It’s a rare commodity in high demand around the world, and one that can’t be imitated or duplicated.

A handful of countries export billions of dollars’ worth of it each year, including to Australia — which cannot generate enough supplies by itself.

And right now, you probably have several pints of it circulating in your body.

Plasma is a light, yellow-coloured component that makes up about half of the blood in our body, carrying life-saving compounds used to treat dozens of medical conditions.

Demand is continuing to surge for the products made from plasma, but the world relies on just a few countries for its supply.

The United States is the biggest of them all.

Why is the United States the biggest plasma supplier in the world?

In the United States, plasma donors can be financially compensated each time they donate. 

The plasma industry is estimated to be worth more than $US30 billion ($45 billion), with private companies offering loyalty bonuses, reward points and large cash payments to entice new donors. 

The ABC compared four social media advertisements from major plasma chains, whose payments ranged from $US30 to $80 ($45–$120) per 880mL donation, with increased payments for repeated and consistent visits or donations during supply shortages.

The commercial plasma industry has helped the United States become the largest supplier of plasma in the world, by far.

Despite making up just 4.2 per cent of the world’s population, the United States accounts for around 70 per cent of all the source plasma in the world blood market, according to most analysts.

The country is so important to plasma supply that other countries have even directly sourced their plasma stateside.

After the outbreak of Mad cow disease in the late 90s, the UK shut down all plasma donations in the country and opened its own plasma collection company in the United States.

The number of plasma centres doubled in the country between 2014 and 2021, with hundreds of them operated by Australian-headquartered biopharmaceutical company CSL. 

In the world’s biggest plasma market, a correlation between those experiencing financial distress and plasma donation is emerging.

Recent US research suggests a decrease in payday loans and increase in foot traffic at nearby stores wherever a new plasma donation centre was built.

Emily Gallagher, a University of Colorado Boulder researcher behind the report, was first drawn to the plasma industry in 2017, when she saw a line of people outside a shopping centre in Missouri waiting to give plasma.

“There was a sign in front of it really advertising itself as a source of income for people,” Professor Gallagher said.

She compared the impact of a new plasma centre opening to the impact of a $1 dollar rise in the minimum wage for the area.

Dr Gallagher’s study concluded people in the US who sold plasma were often experiencing financial distress, more likely under 35, identify as Black, male and more likely to be a parent.

“We found that plasma donors were more likely to sort of be living a bit outside the traditional banking system and more reliant on places like pawn shops and payday lenders,” she said.

The research found plasma donation visits in the US seemed to mirror economic trends, rising after the global financial crisis and dipping during the pandemic when the government sent out stimulus payments to residents.

What’s the situation in Australia?

Unlike the United States, Australia has resolved to generate its blood supply from voluntary, unpaid donations only.

But despite Australia having one of the highest number of plasma donors in the world per capita, there is still a shortfall of one particular plasma product: immunoglobulin.

Former Olympian Michael Klim revealed in 2022 that due to a rare disorder, he required immunoglobulin from the equivalent of six plasma donors every six weeks in order to maintain his ability to use his legs.

As it stands, the only countries in the world that are entirely self-sufficient for immunoglobulin are those that offer to pay their plasma donors.

“Australia is a very high user of immunoglobulin per capita, I think we’re probably in the top three,” National Blood Authority chief executive John Cahill said.

The National Blood Authority administrates Australia’s blood supplies, importing immunoglobulin from four international suppliers — CSL, Takeda, Grifols and Octapharma.

All four companies own plasma centres in the United States.

In 2022-23, Australia imported $399.2 million worth of immunoglobulin to make up the shortfall in supplies, buying plasma products at what Mr Cahill calls “world-best prices”.

Mr Cahill said those long-term supply contracts, along with tight regulation on plasma usage, had kept Australia relatively safe from shortages.

But as the population increases and more clinical uses are found, immunoglobulin demand is increasing at around 8 per cent each year.

As a demand for crucial plasma products continues to outstrip supply, some are asking the question: why aren’t Australian donors paid for their plasma?

What are the pros and cons of paying plasma donors?

For the past 50 years, the World Health Organization has advocated for countries to become self-sufficient on blood supply by only taking voluntary unpaid donations.

“Without a system based on voluntary unpaid blood donation, particularly regular voluntary donation, no country can provide sufficient blood for all patients who require transfusion,” the WHO states in its global blood donation framework.

One major argument against paid plasma donations comes from the theory that paying donors would “crowd out” donors who had already been donating for charity.

The argument would suggest that people who donated for what Australia Red Cross Lifeblood calls a “warm, fuzzy feeling” would be put off by the introduction of money and paid donors.

Australia needs around 800,000 plasma donations each year to meet demands, and almost half of those donations come from just 30,000 donors.

Australian Red Cross Lifeblood spokesperson Jemma Falkenmire said they did not want to risk alienating those lifesaving core donors.

“We really need to make sure that we’re looking after those donors and that they are doing it in a spirit of helping others and that they enjoy feeling good helping others.”

The actual impact of the “crowding out” effect on blood donation has been argued by researchers since the 1970s and continues over the past decade.

One proponent of compensated plasma donations is Peter Jaworski, associate teaching professor at Georgetown University, who said the arguments were missing the bigger picture of plasma donation. 

“The point of collecting plasma is to save patient lives, not to give us an opportunity to express our altruism,” he said.

Is it morally wrong to pay donors?

A major concern raised by critics of paid plasma donations is moral: a fear of vulnerable people being taken advantage of by the commercial plasma industry.

The average plasma donor in the US is under 35, underemployed and makes less than $US20,000 ($30,000) a year.

A report into CSL by Credit Suisse showed the company set up plasma collection centres in poorer areas, particularly towns on the Mexican-US border, where it has launched Spanish-language advertisement campaigns.

According to Dr Jaworski, plasma donors will take home about 30 per cent of the revenue from a litre of plasma, while the company pockets about 5 per cent as profit.

He said that demonising the companies buying plasma or the people being compensated for donating plasma made no sense.

“The issue is poverty, not plasma donation … you don’t make people any less poor by removing an option that puts money in their pocket,” Dr Jaworski said.

He said Australia was still benefiting from the commercial plasma industry while not being directly involved in it.

Is there a safety risk?

Safety concerns have been raised around encouraging people to donate plasma with financial incentives.

If donated blood carries any diseases that could be transmitted during a blood transfusion such as syphilis, hepatitis or HIV, it is unusable and must be destroyed.

The relative risks between unpaid and paid donations can be seen in Lithuania, which offered compensation of around €12 ($19) to plasma donors for much of its history. 

But after joining the EU, Lithuania started to slowly move towards a voluntary donation system, finally achieving a 99.98 per cent rate of voluntary non-remunerated donations in 2020.

In the two decades between, the eastern European country slowly phased out compensation for donations, and in the process got a clear picture of blood quality.

Lithuanian donors who asked for compensation had a significantly higher prevalence of transmissible diseases than those who gave voluntarily, with first-time donors seeking compensation having the highest rate of infections.

While this only applied to red blood donations and not plasma donations, voluntary donors are still highlighted by the WHO as preferred for safety reasons.

“Voluntary donors are recognised to be the safest donors because they are motivated by altruism and the desire to help others and by a sense of moral duty or social responsibility,” the WHO said.

Modern screening processes which test every donation now mean the odds of receiving an infection through donated blood are less than one in a million, according to Australia Red Cross Lifeblood.

Professor Jaworski called the safety argument a “red herring” and outdated, comparing it to a government developing a car safety policy around accident statistics from 1970.

“If safety were really a concern, would Australia still be getting 50 per cent of its plasma from imported sources?” Professor Jaworski said.

US donors can also donate four times more frequently, up to twice a week compared to once a fortnight in Australia.

Professor Gallagher said there was a lack of substantial research on the effects of donating plasma as frequently as the US allowed.

“If you don’t know what sort of price you might pay for this in the future in terms of potential health outcomes, it becomes really hard to know whether it makes sense for you today to go ahead and sell plasma at a high frequency,” she said.

The US Department of Health states on its website that blood volume returns to normal 48 hours after donation.

Australia looks to the future

As immunoglobulin shortages begin to ramp up around the world, the position of some countries towards compensating plasma donors has softened.

Egypt and Ukraine signed commercial plasma agreements in 2020, while Professor Jaworski’s native Canada opened the doors to commercial plasma collection in 2022.

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CSL said in a statement the policy on non-renumerated donations remained a matter for the Australian government to decide. 

“Should there be any changes to legislation or policy governing plasma collections, CSL Behring would work with the relevant authorities to ensure the continued safe and secure supply of blood products in Australia,” a CSL spokesperson said.

For Australia to keep up with demand it will need to encourage 9,000 new plasma donors every month and importantly, keep them donating regularly. 

Around 40 per cent of Australian blood donors will never return after their first donation, with 62 per cent donating no more than two or three times a year.

While Australian Red Cross Lifeblood has ruled out paying donors in cash, it is now trialling giving gifts to donors who make repeated donations.

“The need is growing and at the moment there’s not really any way for us to make it other than people coming in and rolling up their sleeves and donating,” Ms Falkenmire said.

“It doesn’t have to be hundreds of donations like many of our donors, just one or two donations a year might really help boost our supplies.”

To book a blood or plasma donation call 13 14 95, visit lifeblood.com.au or download the DonateBlood App.