MONTREAL -- The Canadian Hemophilia Society has filed a formal complaint
with the RCMP, demanding that criminal charges be laid against those whose
actions and inaction contributed to the "needless waste of innocent lives"
in the tainted-blood tragedy.
In a letter faxed yesterday to the RCMP commissioner, society president
Durhane Wong-Rieger called on investigators to focus on four principal areas
of wrongdoing:
Delays in the introduction of concentrates that were heat-treated to kill
the AIDS virus;
Continued use of a heat-treated product that proved ineffective as late as
1987;
Delays in introducting testing for the human immunodeficiency virus in the
blood supply;
The decision not to introduce surrogate testing for the hepatitis C virus
between 1986 and 1990.
"We feel that the actions of those responsible for the blood system in the
past identified in the commission's final report must be thoroughly
investigated," Ms. Wong-Rieger wrote, referring to the results of the Krever
inquiry into the tainted-blood scandal. "The hemophilia community has been
irreparably harmed. We must be asured that there will be justice and that
the full strength of legal deterrents are brought to bear to assure that the
needless waste of innocent lives will not occur again."
RCMP Commissioner Philip Murray said last week that investigators in the
commercial-crimes unit would read the 1,138-page report of the Commission of
Inquiry on the Blood System in Canada to determine whether there is a prima
facie case warranting further action.
But yesterday's development will force those investigators to turn their
attention to four areas that Mr. Justice Horace Krever analyzed in great
detail in the inquiry report, sometimes singling out individuals for having
failed in their duties.
A number of lawyers and academics have suggested that, based on the facts
outlined by the inquiry, charges of manslaughter and criminal negligence
causing death may be forthcoming. They have also suggested that there may
have been criminal violations of the Food and Drugs Act by some bureaucrats
and health-care officials.
Judge Krever conducted a lengthy analysis of each of the issues raised in
the CHS complaint.
The commission was severely critical of Health Canada officials in their
treatment of factor concentrates, saying the department failed to take
measures that would have reduced the risk of HIV infection among users.
The Bureau of Biologics of Health Canada ordered a switch to heat-treated
concentrates in October of 1984, but the safer products were not made
available to all hemophiliacs until July of 1985. Judge Krever wrote that
the inventory of unsafe products was deliberately used up, and if
blood-system officials had acted properly, "some of the hemophiliacs would
have avoided being infected."
Even after heat-treated concentrates were made available, there were some
questions about the effectiveness of some methods in killing the virus that
causes acquired immune deficiency syndrome. Judge Krever wrote that these
concerns were not acted on promptly enough. As a result, at least seven more
hemophiliacs were infected with HIV in 1986-87.
Judge Krever also provided precise figures on the number of cases of AIDS
infection that could have been avoided had blood officials acted promptly on
the issue of testing. A blood test was available on March 2, 1985, but
universal testing was not in place until November of that year. The lack of
"timely decisions on matters of safety" during that period led directly to
133 cases of preventable HIV infections, he said.
Judge Krever also estimated that 24,000 of the 28,600 cases of blood-borne
hepatitis C that occurred between 1986 and 1990 could have been avoided had
authorities implemented surrogate testing. He wrote that they should have
spent their time and energy reacting to the threat to the blood supply
instead of making excuses not to act.
***********
RCMP to launch blood probe
Eight-member team assigned to investigate
whether to lay criminal charges in scandal
Monday, December 22, 1997
BY ANDRE PICARD
The Globe and Mail
The RCMP are setting up an eight-member investigative team to determine
whether criminal charges will be laid in the tainted-blood scandal.
The force's commercial-crimes unit will announce tomorrow that it will take
three months to investigate whether there was criminal wrongdoing in the
decisions that led to the infection of thousands of Canadians with the AIDS
virus and hepatitis C. It will decide by March 15 whether any charges are
warranted.
In the wake of the release of the final report of the Commission of Inquiry
on the Blood System in Canada, the commercial-crimes unit received a number
of demands, both formal and informal, to set up such an investigation.
A number of current and past officials at the Canadian Red Cross Society,
Health Canada, provincial health departments and pharmaceutical companies
have been notified in recent days that they will be questioned by the
Mounties.
The RCMP are also setting up a toll-free number so members of the public can
call in tips that might assist investigators. That number will also be
announced tomorrow.
The police have opted to make the nature of their investigation public to
counter allegations that they are dragging their feet at the behest of
politicians. (The force feels this is particularly important in the wake of
the Airbus affair, in which the Mounties were perceived by some people as
being used by the governing Liberals to settle political scores with Brian
Mulroney, a former Progressive Conservative prime minister.)
A number of victims of tainted blood have contended that a criminal
investigation has not been undertaken because those most likely to be
scrutinized are elected officials and their mandarins.
An estimated 2,000 recipients of blood and blood products were infected with
the AIDS virus between 1980 and 1985. Another 60,000 transfusion recipients
contracted the potentially debilitating hepatitis C virus between 1980 and
1990.
In an exhaustive report on the tragedy released last month, Mr. Justice
Horace Krever concluded that a significant number of those infections were
preventable and chronicled a series of failures, both institutional and
individual, that contributed to one of Canada's worst public-health
tragedies.
Under the terms of his mandate, Judge Krever was not permitted to make
findings of criminal or civil liability, but he was able, after a long court
battle, to single out individuals for allegations of wrongdoing.
While members of the commercial-crime unit have been studying the 1,138-page
report for several weeks, any charges they lay must be based on evidence
gathered in interviews and from source documents. That is because, under the
terms of the Canada Evidence Act, the testimony of those who appeared at the
inquiry cannot be used against them in criminal or civil proceedings. (The
reason is that the rules of evidence in court are far stricter. For example,
a person charged with a crime can refuse to testify, whereas at an inquiry
that person can be compelled to appear.)
There have been successful prosecutions of blood-system administrators in
the public and private sectors in at least four countries: France, Japan,
Germany and Switzerland. In France and Japan, where the punishments meted
out were most severe, the events that occurred were eerily similar to those
in Canada.
Academics and lawyers who have reviewed the Krever report have suggested,
based on the facts outlined therein, that the charges most likely to be laid
are for violations of the Food and Drugs Act, although there is a remote
possibility that charges as grave as criminal negligence causing death could
be laid.
In a letter sent to the RCMP a few days after the report's release, the
Canadian Hemophilia Society asked investigators to focus on four principal
areas of failure that caused "needless waste of innocent lives:"
The decision not to introduce surrogate testing for the hepatitis C virus
between 1986 and 1990. In his report, Judge Krever said that failure led to
the infection of 28,600 Canadians and that 85 per cent of those cases were
preventable.
Delays in introducing testing for the human immunodeficiency virus in the
blood supply. A test was available March 2, 1985, but universal testing was
not in place until Nov. 1 of that year. The report concludes that at least
133 people contracted HIV in that period.
Delays in the introduction of concentrates that were heat-treated to kill
the AIDS virus. A decision was made in November, 1984, to make the switch to
the safer product, but it was not completed until July, 1985. Judge Krever
concluded that the inventory of unheated products was deliberately exhausted
and, had blood-system officials acted properly, "some of the hemophiliacs
would have avoided being infected."
The continued use of heat-treated products that proved ineffective as late
as 1987. After the belated switch to heat-treated concentrates, questions
remained about the efficiency of heating methods to kill the virus; that,
coupled with the fact that manufacturers continued to use plasma that was
not tested for the AIDS virus, led to the infection of a number of other
hemophiliacs in 1986-87, after the products were declared free of HIV.
The RCMP is also investigating the destruction of a decade's worth of
minutes and taped transcripts of the Canadian Blood Committee, a
federal-provincial body that was responsible for funding and establishing
policy for the blood system when all these events occurred. The federal
Access to Information Commissioner was severely critical of that
destruction, which he concluded was prompted by media interest in the
tainted-blood tragedy.
The investigation of the records' destruction, however, is separate from the
probe to be announced tomorrow. In fact, a decision on that case is expected
early in the new year.
Meanwhile, a number of class-action lawsuits by victims of tainted blood
infected with hepatitis C are proceeding against the Red Cross and federal
and provincial governments.
Advocacy groups have said, however, that they would prefer to resolve the
issue without having to endure lengthy and costly litigation. Many victims
of tainted blood who contracted the AIDS virus were compensated.
At a meeting slated for the end of January, the country's health ministers
will announce whether that compensation will be extended to those who
contracted hepatitis C. In his report, Judge Krever made a strong plea for a
no-fault compensation plan, saying it is the most just and efficient manner
in which to proceed in the case of injuries caused by blood-borne infections

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