A few days before the Indian celebration of Holi, an emaciated man with graying skin, drooping eyes, and rows of purple needle marks on both arms stumbled up to a group of farmers in the sweltering Indian border town of Gorakhpur. The city is the first stop for many thousands of refugees streaming in from Nepal, a country even more perpetually impoverished than India. Over the years endless refugee hardship stories had dulled the farmers’ instincts for sympathy, and junkies were even lower on their list for charity handouts. at first the farmers ignored the man’s request for bus fare. But he persisted. He wasn’t a refugee, he said. He was escaping from a makeshift prison where his captor siphoned off his blood for profit. The farmers shook off their stupor and called the police.

For the last three years the man had been held captive in a brick-and-tin shed just a few minutes’ walk from where the farmers were drinking tea. The marks on his arms weren’t the tell-tale signs of heroin addiction; they came from where his captor, a ruthless modern-day vampire and also a local dairy farmer and respected landowner named Papu Yadhav, punctured his skin with a hollow syringe. He had kept the man captive so he could drain his blood and sell it to blood banks. The man had managed to slip out when Yadhav had forgotten to lock the door behind him.

The emaciated man brought the officers to his prison of the last three years: a hastily constructed shack sandwiched between Papu Yadhav’s concrete home and a cowshed. A brass padlock hung from the iron door’s solid latch. The officers could hear the muffled sounds of humanity through the quarter inch of metal.

They sprung the lock and revealed a medical ward fit for a horror movie. IV drips hung from makeshift poles and patients moaned as if they were recovering from a delirium. Five emaciated men lying on small woven cots could barely lift their heads to acknowledge the visitors. The sticky air inside was far from sterile. The sun beating down on the tin roof above their heads magnified the heat like a tandoor oven. One man stared at the ceiling with glassy eyes as his blood snaked through a tube and slowly drained into a plastic blood bag on the floor. He was too weak to protest.

The room was not unique. Over the next several hours the cops raided five different squats on the dairy farmer’s land. Each scene was as bad as the last, with patients constantly on the verge of death. All told they freed seventeen people. Most were wasting away and had been confined next to hospital-issued blood-draining equipment. In their statements the prisoners said that a lab technician bled them at least two times per week. Some said that they had been captive for two and a half years. The Blood Factory, as it was quickly known in the press, was supplying a sizable percentage of the city’s blood supply and may have been the only thing keeping Gorakhpur’s hospitals fully stocked.

That evening police rushed the men to the local Civil Hospital to recover. The doctors there said that they had never seen anything like it. Hemoglobin supplies oxygen to various parts of the body, and low levels of it can lead to brain damage, organ failure, and death. A healthy adult has between 14 and 18 grams of hemoglobin for every 100 milliliters of blood. The men averaged only 4 grams. Leeched of their vital fluids to the brink of death, all of them were gray and wrinkled from dehydration. “You could pinch their skin and it would just stay there like molded clay,” said B. K. Suman, the on-call doctor who first received the patients from police custody.

Their hemoglobin levels were so low that the doctors were worried about bringing them up too quickly. One told me that they had become physically addicted to blood loss. To survive, the doctors had to give them iron supplements along with a regimen of bloodletting or they could die from too much oxygen in their circulatory systems.

After a few weeks in captivity, the prisoners were too weak from blood loss to even contemplate escape. A few survivors recalled to the police that the original group was much larger, but when Yadhav sensed that a donor was becoming terminally sick, he just put them on a bus out of town so that their deaths would be someone else’s responsibility.

Papu Yadhav kept meticulous ledgers documenting the volume of blood that he sold to local blood banks, hospitals, and individual doctors as well as the hefty sums that came back. The notes made it particularly easy for the police to understand the entire operation. Vishwajeet Srivastav, deputy superintendent of police in Gorakhpur in charge of the case, says that the records showed that Yadhav started as a small commercial venture that only propped up his dairy business. In the beginning, at least, he offered a straight deal to the drug-addled and destitute potential donors that he picked up at Gorakhpur’s bus and train stations.

The $3 he gave for a pint of blood would buy food for several days. It was illegal, but it was also easy money. Yadhav could easily turn over common blood types for $20 quick profit, while rarer groups could fetch up to $150 a pint. It didn’t take long for the situation to deteriorate. As his operation grew, he got tired of trolling the city’s transit points. So Yadhav offered the donors a place to stay. With the men under his roof, it was only a matter of time before he took control of their fates though a mixture of coercion, false promises, and padlocked doors.

The blood business got so big that he needed help. He took on a former lab technician named Jayant Sarkar, who had experience running an underground blood farm in Kolkata before he was chased out of the city in the late 1990s. Together Yadhav and Sarkar grew into one of the main blood suppliers in the region. The business concept was similar to that of Yadhav’s milk farm. The two were so interrelated that he kept the cowsheds and human sheds next to each other to economize on space.

Two months after the initial raid the police rounded up nine men: lab technicians who oversaw collection, secretaries at local blood banks who wanted to line their pockets with extra profits, middlemen who ferried blood around the city, and nurses who tended the herd. Smelling trouble, Sarkar was able to escape the city, but Papu Yadhav was captured near his home and served a total of nine months in jail. After a month at Civil Hospital his former captives migrated back to their homes all across India and Nepal.

It is tempting to view the horrors of Gorakhpur’s blood farm as an isolated incident: the sort of aberration that only happens on the margins of the civilized world and unrelated to the blood supply anywhere else. But the existence of the blood farm suggests a deeper problem with the circulation of human materials in the market. The blood farm could never have existed

without eager buyers who were either incurious about the supply or just didn’t care about the source. and once medical personnel were willing to pay money for blood without asking questions, it was almost inevitable that someone would exploit the situation to maximize profit. In fact, the world volunteer blood system is so fragile that a slight hit to the supply could immediately spark the sort of commercial blood piracy that blossomed here.

I arrived in Gorakhpur on the eve of Papu Yadhav’s release hoping to better understand how a city of two million people became so easily dependent on a blood farm. While the excesses in this city stretch the bounds of the ordinary, the situation was by no means unique to India. Perched precariously on the border of India and Nepal, Gorakhpur is a mashup of the chaos and pollution of an industrial boomtown and the endemic poverty of rural India. a single rail line and poorly maintained road connect Gorakhpur to the state capital of Lucknow. still, the city is the central hub for a dense string of villages in what is one of the most densely populated rural areas of the world. Gorakhpur is the only settlement for almost one hundred miles with any sort of urban infrastructure. As such it’s an important outpost for the government’s presence in the region. The city is in the difficult position of providing basic services for a giant swath of the country, and yet simultaneously being a low development priority. It is a city built on a foundation of shortages.

Worst hit are Gorakhpur’s overburdened medical facilities, which are a lifeline to tens of millions of rural farmers and migrant workers. offering subsidized—and in some cases free—care, the hospitals are magnets for the underprivileged. Even the gigantic Baba Ram Das hospital campus with almost a dozen buildings and a fleet of ambulances has lines of rural patients streaming out the front door. The other major hospitals are even more crowded. The glut of patients poses several major challenges, especially in the blood supply. Even procedures as routine as birth drive up the demand—a pregnant woman in need of a cesarean section will need at least two pints of blood on hand in case of complications. The millions of migrants who come to the city’s hospitals are already sick and in no shape to open up their veins. There are simply too few good candidates for blood donation.

It’s a perfect storm for the worst forms of medical malpractice and ethics. There are no opportunities for the comparatively small local population to replenish the stocks of blood through voluntary donations, so hospitals have little choice but to rely on the underground machinations of local blood dealers. A blue-and-white neon sign hanging a five-minute walk from Papu Yadhav’s former blood farm announces Fatima Hospital, one of Gorakhpur’s five blood banks. There, a patchwork of concrete rubble and construction debris lies just inside the hospital’s iron-and-brick gateway, as the hospital is in shambles while undergoing a major renovation. But the blood bank was too important to put off or leave nonfunctional during the renovation. so the Jesuit church that is financing the construction saw to it that the blood bank was finished first. But for now, that means avoiding stray cats, picking my way across piles of rebar and sand, and climbing unfinished stairways to get to the hematology department.

But once I’m inside it’s like being in a different world. The place is packed with state-of-the-art equipment, including a sub-zero refrigerator that can store blood almost indefinitely and shiny new centrifuges that can separate blood into its component parts. The unit is the brainchild of Father Jeejo Antony, who runs the hospital for the local diocese. However, all the high-tech gear in the world won’t help his main problem. He tells me that they barely collect enough blood to meet his own hospital’s needs, let alone the city’s. The problem, he says, is that most people in India won’t give blood voluntarily. He says that many local people here are superstitious and believe that losing bodily fluids will make them weak for the rest of their lives. This is partly why the city began depending on professional donors.

“Papu Yadhav is only a scapegoat. There are many more people behind the blood sales than low-level people like him,” he says when I bring up the case, adding, “There are agents in every nursing home and every hospital. When a doctor requests blood, it gets arranged somehow.”

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.

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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 rupees, 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 rupees, 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 rupees (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.

Images: Scott Carney