America's Blood Market, Europe's Drug Supply

At 6 a.m. on a Tuesday in McAllen, Texas, the waiting room at Biomat USA is already full [S1]. Most of the people in the plastic chairs are Spanish speakers. They will donate plasma through a machine that separates it from their red blood cells and returns the cells to their arm [S7]. Federal regulations cap donation at twice per week with a minimum two-day interval [S5]. When the session ends, a payment of $50 to $70, loaded onto a prepaid card usable on both sides of the Rio Grande, appears in their account [S1].

What happens next is a nine-month chain of industrial chemistry that most European physicians have never had to think much about.

What the plasma becomes

Plasma is the yellowish fluid that carries your blood cells. It also carries proteins your body manufactures — antibodies, clotting factors, the albumin that maintains pressure in your vessels [S3]. Three of those proteins, extracted from pooled plasma, form the backbone of treatments that are extraordinarily difficult to replace [S3].

Intravenous immunoglobulin, or IVIG, is the concentrated antibody product used for primary immune deficiencies, autoimmune conditions, and a growing range of neurological disorders [S3]. One patient with a primary immune deficiency, treated for a year, requires the plasma of approximately 130 separate donors [S7]. That number is not a quirk of inefficiency: immunoglobulins make up a small fraction of plasma by volume, and clinical dosing requires enough of them to actually modulate an immune system [S7].

Albumin — the protein that keeps fluid in your blood vessels rather than leaking into surrounding tissue — is the standard intervention for liver failure and major surgery [S3]. Plasma-derived clotting factors remain important for hemophilia treatment, particularly in lower-income countries where recombinant alternatives are less accessible [S3].

Recombinant production of IVIG at clinical scale has not been achieved — the challenge is not protein size but immunological diversity: a functional substitute must replicate the antibody profiles of thousands of distinct donors [S3]. Plasma-derived albumin similarly remains the overwhelmingly dominant clinical source globally, and full substitution at scale has not been realized [S3]. The supply of these medicines is, for now, directly pegged to the number of people willing to donate plasma frequently and for pay.

After donation, plasma enters a pipeline spanning 7 to 12 months: quarantine, pooling, fractionation through the cold-alcohol precipitation process developed in the 1940s, purification, viral inactivation, fill-and-finish, regulatory lot release [S6]. A donation in McAllen in January will not exist as finished IVIG on a hospital shelf until late autumn, at the earliest [S6].

The numbers behind the dependency

The United States collects approximately 67% of the world's source plasma supply [S4]. The European Union produces just 12% [S4]. Around 70% of all plasma-derived medicines sold worldwide are manufactured from US-collected plasma [S4]. US regulations permit donation twice per week — up to 104 donations per year per donor — one of the highest permitted frequencies in the world [S5].

The reason for this gap is not population size. It is payment. The EU has enshrined the principle of voluntary non-remunerated donation in its blood directives, with most member states prohibiting direct payment to donors — though Germany, Austria, Hungary, and the Czech Republic permit modest flat-rate compensation under expense-reimbursement frameworks [S4] [S5]. Canada, Australia, and Japan apply similar restrictions [S3]. The WHO's Voluntary Non-Remunerated Donation principle frames payment as exploitation — the concern being that financial pressure, not altruism, drives donation among economically vulnerable populations [S3].

The practical consequence: unpaid European donor pools cannot generate the volume that paid American ones do. Researchers have cited figures suggesting roughly 38% of plasma used for fractionation in the EU is imported from the US [S4]; the share of finished plasma-derived medicines derived from US plasma is likely higher still, given that US fractionators supply global markets [S4]. The European Blood Alliance actively campaigns for increased domestic plasma collection — an implicit acknowledgment that the current arrangement cannot sustain European patients on its own [S4].

The ethical line, drawn at the border

The US plasma industry — dominated by CSL Behring (Australian-owned), Grifols (Spanish), and Takeda (Japanese) — has not distributed its collection centers evenly across the country [S3] [S4]. It has concentrated them in economically depressed zip codes along the US-Mexico border. McAllen, El Paso, and Laredo combined host collection centers from at least CSL Plasma and Grifols Biomat USA, with multiple centers per city [S1]. The business model depends on stable, repeat donors — people who return twice a week because the income matters enough to plan around.

Grifols, headquartered in Barcelona, Spain, operates 17 plasma donation centers along the US-Mexico border, more than any other company [S1]. Its own employees at five Texas centers estimated that Mexican citizens make up 60% to 90% of donors on any given day [S1]. Over 600,000 liters of plasma flow annually from Mexican donors through Grifols' Texas facilities [S8]. Those donors cross specifically because paid donation is unavailable at home — Mexico, like Spain, does not permit it — and because $50 to $70 per session, twice a week, adds up to as much as $400 a month [S1]. Most use it for food, electricity, and diapers [S1].

Pharmaceutical companies acknowledged in federal court filings that donations from Mexican nationals provided as much as 10% of the plasma collected nationwide in the US [S2].

In June 2021, US Customs and Border Protection issued guidance declaring plasma sales by Mexican nationals on B-1/B-2 visas to constitute "work," abruptly banning the practice [S2]. Donations at some border centers fell by 20% to 90% almost immediately [S2]. CSL Behring, Grifols, and Takeda sued, arguing the reclassification was an arbitrary reversal of longstanding policy [S2]. In September 2022, a federal district court in Washington, D.C. issued a preliminary injunction restoring Mexican nationals' right to sell plasma while litigation continued [S2]. As of late 2025, the practice continues [S8].

The Möbius strip

Pause on the corporate geography, because it is extraordinary.

Grifols is a Spanish company. Spain prohibits paying plasma donors [S1]. Grifols operates the largest network of paid-donor border centers in Texas — targeting a donor population from a country that also prohibits paid donation — collecting plasma that will become medicines largely consumed by European patients [S1] [S4].

A German patient receiving an IVIG infusion for a rare immune condition is, in many cases, consuming plasma that came from someone who crossed the Rio Grande because they needed the $50 — a transaction Germany does not permit at home in anything like this commercial form, outsourced invisibly across an ocean [S4]. The ethical prohibition isn't against the transaction. It's against having to watch it.

The delayed fuse

COVID-19 demonstrated what happens when the system is stressed.

Source plasma donations were disproportionately impacted by the pandemic in spring 2020 — centers shuttered, mobility collapsed [S6]. But because the manufacturing pipeline spans up to a year, the shortfall didn't manifest as product scarcity immediately [S6]. Hospitals began quietly rationing IVIG and albumin from early 2021 onward [S3] [S6] — a delayed echo of a donation crash nine to twelve months earlier. Hemophilia patients and immune-deficient patients were caught in a supply hole that arrived well after the emergency that caused it had passed.

The Blood journal published "Shortage of plasma-derived products: a looming crisis?" in May 2022, documenting the structural fragility and warning that "local shortages may have international consequences" given the global dependency on US-collected plasma [S3]. The pipeline, the authors noted, makes the supply chain nearly impossible to manage reactively: by the time a shortage is visible at the bedside, the plasma that would fix it is still months away from existing [S3].

The EU's ethical position on paid donation is not hypocritical in the sense of being secretly wicked. It rests on a genuine principle, applied consistently within its borders. What it is, structurally, is sustainable only because the people making the transaction it won't permit at scale are doing so somewhere it doesn't have to see. The collection centers in McAllen are not an American problem that Europe imports medicine from. They are the supply chain — and the supply chain runs through a waiting room at 6 a.m. where the chairs are already full.