The Red Market (17 page)

After showing me around the lab, he leads me to his expansive office downstairs and offers me a cup of spiced chai. When we’re comfortable he tells me that he moved to Gorakhpur from his home state of Kerala to make a difference in people’s lives, but he’s unsure that anything he does with a voluntary blood bank is going to lessen the pressure. In fact, he says other people have come up to replace the Yadhav gang. One week after the police arrested Yadhav, requests for blood at the blood bank spiked 60 percent. But now, a year later, “the demand has fallen off.” There are no new blood banks in the city, and no sudden influx of donors, but blood is coming from somewhere.

Legal blood donation works slightly differently in India than it does elsewhere in the world. Since few Indians are willing to donate through pure altruism, patients are expected to provide their own donors to give blood to a blood bank to replace the pints that they will use during surgery. Once the patient has received credit for a blood donation through a friend, they can draw a matching unit for their own surgery. In theory this means friends and family must step forward to come to the patient’s aid. But the reality of the system is different. Instead of asking their relations to give blood, most people rely on an informal network of professional donors who hang out in front of hospitals willing to give blood in return for a small fee.

Father Antony says that there is little he can do to stop the blood selling. Hospitals are caught in a double bind between saving the lives of patients on the operating table and potentially exploiting donors. From the clinical perspective, when a patient is dying on the operating table, buying blood seems like the lesser of two evils. He tells me that his hospital is too small to attract semiprofessional donors, but all of the major hospitals in the city have them. A good place to start, he says, would be the same hospital that treated Papu Yadhav’s prisoners after their rescue by police.

DR. O. P. PARIKH
, director of Gorakhpur’s Civil Hospital, has donated thirteen pints of blood in his life and would like to donate four more before he retires at the end of next year. Yet he says that he is the exception to the rule. The rest of the city is not as giving as he is. Responsible for the overall operation of the hospital, he says that blood supply is a constant problem. “People here are afraid of donating. They don’t want to exchange blood; they just want to buy it.” And at
1,000, or about $25 for a pint, it isn’t hard to find donors.

Fifty feet outside of Parikh’s door is a string of makeshift tea shops and cigarette sellers who double as blood brokers. After a discreet inquiry with a man with
paan
stains across his lower teeth, I’m told to meet a man named Chunu, who is the resident professional donor. “Just be sure that you trade it in at the bank. He’s got HIV; the blood isn’t always screened,” the man warns before sending me on my way. Five minutes later I’m in an alley behind the hospital face-to-face with a small, bearded man holding a shawl over his head and ears. I tell him I need a pint of B negative blood as quickly as possible.

“B negative is rare and difficult to find these days,” he says. “You can get it but we need to send for it from Faizabad or Lucknow,” two district capitals about one hundred miles from here. He says he could arrange it for
3,000, a high figure. I tell Chunu that I will think about it and leave him outside the hospital gate to speak with other customers.

Civil Hospital’s blood bank is a picture of helplessness. The steel refrigerator containing blood packets is close to empty, with only three packets ready for transfusion. The blood bank’s director, K. M. Singh, says, “Yesterday someone came in and asked for blood, but we had to turn them away. I tell them that blood is not for sale; you have to give it to get it. But they went away and came an hour later with a donor. How am I to know if they paid that person?”

Gorakhpur’s five blood banks can only fulfill about half the required demand. Responsible for providing their own blood for operations, patients sometimes don’t even know that they are breaking the law when buying blood.

The maternity ward at Baba Raghav Das Hospital, the city’s largest government medical institution, is a dismal place to bring life into the world. A coat of translucent green paint on the giant bay windows, put there presumably to reduce the glare, bathes the concrete wards in a sickly light. In the cramped ward about fifty women, still wearing the clothes they brought from home, recover from cesarean sections on thin cots. Some have beds, while others are forced to recline on the concrete floor.

There are dozens of newborns in the room, yet oddly none of them seems to be crying. It is as if the place’s cavelike qualities swallow up all the sound. A woman coddling a baby girl adjusts her robe before removing her own catheter and draining a red soupy mixture into a wastebasket below her bed. Despite the conditions, BRD offers these people a rare chance to see a doctor. The wards are just one of the prices they pay for access to medical assistance.

One migrant, Gurya Devi, has traveled more than one hundred miles from a farming village in the neighboring state of Bihar because she feared there might have been complications during labor. A doctor who never told her his name spent a total of five minutes meeting with her. He said that she would need a cesarean section. As a precaution, he said they would need a pint of blood on hand, and could get a donor for
1,400 (about $30). “It was easy,” she says. “We didn’t even have to think about it; the doctor arranged it all.”

The blood could have come from anywhere.

RELYING ON PROFESSIONAL DONORS IS DANGEROUS
for both donors and recipients. British sociologist Richard Titmuss, whose exposition on the blood trade transformed donor systems in the West, was mentioned in the introduction of this book; he predicted that paid blood would not only create a commercial incentive to lower ethical standards in order to increase the supply, but would decrease overall quality of the blood in blood banks. In his book
The Gift Relationship,
he studied the spread of hepatitis in blood banks in the United States and Europe and anticipated the contamination of the international blood supply by viruses like HIV. While his conclusion, relying only on altruism in blood exchanges, has possibly fueled a black market for human tissue, he correctly illustrated how a financial incentive can force people into making irresponsible health-care decisions.

The blood seller I met outside Civil Hospital was willing to sell allegedly HIV-infected blood to a passerby as long as he made a small amount of cash. It’s not hard to see how the breakdown in blood-supply regulation could fuel an epidemic.

Until 1998 blood selling wasn’t only legal in India, it was a mainstream career option with a powerful trade union and commercial donor rights organizations. When India switched to an all-voluntary policy, the price of blood shot up from about $5 a pint to almost $25, a figure that remains out of reach for many ordinary patients. While the laws changed to make paid blood illegal, the country was unable to create an alternative system. The shortage stretches across all the medical industries that depend on a steady supply of blood. The need for blood components—both red blood cells and clotting factor, which is used to treat hemophiliacs—exploded, and India had to start importing an annual $75 million worth of blood components from abroad. (Oddly enough, many of those components originate from US blood donors. The United States is one of the largest exporters of blood in the world, with an export industry that grosses billions of dollars a year.)

In India the problem isn’t that there is a lack of laws meant to regulate the buying and selling of medical services, but a near total absence of a plan to collect blood in an ethical manner or at a scale that will meet the nation’s needs. The vacuum between legal mandates and police priorities creates an opportunity for a black medical market to flourish.

The free-for-all in Gorakhpur is just an extreme example of a fundamental conflict playing out between private and public medicine the world over. The situation had a parallel in the United States during the transition from the socialized medicine of the New Deal to the for-profit models that have dominated since World War II.

Up until the 1950s in the United States most hospitals were charitable institutions often affiliated with the government. Medical bills were paid out of pocket or were vastly subsidized by the government. The age of for-profit medicine propelled by private insurance policies was only beginning by the time President Eisenhower was in office. But institutions learned that some people would pay a premium for more sophisticated care. Private hospitals staffed with specialist doctors whose advanced knowledge was a scarce commodity started to replace the massive public institutions mostly staffed by general practitioners.

The blood supply went through similar managerial changes. In World War II soldiers on the front line needed massive quantities of blood to help repair their wounds. Highly perishable, whole blood would not keep for a transatlantic voyage. To find an alternative, the Red Cross helped popularize centrifuge technology that could separate red blood cells from blood plasma. Although it doesn’t have hemoglobin, plasma adds needed volume to a person’s circulatory system during surgery, and is a key factor when treating bleeding wounds. Just as important, plasma has a longer shelf life than whole blood and can better survive a long overseas journey. Plasma allowed Americans to donate massive quantities of blood voluntarily, and citizens felt that they were doing something very specific to save a soldier’s life on the front lines. Richard Titmuss was inspired by the United States’ and Britain’s home war effort to aid their armed forces and wrote that blood donation gives the donor a sense of purpose and solidarity in times of national crisis.
¹⁶

During the war, surgeons got used to operating with larger available supplies of blood and developed more complex surgical techniques that greatly advanced the field of surgery. After the war the demand for blood remained high as doctors transferred their battlefield knowledge to the civilian sector. But without a war effort to inspire donation, the country needed a more efficient system for blood collecting.

Between the 1940s and 1960s paid blood collection centers coexisted unsteadily with unpaid voluntary donation spots. The class differences were stark. The paid collection points mostly set up shop near skid-row shantytowns while volunteer programs ran blood drives at churches and maintained welcoming centers in more respectable parts of town. There were clear differences in quality as well. Driven by monetary incentives, paid donors were not concerned with the safety of their contributions, only the paycheck that came after donating. The blood collection points also skimped on cleanliness. Titmuss noted that paid donors had higher frequencies of blood-borne diseases. He wrote that hospitals depending on for-profit blood banks contributed to the spread of hepatitis through transfusions. The instances were significantly lower when people volunteered their blood. Journalists covering blood banks at the time noted that the conditions at the for-profit locations were shabby, sometimes with dirt floors and crumbling walls and “worms all over the floor.”
¹⁷
The focus was on harvesting blood, not the condition of the donor.