With hospitals unable to supply enough free blood for operations, both private vendors and hospital staff are getting in on the act.
By Ekaterina Terzieva and Albena Shkodrova in Plovdiv and Sofia**
"You will recognise them easily," a source said of the blood vendors. "They dress in shabby clothes and hang around, pretending to go past places by accident where no one could possibly pass by chance."
And there they were, at the back of a regional hospital in the outskirts of Plovdiv. Just as our informant suggested, they were pretending to accidentally pass by the entrance to the blood center, surrounded by woods.
There were a half-dozen poorly dressed people. Seeing us approach, a young man came up and asked, "Are you looking for blood?"
They turned away in disappointment on discovering we were journalists, but two of the older ones agreed to talk: selling blood was the only way they could survive, they said. One donation a month doubled their monthly income of 50 euro, helping them to feed their families.
Selling blood in Bulgaria is illegal. A state system, based on voluntary donations, is obliged to supply all hospitals with all the blood and blood products they need. But in recent years the number of donors has fallen sharply and the shortage of blood has grown. This has created a new market, in which thousands of poor people sell their blood anyway.
An investigation by Balkan Insight reveals that hospital staff are also involved in this criminal activity.
In a Plovdiv hospital, we found low-level health officials, including sanitary workers, technical support and security staff involved in an organised trade, offering an easy, but often expensive and illegal solution to people in need.
In their own, internal system, parallel to the one of the street vendors, they sell their blood to people in need.
We went undercover to see how the system worked. On October 10, we approached the security guard on the door of the Accident and Emergency department of Plovdiv hospital and asked for blood.
"One moment," the guard replied, disappearing for 15 minutes before returning with a middle-aged woman in nurse's uniform.
The nurse took us to a secluded spot in the car park and explained that she was new, so it would be the first time she sold blood.
With a monthly salary of only 160 leva (80 euro) she urgently needed to supplement her income, she maintained. Many of her colleagues did the same, she added, listing a series of names of people from the morgue and from other departments. Several days ago, a colleague had sold blood to a woman from Sofia for 80 leva a unit, she added.
A second visit backed up her account. In response to another request for blood, hospital and parking staff rushed off to find a donor, evidently hoping to get a cut. It was obviously routine, as if everyone knows by heart the right lines and gestures.
The man who finally came down to "donate" on this occasion was dressed in a technician's blue overall and said he had given blood more than 30 times. The money was to be paid to the guard.
This price - 100 leva - was a bargain, it turned out. At other hospitals, donors are said to charge six times that amount. The most expensive blood is in Sofia, where one unit may even cost 250 euro.
Hospital managers deny all knowledge of these transactions. At Plovdiv, the director, Georgi Yordanov, gasped, "Is it true?" when informed about this trade on his doorstep.
In an interview for BIRN Yordanov said he was only responsible for staff conduct within working hours and on hospital premises. Nor did he condemn the involvement in his staff in blood trade. "Although they are probably acting illegally and seeking financial gain, these people are also doing something extremely humanitarian," said Yordanov.
A LUCRATIVE TRADE
In theory, the state is obliged to supply enough blood to all hospitals, and patients who have paid into social security should be taken care of, for only a symbolic payment.
In practice, there is an acute shortage of blood and when patients need transfusions, hospitals mostly ask the relatives to donate a quantity of blood, or make a "donation", which often happens to cover the price of the relevant quantity on the black market.
The law is far from clear-cut on the matter of these patient payments. It does allow donors to seek and receive "symbolic presents", for example. In reality, the sums sought are far more than symbolic.
No one knows exactly how much blood is being sold illegally each year in Bulgaria but the statistics concerning legal, voluntary donations highlight the extent of the problem.
According to the health ministry, the quantity of donated blood was 73,066 litres in 1993. By 2003, this had dropped to less than one-tenth of that figure, to 6,549 litres. Assuming demand remained roughly constant, the difference of 66,500 litres has been covered by the black market. If the average price per unit is about 50 euro, it suggests the trade is worth
between seven and eight million euro a year.
WHERE ARE ALL THE DONORS?
Many experts attribute the shortage of blood to changes in people's perceptions concerning their obligations to society. Since the fall of the communist system and the transition to capitalism, the practice of voluntary contributions has gone into decline. In spite of that, the politicians have left the old system of regulations for donation in place, forcing the deteriorating health system to rely on good will.
The old bonuses offered to donors in communist era, such as chocolate, or coffee, have lost their attraction now they are no longer seen as luxuries. Pride in being a good citizen, which drew many donors to the blood centres in those says, has also declined.
At the same time, the HIV/AIDS epidemic in the 1980s created new fears about blood and the use of needles - even though no accidents concerning infection have been reported in Bulgaria in the last five years.
"The state no longer possesses the power of the old regime to put all soldiers in the army in rows and make them donate," said Zelma Almaleh, the Sofia-based NGO International Healthcare and Health Insurance Institute.
"But what was perhaps most crucial in reducing the numbers of donors was suspicion about how people's blood is being used."
Almaleh says mistrust of the state and the healthcare system in particular caused many Bulgarian donors to withdraw their services.
The number of donors speaks for itself. From 257,175 in 1990, it fell to 148,041 in 2003.
Parliament discussed the problem in 2003 and 2006. But blood donation has remained a voluntary, humanitarian act. Instead of paid donations, which some deputies wanted, parliament set up new controls to guarantee proper treatment of donations.
Almaleh, whose institute tackles healthcare policy, says current national legislation is, in fact, fully in harmony with EU norms. The real problem is inefficiency.
Currently, five blood centres throughout the country collect blood and then distribute it to some 217 state hospitals. Once per year each hospital orders a quantity of blood to supply its work for the coming 12 months. This is supplied for free.
However, no hospital may ask for more blood than it has used the previous year and in fact most hospitals run short long before the planned period expires. In this situation, they are supposed to buy stocks from the blood centres. But hospital managements normally claim their budgets are insufficient for such purchases.
A FORM OF BLACKMAIL
One exit strategy from this dilemma on the part of the hospitals is to encourage the relatives of patients to give blood, or make financial donations.
Those who donate money or give blood to the blood centres then receive a receipt. Technically these are illegal documents, explained Dr Ivan Ivanov, former chief of a department at Plovdiv blood centre, as they violate the law concerning the anonymity of donors and recipients.
But many hospitals demand such receipts before they will proceed with any operation.
Failure to comply can have fatal consequences, when hospitals proceed with operations without having secured the right amount of blood.
"This usually happens when, say, ten units of blood are needed but the hospital has olnly four," said a source from the University Hospital in Plovdiv.
Such incidents were most common, he added, when "the patient has no family or his family lives far from town".
"It is a form of blackmail of the patients," said Zelma Almaleh. "Although most people would gladly help in a difficult situation there is an element of abuse in this practice of hospitals."
It also directly stimulates the black market in the sale of blood, which shows no sign of declining while the dilemma created by the shortage of blood in Bulgaria continues.
* This article was made available to Sofia News Agency for publishing by Balkan Insight, Internet publication of the Balkan Investigative Reporting Network (BIRN)
** Ekaterina Terzieva is a regular Balkan Insight contributor and correspondent for Bulgarian national daily Sega. Albena Shkodrova is BIRN's Bulgaria country director. Balkan Insight is BIRN's online publication.
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