IT all started with an act of love and kindness. But the good samaritan who
donated the first unit of AIDS-tainted blood set off a chain reaction that
has left countless broken hearts and shattered lives.
More than 1,000 Canadian hemophiliacs and transfusion patients have
contracted the deadly virus from blood and blood products since that fateful
donation some 15 years ago.
Today, Valentine's Day, the Commission of Inquiry on the Blood System in
Canada will start public hearings to figure out how the gift of life turned
into a death sentence for so many.
The mandate of Mr. Justice Horace Krever is twofold: first, to determine the
how and why of the country's worst ever health-care disaster. Just as
important, he will propose a revamping of a blood system that has not been
seriously scrutinized since it started operating 50 years ago.
Marlys Edwardh, counsel for the commission, has promised the process will be
people-oriented.
The emphasis will be on the 1,000 victims of tainted blood, who are dying at
a rate of three a week; the 300,000 Canadians a year who require treatment
with blood derivatives; and the often-overlooked 1.1 million volunteer blood
donors who are the foundation of the Canadian blood system.
The hearings will begin, however, with testimony from representatives of the
institutions that administer the $220-million blood system. Each
organization can expect intense scrutiny of its actions and inaction during
the 1978-85 period, when the vast majority of HIV infections occurred. Each
of the players would have a lot at stake in a revamped system:
The Canadian Red Cross Society: The charitable group, which is responsible
for the collection, manufacture and distribution of all blood products, has
become the whipping boy in the scandal, and is out to restore its
reputation.
The Red Cross will try to prove it did all in its power, given the
scientific knowledge and government funds at the time, to prevent the spread
of AIDS via blood, and argue that much of its efforts were thwarted by
government bureaucrats.
The Red Cross also has set out to consolidate its control of the blood
system, notably by building a blood fractionation plant. Those efforts are
being actively opposed by provincial health ministers, who last week
approved an action plan that aims to revamp the system before the inquiry
finishes its work.
The Canadian Blood Agency: Formed in 1991, the agency representing the
provincial health ministries is the newest player, but could emerge as the
most important.
Its predecessor, the Canadian Blood Committee, is blamed for exacerbating
the tainted blood tragedy, with some arguing that hundreds of lives could
have been saved if its members had acted faster. Instead, the committee took
eight months to distribute blood products that had been heat-treated to kill
HIV, and another eight months to implement testing that would effectively
end the AIDS threat in blood.
The CBA wants to take charge of the blood system, not only paying the bills
but establishing policy and making key decisions. In this scenario, the CBA
would contract the Red Cross to collect and distribute blood.
The proposal raises one of the most difficult questions Judge Krever will
have to answer: Who owns the blood Canadians donate? . Health Canada, bureau
of biologics: The federal government was ultimately responsible for ensuring
that the blood and blood products provided to Canadians were safe. The
bureau will argue that this was not scientifically possible before 1985, but
the health ministry will have to answer some tough questions about why it
did not warn Canadians about the dangers of the AIDS virus in blood.
Health Canada and its political masters also will have to explain why, even
after the tainted blood tragedy, it took years before blood was regulated,
and why there is still no emergency response system in place. . The
provinces and territories: They will be questioned about their hospitals'
failure to warn hemophiliacs and transfusion patients of the possible
contamination of blood, and the lack of follow-up to find people exposed to
potentially AIDS-tainted blood.
A political decision in the early 1980s to fractionate blood at Connaught
Laboratories Ltd., then owned by the Ontario government, will be probed in
depth. The move resulted in hundreds of thousands of blood donations being
wasted and may have contributed to the infection of hundreds of
hemophiliacs.
Further, the provincial health ministers will have to explain why they
denied compensation to victims until a few months ago, and why the deadline
for accepting the money is March 15, well before Judge Krever completes his
investigation.
The provinces, which long resisted an inquiry, are now counting on it as a
way of taking control of the blood system. The process will also be
monitored closely because its very public nature could serve as a model for
implementing health-care reforms in coming years. . The Canadian Hemophilia
Society: The non-profit group speaks for the 2,300 Canadians with blood
disorders, such as hemophilia. The group is criticized by breakaway factions
for having been too complacent during the period when contaminated blood
products were being distributed.
The CHS will actively be promoting a blood system that would be more
consumer-oriented and respond quickly to any crisis.
But overwhelming the volative mix of blood, money and politics will be the
intense personal dramas of the victims.
Almost 400 hemophiliacs and transfusion patients have died without receiving
a full explanation for the tragedy.
More than 100 more will likely die before the commission tables its final
report, and many will tell their poignant stories in the months to come.
Their legacy, they hope, will be a blood system with enough safeguards to
prevent an act of generosity from ever again becoming a poison that leaves
so many to die in silence.

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