Twenty-three months of public hearings into Canada's tainted-blood tragedy
have ended, leaving the future of the country's blood system in limbo until
a final report is delivered Sept. 30.
The only certainty is that the status quo will not be maintained, because
the current system is not able to deal with another AIDS-like crisis, the
hearing was repeatedly told.
The final report of Mr. Justice Horace Krever, the Ontario judge heading the
federal Commission of Inquiry on the Blood System in Canada, will take
several months to write, with additional time for translation and printing.
The inquiry will continue in early February for final submissions by
lawyers.
The inquiry's mandate is twofold:
To determine the root of the public-health disaster in which more than 1,200
hemophiliacs and transfusion recipients became infected with the AIDS virus
between 1980 and 1985, and another 12,000 became infected with the hepatitis
C virus between 1985 and 1990;
To make recommendations on how Canada's blood system should be revamped to
prevent a similar tragedy in the future.
Under his mandate Judge Krever can make only findings of fact and
recommendations. He cannot apportion blame nor suggest criminal charges. His
recommendations, while they are not binding on federal and provincial
ministers of health, are expected to serve as the blueprint for rebuilding
the troubled blood system for the 21st century.
The organizations that stand to feel the greatest impact from the report are
the Canadian Red Cross Society, which currently collects and distributes all
blood in Canada, and the Canadian Blood Agency, which sets policy and funds
the $250-million-a-year blood program on behalf of the provinces.
The Red Cross has, by far, the most to lose, in terms of reputation and
funding. The humanitarian agency has staked its future on the construction
of a $300-million blood-fractionation plant in Bedford, N.S., a project it
has undertaken in conjunction with the pharmaceutical company Bayer Inc.,
and its continued control of the blood program.
If the commission's report calls for a halt to the plant, it would place the
Red Cross in a precarious financial position. More important, if Judge
Krever calls for the Red Cross to get out of the blood business altogether,
as some witnesses have suggested, the charity would lose more than
two-thirds of its revenue.
Conversely, if the Red Cross is given a vote of faith, the Canadian Blood
Committee could be disbanded and the Red Cross's preferred plan, "selling"
blood and blood products directly to hospitals, could be implemented.
Judge Krever is also expected to recommend whether Canadians should be paid
for some forms of blood donation. The Red Cross has been collecting blood
from volunteers since 1940, but Canada is perpetually short of plasma, the
portion of blood used to manufacture blood products.
In the three years since the tainted-blood tragedy first became front- page
news in Canada, blood donations have fallen by almost 20 per cent. During
that same period, it is estimated that more than 300 victims of tainted
blood have died.
The public inquiry was announced on Sept. 16, 1993, by then federal health
minister Mary Collins. She did so over the objections of a number of
provincial health ministers who wanted a much more limited investigation.
The original deadline was September, 1994. The budget was set at $2.5-
million, with an additional $500,000 for intervener funding to cover legal
expenses for consumer groups.
Yet in his first public comments, Judge Krever made it clear that the
deadline was "likely not a reasonable one for an inquiry of this magnitude."
He also asked for more money.
Today, the budget stands at slightly more than $11-million, with an
additional $2.5-million for intervener funding for 16 groups. Judge Krever
has asked for an additional $3.3-million to complete his work, but it has
yet to be approved.
The Red Cross, pharmaceutical companies and federal and provincial
governments did not receive funding, but they are spending millions more.
The Red Cross alone has spent more than $10.5-million in legal fees and
printing costs for the mountains of documentation it has provided.
In fact, more than a million pages of evidence have been submitted to the
commission of inquiry. The testimony of witnesses has produced another
50,000 pages of written transcripts.
When the public hearings opened, Judge Krever vowed that all victims of
tainted blood who are still alive would be granted the right to testify. A
total of 168 of the estimated 600 people infected by bad blood who are still
alive took him up on the offer. Much of their testimony, heard in the first
phase of the inquiry, was heart-wrenching.
Another 292 expert witnesses took the stand, bringing the total of those who
testified to 460. Consumer groups, however, have expressed bitter
disappointment that not a single politician was called to the stand. Earlier
last week, commission lawyer Marlys Edwardh announced that former federal
health ministers Jake Epp and Monique Begin would not be called as witnesses
because preliminary interviews revealed that they could add nothing
substantive.
Victims were also upset that the inquiry did not probe the issue of
compensation. There were two "humanitarian assistance" programs, one by the
federal government in 1989, and another by the provinces in 1994. Victims
were particularly bitter about the latter, which they felt was imposed on
them under duress before the commission made its findings. Judge Krever,
however, decided that his mandate did not allow him to investigate the terms
of the compensation deal.
The commission held 235 days of public hearings in nine provinces, with the
bulk of its work in Toronto. (Evidence from Prince Edward Island was
collected in Halifax, and that from the Northwest Territories in Edmonton
and Toronto; no one in the Yukon is known to have been infected by tainted
blood.)
In the end, the two issues at the heart of the inquiry proved to be the same
as at the outset: delays in the introduction of safer, heat-treated blood
concentrates for hemophiliacs, and the delay in testing blood donations for
the AIDS virus.
The inquiry heard that on Nov. 14, 1984, the federal government ordered a
switch to heat-treated concentrates, but their distribution was not fully
phased in until July 1, 1985. Evidence was introduced showing that thousands
of units of the untreated blood products, virtually all of which were likely
infected with the AIDS virus by 1985, were distributed, even though there
was months of inventory of the safer products.
Similarly, much time was spent trying to explain the delay in AIDS testing.
A commercial test kit went on sale in the United States on March 2, 1985,
but universal testing did not begin in Canada until Nov. 4 of that year.
Originally, it was believed there was a lack of funding to pay for testing,
but it turned out there was a $4-million surplus in the blood budget that
year. At least 55 Canadians contracted AIDS from transfusions during that
eight-month delay.
The lack of apology from the Red Cross and provincial governments is another
issue that has taken on importance in recent weeks, since Judge Krever
demanded that Douglas Lindores, secretary-general of the Red Cross, explain
why the humanitarian agency has refused to "utter the A-word."
Another bombshell that emerged during the inquiry is that the Canadian Blood
Committee, the precursor to the Canadian Blood Agency, deliberately
destroyed audio tapes and full transcripts of its meetings in 1989. At the
time, a number of victims of tainted blood had already launched lawsuits and
the meetings of those who ultimately controlled the blood system were deemed
to be crucial evidence. The federal Information Commissioner is currently
investigating the destruction of documents.
Judge Krever issued his interim report in February, 1995. At the time, he
warned that Canadian public health officials and hospitals had not made
adequate efforts to contact the 3.5 million Canadians who received blood and
blood products between 1978 and 1990 to warn them they may have been exposed
to the AIDS virus or hepatitis C.
In the introduction to that report, the judge also cautioned that there is
"no justification for complacency.
"To the question whether the tragedy of 1978 to 1985 could happen again with
a different contaminating agent, I believe the answer is 'Yes.' How to
minimize the likelihood of such a calamity is the challenge to be addressed
in the further work of this inquiry and the final report," he wrote.

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