Have we forgotten the lessons of the tainted blood scandal?
Twenty years ago, on Nov. 26, 1997, the final report of the Commission of Inquiry on the Blood System in Canada was made public.
The 1,197-page tome, known colloquially as the Krever report, dispassionately catalogued the causes of Canada worst-ever preventable public-health disaster.
The tainted-blood tragedy left roughly 2,000 recipients of blood and blood products infected with HIV-AIDS and another 30,000 infected with the hepatitis C virus (HCV).
Those numbers are so staggering that, even to this day, they remain hard to comprehend.
More difficult, still, to understand is the breadth and depth of the bureaucratic bungling, regulatory dysfunction, corporate greed, political dithering and quasi-criminal inaction that led to tens of thousands of Canadians being infected with HIV and HCV, especially when you consider an estimated 85 per cent of those cases were deemed preventable.
The tainted-blood tragedy is largely forgotten, so let’s summarily review some of the worst horrors:
- When a new pathogen (latter dubbed human immunodeficiency virus, or HIV) first emerged in the early 1980s, it was fairly obvious early on that it was blood-borne. Yet the Red Cross was slow to implement screening;
- When an HIV test became available, there were delays in implementing it;
- Blood products used principally by hemophiliacs were highly infected, but there was a reluctance to purchase products heat treated to kill the virus because of the cost; even after it was known that non-treated blood products were contaminated, stocks were used up;
- Canada was determined to build a blood-fractionation plant for prideful reasons, but it was an abject failure and millions of litres of donated plasma were wasted;
- Because of plasma shortages, products were purchased from blood brokers with dubious sources such as U.S. prisons;
- The failure to protect the public from HIV was repeated again a few years later with HCV: screening was inadequate and testing was delayed;
- Contact tracing was slow; those infected were not notified promptly and they, in turn, infected their loved ones;
- The regulator, Health Canada, did little independent verification of the safety of blood products, trusting the Red Cross claim that only one in one million blood donations were contaminated. That number was a fabrication;
- The provinces, who funded the Red Cross for collecting blood and distributing blood products, were largely hands off and indifferent to safety;
- When the severity of the blood scandal began to become clear, the committee overseeing funding of the blood system shredded all its documents.