When Wang Rui’s water broke, it was far too early: The expectant mother from Shanghai wasn’t due to give birth for another six weeks. Swiftly admitted at the hospital, her scans showed that a natural childbirth would put her at risk of extensive bleeding — so doctors advised Wang to have a cesarean section.

In China, women often don’t learn that they have a rare blood type until they become pregnant or plan to become pregnant. This was precisely the case for Wang, who discovered three years ago during a routine prepregnancy checkup that she has Rh negative blood — nicknamed “panda blood” because of its rarity.

With just 24 hours to source 400 milliliters of Rh negative blood for the operation that could potentially save her life, Wang didn’t hesitate. She contacted members of the Shanghai chapter of China’s Rare Blood Alliance, known within the rare blood community simply as “the alliance.”

Wang’s son, Yang Jiaheng, is now almost three months old, and in sterling health. But according to the alliance, few stories involving Rh negative blood are so positive.

For those in China with unusual blood types, such as Rh negative, any kind of medical procedure presents a huge risk. Stocks of rare blood in public hospitals are dangerously low, and as a result, patients are forced to resort to illegal, unregulated networks of suppliers who charge their desperate customers steep premiums.

A year before Wang’s successful operation, a married woman called Hu Meiling was told by doctors that her husband needed 1 liter of Rh negative blood for an operation to repair his fractured hip and leg bones after a car accident. There were no reserves at the hospital’s community blood center near the family home in Weifang, in the eastern province of Shandong. Instead, a doctor explained to the 46-year-old Hu that to optimize the chances of success for her husband’s operation — and for seeing him walk again — she had just 21 days to find a blood source.

This was the first Hu had heard of her husband’s rare blood type. Frantically, she and her family began sending out messages on social media and posting notices in online forums, asking for volunteers who would be willing to donate the blood. But for the first two weeks, no one came forward.

“My husband supports the family financially,” Hu told Sixth Tone. “If the operation were unsuccessful, we could not have managed.”

By the third week, Hu had found two volunteers who agreed to donate 200 milliliters of blood each, as well as a middleman who would arrange for someone to donate the remaining 600 millimeters for a fee. The middleman paid an Rh negative blood carrier to go to the local blood center, give the agreed-upon amount, and receive an official certificate of donation. The family would then contact the hospital to inform them that the blood was available, and delivery would be arranged.

To reiterate, buying and selling blood is completely illegal in China, having been outlawed in 1998 — and for this reason, Hu refused to tell Sixth Tone how much she paid for the blood.

According to Xie Yingfeng, the alliance’s organizer in Shanghai, 400 milliliters of Rh negative blood sells for around 20,000 yuan ($2,900) on the black market, though the final price for customers tends to be much higher because of the middleman’s cut.

Nearly 13 years after the alliance was established, the national NGO has just 30,000 members, a fraction of the 6.8 million Chinese people estimated to carry Rh negative blood. Xie admits that the alliance’s ability to help people is limited by a lack of interest in donating — even among its members.

“Donation rates are far from sufficient to meet the demand,” said Xie. “There are far fewer donors than there are carriers who have registered with us. I often send notices asking for donors, but there’s no response. So I call our most passionate and committed volunteers, one by one, to see if anyone is available.” Out of the Shanghai alliance’s 600 members, just 100 have donated blood at least once, he added.

China is now facing a severe shortage of blood, both common and rare. Domestic media reported in early 2016 that at least 50 of the 70-plus large- and medium-sized cities in China, including Beijing and Shanghai, are dealing with shortages. The National Health and Family Planning Commission said in June of last year that 13.2 million people — less than 1 percent of the population — donated blood in 2015. There are no official statistics for the number of people who donate Rh negative blood.

It’s been 19 years since China introduced a voluntary blood donation system. But despite government attempts to educate people about the importance of blood donation, the proportion of the general population that volunteers is far lower than in other countries, and many people are ignorant of how the process works. Compared to China’s 1 percent of blood donors, the figure in the developed world is closer to 4 percent.

On Tuesday, the city of Mingguang, in the eastern province of Anhui, issued annual donation targets for its blood center, with local media reporting that by the end of the year, at least 85 percent of urban residents, 75 percent of rural residents, and 95 percent of university students should have a basic understanding of the importance of blood donation. Yet some experts have criticized this goal-oriented approach. Professor Jiang Lei from Jilin University in northeast China told state news agency Xinhua in 2011 that the process needs to become more transparent before people can be expected to change their habits.

“It’s important that blood centers publicly disclose the amount of blood they collect, the amount they transfer to hospitals for clinical use, and the costs associated with their operations,” Jiang said. “Voluntary blood donation is a charitable cause. Only when the entire process is open and transparent can it win the hearts of the public.”

The consequences of China’s blood shortage are hard to evaluate. Media reports tend to focus on situations where doctors and nurses heroically donate their own blood in times of crisis, rather than on adverse outcomes for patients, which are of course more common. In such a populous country with such a thinly stretched health care system, the lack of blood is a sensitive subject.

Cheng Ling was one of the two volunteers who, after finding out about Wang’s situation, agreed to donate her blood.

“It was the first time I had heard of one of our own members — and a volunteer herself — being in need,” said the 31-year-old Cheng. “We had never met before, but I felt that we were connected because we share the same rare blood. I was initially scared of donating, but the other group members gave me courage.” Like Wang, Cheng also learned about her rare blood type during a pregnancy checkup.

The Shanghai alliance is inundated with calls for help. Xie the organizer, originally from Fukang in the northwestern region of Xinjiang, has given more than 10 liters of his own blood over the past decade. However, without public awareness campaigns, he doubts that more people will follow his lead. “If we want to make a real difference, we need to have at least 500,000 members,” Wang Yong, the founder of the national alliance, told Sixth Tone in February. “Unfortunately, I don’t see this happening in the near future.”

There are many commonly held misconceptions about the dangers of giving blood in China. According to Xia Yi, a doctor in Shanghai’s Jinshan District, some people believe it’s not so easy to replace blood once it has been lost. In addition, many Chinese are terrified of blood-borne diseases after tens of thousands of people contracted HIV in the ’80s and ’90s from donating their blood at unlicensed clinics in exchange for cash.

Moreover, China’s primary and middle schools do not educate children about the importance of giving blood, or about how doing so impacts one’s health, a middle school teacher from Shanghai — who asked that her name not be used because of the sensitivity of the subject — told Sixth Tone. Instead, blood donation drives are more likely to be found on university campuses, where students are given little information about the procedure and its health implications.

In the absence of voluntary donors, a network of opportunists looking to profit from those who can’t access Rh negative blood has carved out a niche. Xie and his colleagues work diligently to prevent their ranks from being infiltrated by these middlemen, many of whom hope to buy blood from alliance members and turn it for a profit. “It’s not fair to put a price on lifesaving blood, and for someone to make money from this,” Xie said.

Since his surgery, Hu’s husband has recovered, and although he is no longer able to do physically demanding work, the couple have started a small business that they can run together from their home.

Buying the last 600 milliliters of blood cost Hu and her family a substantial sum of money, but she explains that when it comes to health, there’s no limit to what people will pay. “That’s why most families pay whatever the scalpers demand,” she said. “Blood saves lives, and lives are priceless. Money is meaningless if you’re not alive to use it.”

Wang Rui, meanwhile, is dedicated heart and soul to taking care of her baby boy. But whenever she thinks of her C-section, she remains deeply grateful for the donors who came forward to help her.

“The only way I can ever repay them and the alliance is to offer more of my own blood to people in need,” she said. “If I’m destined to be special, I hope to use my ‘gift’ to help and save others, too.”

Editor: Sarah O’Meara.

(Header image: A blood donor in Suichuan, Jiangxi province, Aug. 1, 2011. Xiao Yuanpan/IC)