Fernando D., a 35-year-old father of two has crossed the border from Juárez to El Paso to donate blood plasma twice a week, every week, for two years straight. He has a dark scar on both arms where the needle pricks, but he considers it a small price to pay for the $400 a month he earns “donating” plasma in the U.S.

The money helps feed his family.

“I have so many expenses,” he said. “I have to fix my truck. I have to pay the bills of the house. I have two kids in school. It’s a lot. It’s stressful, and I have to make money somehow.”

The U.S. exports $21 billion in plasma each year, relying on donors like Fernando ― one of the approximately 10,000 Mexicans who cross the border each week to sell their blood plasma. That figure is based on internal documents obtained by Searchlight partner ARD German public television from two plasma collection companies. ARD has produced a documentary about the practice.

This story originally appeared at Searchlight New Mexico and is reprinted with permission.

The U.S. supplies nearly three-quarters of the world’s plasma, which is used to make life-saving pharmaceuticals. Some of the country’s most productive donation centers are located at the U.S.-Mexico border ― often within walking distance of an international bridge.

Three multinational plasma collection companies operate in El Paso: Spain’s Grifols, U.K.-based BPL and Australia’s CSL. They lure Mexican donors to the U.S. side with monthly compensation rates that top what maquiladora assembly plants and many middle-class jobs pay in Juárez. Fernando, for instance, earns roughly double what he’d make as a factory worker. Like many Mexican donors, he donates at the highest rate permitted, potentially risking both his health and his border crossing visa.

Internal Grifols documents obtained by ARD show that centers in the U.S. interior receive around 1,000 paid donations a week. But centers at the border, on average, pull in more than 2,300 donations weekly, according to an ARD calculation based on data obtained from two companies over two different weeks.

The company documents also show that the border centers rank highest nationwide in donor frequency: Grifols’ list of centers with the most “top” donors ― those who donate 75 times or more per year ― is led by locations at the southern border. 

None of the Grifols or other centers granted on-site access, and employees who spoke with ARD requested anonymity. Employees of five Grifols locations near the border estimated Mexican nationals make up 60 to 90 percent of their donors each day, depending on the center.

In El Paso, just blocks from the Mexican border, people line up on Paisano Drive outside BPL for the doors to open at 9 a.m. Less than a mile away at the Grifols on Texas Avenue, a steady traffic of donors walks in the front door and out the side door all morning, day and evening. 

Donors are paid on debit cards. People with their elbows wrapped in cotton and first aid tape wait in lines at El Paso’s downtown Walgreens and CVS stores to retrieve the cash, before exchanging the dollars for pesos at one of the many casas de cambio in El Paso or Juárez. 

The science and business of plasma

If the U.S. is the world’s top exporter of source plasma, it’s in large part due to the difference in regulations that help dictate the availability of supply: The U.S. Food and Drug Administration allows donors to donate twice weekly, or 104 times per year, while the Council of Europe recommends a maximum of 33 donations annually. 

In Mexico, it’s been illegal to donate blood products for money since 1987, after the country’s blood supply became contaminated during the HIV crisis.

The valuable components of blood plasma are the proteins it contains. The human body needs time to regenerate plasma, so donation frequency has been a matter of concern for the industry and regulators. 

Dr. Peter Hellstern, director of the Center of Hemostasis and Thrombosis in Zürich, conducted one of the few existing studies on long-term, high-frequency plasma donations. He found that frequent plasma donations, up to 60 times annually, are safe as long as the donor’s health is regularly monitored.

While the FDA requires that companies test donor protein levels before every donation, donor blood is checked only once every four months for immunoglobulin G, the most important antibody ― and there is no defined minimum level. That’s not often enough to ensure a donor’s immune system isn’t compromised, Hellstern said.

“Because of this, the donor can begin having a depletion of important proteins, which defend the body against diseases,” he said.

The companies and FDA say the procedure is safe for both donors and recipients. 

The FDA regulates plasma donations “to assure the safety and potency of the blood product and the health of the donor,” according to an emailed statement. “There are many safeguards in place, including the use of donor screening with specific questions about a donor’s health, testing donations for certain infectious agents, and requiring that plasma-derived products are subject to pathogen inactivation procedures.” 

At the request of Searchlight and ARD, Fernando and two other high-frequency donors agreed to have their blood protein levels tested in a private laboratory in Ciudad Juárez, a study supervised by Hellstern.

The tests, performed by Quest Diagnostics, revealed all three donors had blood protein levels below the norm of the local population, taking their respective ages and weights into account. Christian Cumplido, clinical pathologist and medical director of Quest Diagnostics, reported the results to Fernando in the basement blood bank of the Hospital Juárez in May.

“The chronic nature of the donations and the frequency obviously has resulted in a loss of proteins,” Cumplido told him.

“For example, when you donate plasma, generally they do a purification of these immunoglobulins and they give them to other people, which is great,” the doctor said. “The problem is, if I’m a donor, I need to take care to not enter a state of acquired immunodeficiency.” 

If Fernando wasn’t careful, Cumplido explained, his blood could end up resembling that of someone with an autoimmune disease. The results showed levels of total proteins and immunoglobulin M, a key antibody, below the average range of the local population. His albumin and immunoglobulin G levels registered at the low end of the average range.

“For someone your age, in normal health, it seems low,” Cumplido said.

Human blood consists of 55% plasma; the remainder is red and white blood cells. The plasma itself is 92 percent water and the rest is made up of proteins ― what’s commercially valuable. Among the most prized proteins are the immunoglobulins, or antibodies produced by the immune system, that can be fractionated to produce drugs to treat patients with blood diseases or autoimmune disorders.

Plasma is harvested through a process called apheresis, which can take one to two hours.

Once a donor’s vein is tapped, a machine extracts whole blood into a centrifuge and spins it into its separate components. Red blood cells are mixed with an anti-coagulant and returned to the donor’s body. Plasma is skimmed off to be processed and sold on the world market. 

The U.S. exported 22 million liters of plasma in 2018, 89 percent of which went to Austria, Germany, Spain and Sweden to be fractionated and sold globally, according to Marketing Research Bureau Inc., which tracks the industry. Much of the plasma that is exported makes its way back to the U.S. in the form of medication.

Companies pay bonuses for big donors

Donation centers at the border draw dedicated donors with colorful flyers and Facebook promotions in Spanish and English. The companies’ system of compensation is set up to reward those who come often. 

For example, Grifols offers tiered payments that rise with consecutive donations: $25 for the first, $40 for the second, $35 for the third, $40 for the fourth, and so on. By the eighth or ninth donation, a dedicated donor like Fernando can earn $60. 

“Plasma donors are compensated because of the time and commitment involved in being a regular plasma donor,” Grifols says in a statement. “This helps assure enough plasma to help treat patients around the world who need life-saving plasma medicines. It can take as many as 1,300 donations to treat just one patient for a single year.” 

At BPL, compensation increases with each second donation in a week, and the company offers bonuses for reaching the sixth and eighth donation in a month.

“Each of our centers is operated in strict accordance with all FDA and industry requirements,” BPL says in a statement.“We are proud to support the creation and manufacturing of lifesaving drug therapies and are committed to following all applicable guidelines that exist to promote the safety of both plasma donors and the patients who use plasma derived therapeutics.”

CSL pays donors based on body weight, which determines how much plasma can be collected —between 625 mL and 800 mL per session, according to FDA rules. Donors who weigh between 110 and 149 pounds receive $20 per donation, while someone weighing 175 to 400 pounds can earn up to $40 per donation.

“Plasma collection is highly regulated by laws that are enforced by numerous state and federal government agencies in the United States, as well as by international regulators,” CSL said in a statement. “We work hard every day to ensure the safety of donors, employees and the plasma that we collect, which is ultimately manufactured into critically needed therapies for individuals suffering from a variety of rare diseases, allowing them to lead a more healthy life.”

Both Grifols and BPL advertise earnings of more than $300 monthly; with frequent donations and earned bonuses, donors can make up to $400 a month.

The average wage in Chihuahua state, which includes Juárez, is about 8,000 pesos monthly, or less than $450, according to Mexico’s labor bureau.

Prepping for plasma

Some months, Fernando says he can make as much donating plasma as he would working construction. He can earn $80 a day laying tile in El Paso but is careful not to take jobs too often, so he doesn’t get caught violating the terms of his border crossing visa. The construction work he picks up in Juárez pays just 300 pesos per day, or $15; groceries can cost 600 pesos a week, or two days’ pay, he said.

He eats a breakfast of champion donors: three eggs and beans cooked without oil. He won’t touch coffee or milk, flour tortillas, pan dulce or anything rich that could cause fats to show up in his blood and make him ineligible to give. Plasma centers recommend donors avoid foods high in fat or sugar to ensure the quality of the plasma. 

“I even bought new pans ― Teflon, no oil,” he said. “Several times I went and they didn’t let me donate. I don’t want to risk them telling me I can’t donate. So I know exactly what to eat now, and I follow that recipe.”

Mexicans, including Fernando, typically cross using the B-1/B-2 visa ― known in Spanish as the visa laser ― a scannable identification card that allows its holder to travel for a limited time in the borderland. It’s the most common visa issued by the U.S. State Department to Mexican border residents.

The State Department says the border crossing card is not to be used for making money on U.S. soil: “Generally, an exchange of goods or services for remuneration in the United States is found to be inconsistent with permissible activities on a B-1/B-2 visa,” a representative said in an email, adding that explicit provisions relating to plasma donation do not exist.

U.S. Customs and Border Protection, whose officers process people crossing the border, says plasma “donation” for compensation is a gray area. 

“If people are using a B-1/B-2 visa to cross the border and earn money selling plasma, they could put that document at risk,” said Roger Maier, CBP spokesman for the El Paso field office. “The B-1/B-2 visa is not a document that allows someone to work or live in the United States.”

From the industry’s perspective, the border crossing card “confirms the individual is in the U.S. legally,” according to an emailed statement from the Plasma Protein Therapeutics Association, a lobby group that represents, among others, three companies that operate facilities in El Paso.

“That individual can donate plasma and receive compensation for that donation if he or she meets all other health and residency requirements for plasma donation at that center,” the PPTA wrote.

Given the cross-border nature of the donations, “often, donors only receive information describing health risks and possible side effects from the plasma donation center, while any physicians they may see are unaware a patient is a frequent donor,” said Dr. Kristina Mena, El Paso campus dean of the University of Texas Houston School of Public Health.

“Since they receive compensation per donation, they may feel pressured to donate often based on their financial situation,” she said. “These issues of this common practice should prompt a public health conversation within our region, as it incites ethical concerns.”

Despite the doctor’s recommendation that Fernando cut back on his donations to raise his blood protein levels, a few months later he was still donating twice a week, every week. 

“I keep it up because I don’t have a steady job,” he said. “The gigs I get come week by week, but the plasma donations are a sure thing.”