This article was originally published on Nov. 27, 1997.
The front page of The Globe and Mail on Nov. 27, 1997.Globe and Mail Archives
The tainted-blood tragedy could largely have been prevented if governments and the Red Cross had taken even minimal safety precautions and honestly informed Canadians about the risks of AIDS and hepatitis C, a long-awaited report concludes.
The exhaustive chronicling of the “unprecedented disaster” by a federal inquiry prompted apologies yesterday from Health Minister Allan Rock and the Canadian Red Cross Society, which operated the blood system for 50 years but will cease that function next September.
“We can’t undo the damage – I wish we could – but we can express our profound sadness and our deep regret for the harm done to so many Canadians and their families,” Mr. Rock said. “The federal government accepts its share of responsibility for past shortcomings in the system. We are sorry for all that has happened.”
Red Cross President Gene Durnin echoed those sentiments. “To the victims and their families, while we cannot feel your pain, we hurt with you; while we cannot know your suffering, we weep with you; while we cannot feel your loss we grieve with you,” Mr. Durnin told a news conference. “We are very sorry, we apologize.”
There is indeed much to be sorry for, according to Mr. Justice Horace Krever of the Ontario Court of Appeal, who headed the Commission of Inquiry on the Blood System in Canada. His three-volume, 1,138-page report is severely critical of the behaviour of the “systemic failure” of institutions, including federal and provincial public-health agencies and the Red Cross.
Judge Krever also does not shy away from singling out individuals for criticism, many of them senior bureaucrats and administrators of the humanitarian agency. Among those singled out repeatedly are Dr. John Furesz, director of the federal Health Department's Bureau of Biologics from 1974 to 1992; Dr. Roger Perrault, head of the Red Cross Blood Transfusion Service from 1974 to 1991, and Dr. Martin Davey, assistant director of the BTS from 1981 to 1987.
If there was one great disappointment for victims, it was that politicians got away scot free, said Durhane Wong-Rieger, head of the Canadian Hemophilia Society.
Johanne Decarie, right, speaks to reporters on the Krever Inquiry in Ottawa on June 25, 1997, as Durhane Wong-Rieger, left, president of the Canadian Hemophilia Society looks on. Decarie contracted HIV through a blood transfusion in August 1985, and subsequently passed it on to her eight-year-old daughter Billie Jo, centre.David Lucas/The Canadian Press
“While the report is quite strong over all, we are disappointed that the level of responsibility and blame stops at the lower levels,” she said. “This falls short of telling the whole story.”
The analysis of past failings and its emphasis on institutions is directly reflected in the commission's recommendations for avoiding a repetition of the tragedy.
Judge Krever calls on politicians to make an overriding commitment to a public-health philosophy. This means not only spending more on blood safety but creating a no-fault insurance plan to compensate all those who are harmed by transfusions.
Mr. Durnin supported the no-fault concept, saying: “We should not surrender victims to a court system which is unaffordable and which may or may not satisfy their needs over the long term.”
A government-funded compensation system could also relieve the Red Cross of huge liabilities that threaten it with bankruptcy due to the tainted-blood scandal.
Saskatchewan Health Minister Clay Serby, chairman of the council of provincial health ministers, said in Regina that he will convene a meeting in January to discuss the issue of no-fault compensation. (The provinces would have to fund such a system.)
Judge Krever says that the way to restore confidence in the battered blood system – particularly to get donors giving again – is to create a unitary system in which consumers play a central role.
It is an approach that pleased consumers.
“This is the document of a tragedy but it is also a blueprint for the future,” said Paul Nesseth, a lawyer who represents Ontario hemophiliacs. “It’s very good that Krever reviewed the tragedy of the past. But he also makes many recommendations for the future, and the challenge to governments is to follow those recommendations if we are to have a safe blood system.”
An estimated 3,000 Canadians have died or will die from tainted blood. (More than 400 are estimated to have died in the four years since the inquiry began.) The total consists of more than 1,200 hemophiliacs and transfusion recipients who contracted the AIDS virus between 1980 and 1985, and about 15 per cent of 12,000 recipients of blood and blood products infected with hepatitis C between 1980 and 1990.
The history, which comprises more than 1,000 pages in the report, tells the tale of years of official indifference about AIDS and hepatitis C, bureaucratic foot dragging, lax regulation, outright misrepresentation of public-health risks and shortsighted politicking and penny pinching.
If there is an overriding theme throughout the report, it is that consumer safety must be the guiding principle of all health-care policy. Shutting the public out of the decision-making process is a recipe for disaster, and putting fiscal or financial concerns before safety is a betrayal of the public trust, Judge Krever writes.
“The Bureau of Biologics of Health Canada provides a service to Canadians,” he writes in one of many such statements. “It has only one client – the public – and the safety of the client must remain its paramount concern.”
The report highlights five major areas of failure in the tainted-blood tragedy:
1. Even though the AIDS virus was isolated only in 1983, it was obvious by mid-1982 that HIV was probably blood-borne. But the risk was not taken seriously. Regulators and public-health officials missed a vital opportunity to take preventive measures that would have saved lives, Judge Krever wrote.
He says the “primarily responsibility” for protecting the blood supply fell to the Red Cross but its response was “ineffective and half-hearted.”
2. Factor concentrates used by hemophiliacs were infected widely and early, and little effort was made to promote the use of safer alternatives. Canada’s dependence on U.S. blood products greatly increased the risks. By 1984, for example, 97 per cent of hemophiliacs using products from Cutter, the principal supplier of the Red Cross, were at risk of infection. Judge Krever writes that the regulator made no effort to make these products safer.
3. The conversion to safer heat-treated concentrates was unacceptably slow. Judge Krever concludes that the Red Cross deliberately exhausted its inventory of non-heated products before making safer ones available. Some, though not all, hemophiliacs could have avoided contracting AIDS, he writes.
4. The slow introduction of AIDS testing was unjustified and deadly. The reasons for this are numerous, he writes, including the fact that the Red Cross was a “tentative and ineffective decision-maker,” the provincial politicians were “unacceptably slow” in providing funding and provincial health officials failed to fulfill their basic public-health duties.
5. There was a lack of leadership when it came to trying to trace recipients of blood and blood products who were at risk. “Government officials appear to have been more concerned about preventing public questioning about the safety of the blood system and deflecting controversy than about informing persons who might be infected,” Judge Krever writes.
The report provides a sense of closure for the victims of tainted blood, many of whom crowded into a hotel room yesterday to begin reading the massive report.
Over all, they were pleased with the commission's even spreading of blame among a number of institutions and individuals. Yet the report's release also prompted renewed calls for further action, including more comprehensive compensation and the laying of criminal charges.
Ken Arenson, a lawyer who represents a number of victims who opted out of the compensation plan in favour of pursuing lawsuits, called for the appointment of a special prosecutor to study the report and find grounds to commence prosecutions against senior blood-system officials.
The question of whether Judge Krever would name individuals in the final report was the subject of much speculation. The commission fought a lengthy legal battle to have the right to explicitly state facts that implied misconduct. It won that right in the Supreme Court of Canada.
With reports from Scott Feschuk and The Canadian Press