order by force. Thisnewspaper would welcome an end to Iranian belliger ‘ence and (othe regime itself, but a wish based on a hunch is not a policy, Instead, faced with the probable failure of Mr ‘Trump's scheme, the parties to the deal should strive to keepit alive foras long as they can, One aim is to demonstrate to Mr ‘Trump and his supporters that global rules do matter. The EU_ should, for instance, continue to meet Iranian officials and protestto the World Trade Organisation about American sanc tionsonits companies, asit did 20 years ago when Americaap ied secondary sanctions over Cuba. The otheraimisto hold »» sa, =)