In the summer of 1983 Dr. Thomas Bowen, medical director of Calgary's Red Cross Blood Centre, was ordered by the national Red Cross office not to mark blood donations from people suspected of being homosexual, intravenous drug users, or otherwise at a high risk of contracting AIDS. Nevertheless, for two years Calgary nurses put a black dot on suspect samples so that they were not used for transfusions. Dr. Bowen did not tell the national office this, because senior Red Cross bureaucrats were committed to a policy of "voluntary self-exclusion" and Dr. Bowen did not want to be told to stop doing it.

Nobody knows how many lives Dr. Bowen saved by this expedient. After testifying at the Commission of Inquiry on the Blood System in Canada, Dr. Bowen said that it was just "luck" that he took appropriate steps while the Red Cross did not. But the head of the commission, Justice Horace Krever, disagrees. In his report, released November 26, Mr. Justice Krever maps out with devastating precision exactly how and why the guardians of Canada's blood supply let thousands of people die unnecessarily through inaction, cowardice, bureaucratic bungling and lies.

The report details how top Red Cross bureaucrats refused to properly screen donors because they were afraid of offending the gay community and the public; how they publicly insisted that the risk of transmitting AIDS by blood transfusion was "overrated," while privately acknowledging that contamination of the supply was only a matter of time; how they frittered away an 18-month opportunity between 1983 and 1985 to implement AIDS prevention measures already in place in the U.S.; and how they later distributed blood products to hemophiliacs that they should have known to be contaminated.

Other factors contributed to the debacle, such as political infighting between the Red Cross and federal and provincial agencies. Neither Ottawa nor the provinces did anything to stop the medical malfeasance, and as a result over 1,100 Canadians got AIDS and over 60,000 were infected with hepatitis C. But the "primary responsibility" for preventing such a catastrophe was in the hands of one entity: the Canadian Red Cross.

Mr. Justice Krever begins the story in the U.S. In December 1981 the New England Journal of Medicine warned that "a nation-wide epidemic of immunodeficiency among male homosexuals" was occurring and that it was beginning to affect drug users. The mortality rate (over 40%) was alarming, and the number of cases was doubling every six months, but epidemiologists were particularly troubled by the association with homosexual males. Because diseases spread more quicklyamong homosexuals, it is sometimes considered a bellwether of impending epidemics. Mr. Justice Krever also notes that homosexual males were frequent blood donors in those days, believing that it would improve their public image.

By spring 1982 it was widely acknowledged in America that the new "gay-related immunodeficiency" might be infectious. A July 1982 outbreak of 34 cases among Haitian immigrants frightened officials, who thought initially it to be a new phenomenon; it was later discovered that most of the Haitian men had had sex in their birthplace with visiting New York homosexuals. Meanwhile, there were reports of AIDS-like symptoms in the prison population. That summer the Centres for Disease Control in Atlanta noted that the agent might be a blood-borne virus, and so "hemophiliacs would be prime candidates to develop this syndrome."

The U.S. quickly took measures to suppress AIDS. At the time, 75% of AIDS patients were gay or bisexual men and 15% were intravenous drug users. Beginning in January 1983 the Americans implemented measures designed to discourage or prevent these people and their sexual partners from donating blood. They began a general education program for the public, they insisted that information on AIDS be presented at clinics, and in many cases they questioned donors directly and excluded those who were members of high-risk groups or exhibiting AIDS symptoms. All this was happening by March 1983; U.S. inquiries later determined that even more should have been done earlier.

In Canada, Dr. Roger Perrault, national director of the Canadian Red Cross Society's blood transfusion service, had been struggling with regular and severe blood shortages. New procedures like transplants had increased demand for blood, and the Red Cross was required by the provinces to fill all requests. However, bureaucrats discouraged transfers of blood from surplus to needy regions. Much of the blood used by hemophiliacs consequently came from the U.S., where the rates of infection were four times as high.

In August 1982 Dr. John Furesz, the director of Canada's federal Bureau of Biologics, the agency responsible for regulating blood products, asked Dr. John Derrick, the head of Red Cross blood products services, to coordinate the surveillance of new cases of the disease, particularly among hemophiliacs. On September 9, 1982, a Red Cross committee rejected the request because "the evidence suggesting that hemophiliacs could be at risk in developing AIDS had been overpublicized and was still inconclusive."

The committee also argued that it was not in a position to take on that role, which was nonsense, as Mr. Justice Krever points out; the agency had controlled the safety of the blood system for years and had responded to numerous threats in the past, such as syphilis and hepatitis B, through screening, testing and other measures. Dr. Furesz, for his part, never followed up his own request to ensure that it had been acted on.

Meanwhile, the AIDS cases were increasing rapidly. By December 1982 there were 800 in the U.S. and 21 in Canada. In the U.S., several dozen hemophiliacs had already been infected with HIV, the human immunodeficiency virus that causes AIDS. The Canadian Red Cross was aware of developments and government actions in the U.S. At a committee meeting on January 21, 1983, an American doctor advised the Red Cross governing committee to implement direct questioning about AIDS symptoms and high-risk groups in its questionnaire. The Red Cross declined because it was "concerned that it might offend donors," notes Mr. Justice Krever. "This concern was not the result of any study of donor attitudes by the RC."

It had more to do with a furious controversy a month earlier. A Medical Post article had summarized research on hemophiliacs with failing immune systems, and Dr. Joseph Shuster, a McGill University researcher, had been quoted as saying "there is 'no question' that gay men should not donate blood until the issue is resolved." But the assistant director of the Red Cross's Blood Transfusion Unit, Dr. Martin Davey, was quoted as downplaying the risk and saying that rigorous scientific proof would be needed before high-risk donors were excluded. Nevertheless, the gay community was outraged. "Facing a difficult public relations problem," writes Mr. Justice Krever, the Canadian Red Cross adopted a policy of "voluntary self-exclusion" on March 10, 1983.

The plan was to get gay community leaders and other high-profile members of risk groups to convince their fellows not to donate blood. A press release was issued describing the new policy and listing known risk groups: gays, IV-drug users and Haitians. The public was assured that "everything possible" was being done to protect blood recipients.

Montreal's Haitian community resented the stigma the press release placed on them and denounced the Red Cross as racist. They complained to the Quebec Human Rights Commission, the Haitian embassy protested, the Red Cross was picketed, and donations fell off, exacerbating the blood shortage. "As a humanitarian and non-discriminatory organization...the Red Cross was particularly sensitive to the accusation that it was acting in a racist manner," observes Mr. Justice Krever.

Gay leaders, for their part, worried about being turned into scapegoats for AIDS. They also worried that they would lose, writes Mr. Justice Krever, "the sexual freedom that many had come to enjoy and that had become a defining element of the gay community." However, many leaders decided the problem was real and chose to help as best they could. In a March 22 meeting with Dr. Derrick, gay spokesmen warned the Red Cross that some gays might prefer to let the blood supply become tainted if they were not given a chance to withdraw their blood confidentially. They also warned that the gospel of self-exclusion was unlikely to reach homosexuals who were "outside the gay community" because they were in the closet or the homosexual underworld.

On March 24 Dr. Derrick informed a meeting of Red Cross medical directors that the number of American AIDS cases, at the time 1,250, was expected to reach at least 8,000 by the end of the year. He also warned of an imminent crossover into the heterosexual population. Dr. Derrick estimated that Canada was about 18 months behind the U.S. in the spread of AIDS and argued that many cases could still be prevented. However, when informed that some B.C. nurses were discarding blood tagged as coming from high-risk individuals, Dr. Perrault insisted—according to the formal minutes of the meeting—that blood from high-risk donors was "not to be singled out at the moment."

In his testimony to the inquiry, Dr. Perrault claimed that he only meant that the risk-group status should not be marked on the patient's record. But Mr. Justice Krever thinks that claim rings hollow; Dr. Davey told the same March 24 meeting that "no centre should be asking any questions other than the basic: 'Are you well?' and most definitely, no centre should be conducting its own diagnostic quiz for AIDS."

Five days later, at a meeting of the Red Cross AIDS working group, Red Cross honorary counsel Michael Worsoff said that the Red Cross had, "above all," a moral and legal obligation to assure the safety of the blood it accepted. The agency, he argued, must not wait for rigorous scientific proof before taking strong measures to contain the disease, nor should it worry about occasional complaints of discrimination. But despite the mounting concerns about AIDS, the possibility that it was blood-borne, the warnings of legal culpability, and the likelihood that voluntary self-exclusion would not work, Drs. Perrault, Davey and Derrick continued with their program.

The Red Cross public information "campaign" consisted initially of two press releases and a letter from Dr. Derrick to the directors of local blood centres. The letter, delivered in July 1983, provided an incomplete list of contact names for gay organizations and asked blood centre directors to work out local communications strategies. Some directors did, some did not, and the head office made no follow-up efforts. Dr. Davey testified that the Red Cross worried that if some members of the gay community were sufficiently provoked by discriminatory policies, they would deliberately donate in protest. "At this time, no gay person in Canada had ever made such a threat," wrote Mr. Justice Krever.

Homosexual communities in some cities did begin their own communication campaigns, which were as blunt as anything in the U.S. "If you're here," read one poster in Vancouver bath houses, "don't give blood, now, more than ever." If gays were found responsible for the spread of AIDS, there could be "dangerous repercussions," the poster warned. A 1985 study found that, given its large gay population, Vancouver's rate of transfusion-related AIDS was half of what was expected.

On May 30, 1983, Dr. Davey, who is not an epidemiologist, wrote a memorandum in which he divided the number of reported full-blown AIDS cases in the U.S. by the number of transfusions. He concluded incorrectly that the chances of getting AIDS from the blood supply were 1.5 in a million. He did not account for cases where the symptoms were less than full-blown, or for the thousands who had AIDS but were showing no symptoms. The "1.5 in a million" figure was cited several times over the next few months by Dr. Derrick and other Red Cross officials to explain why they were not taking more direct action.

In July 1983 four months after the U.S. and most other developed countries were explaining risk groups and AIDS symptoms to blood donors, the Canadian Red Cross began to consider following suit. A 400-word brochure took another 10 months to produce. When it finally got to the clinics in May 1984, it was used sporadically or not at all. It was badly written and said nothing about AIDS symptoms—only that donors should be in "good health." AIDS's long latency period, already well known, made this warning all but worthless. However, at least it asked homosexuals with "multiple partners" not to donate, though it did not quantify "multiple."

When the brochure was finally redrafted in the summer of 1985, it said that "active homosexual or bisexual males" should refrain from donating, leaving the door open for temporarily inactive homosexuals. By that time in the U.S., the criterion for exclusion had advanced to "any male that has had sex with another male since 1977." "There is no reasonable explanation for [this discrepancy between countries]," writes Mr. Justice Krever, adding that U.S. blood collectors had adequate pamphlets in place within days of being told to do so by federal authorities.

He also lambastes the Red Cross for refusing to step on a few toes when the possible alternative was allowing a fatal disease to contaminate the national blood supply. He shows that the Red Cross knew of U.S. rules that allowed homosexual men to withdraw their donations with a discreet telephone call without revealing their sexual habits. Because of this and other methods, American donation levels had suffered little. The Red Cross did not adopt the measures.

In November 1983 Dr. Derrick argued that "There are many now who consider that the importance of AIDS as a threat to public health in this country has been overrated." The question whether AIDS was blood-borne was settled two months later by a January 1984 article in the New England Journal of Medicine. Dr. Davey interpreted this study as "only a statement that increased the odds considerably." But in the same month a memo from a Red Cross staffer confided that "Dr. Derrick has shared his profound concerns of our culpability when (not if) Canadian doctors identify transfusion-related cases of AIDS. The attached copy from the January 9th Globe and Mail indicates we are routinely screening for AIDS. I believe this would be difficult to prove."

By March 1984 there were 37 adults and eight children in the U.S. who had almost certainly contracted AIDS through blood transfusion. Nevertheless, the Red Cross prepared an article for the Canada Diseases Weekly Report that stated that "There is currently no available evidence that blood transfusion recipients are at higher risk of developing AIDS."

After a test for the presence of HIV antibodies was developed in January 1985, it was apparent how pervasive the virus had become among the high-risk groups. Various U.S. studies showed HIV antibodies present in 22% to 65% of homosexual males, 87% of intravenous drug users and 56% to 72% of persons with type-A hemophilia. Drs. Davey and Perrault testified at the inquiry that they were "overwhelmed by new discoveries" about AIDS and were not convinced until 1985 that it could be spread through transfusions.

"By the summer of 1985, the senior RC officials still did not appreciate the serious threat that AIDS posed to the blood supply," writes Mr. Justice Krever. He concedes that it is easy to be critical in hindsight, but he still insists that the Red Cross should have known sooner.

Dr. Davey told a July 4, 1985, federal-provincial AIDS meeting that if HIV antibody testing had been available in 1980, it would have prevented only three cases of AIDS. He was wrong. In all, 1,148 cases of AIDS were eventually attributed to transfusions done between 1978 and 1985. The introduction of an affordable screening test for the AIDS virus should have reduced the danger to the blood system, but the Red Cross did not start using the test until the fall of 1985, eight months after it became available. In the meantime, 133 transfusion recipients got HIV.

As time wore on, explains Mr. Justice Krever, the Red Cross began delegating decisions on sensitive issues to outside agencies, like the National Advisory Committee on AIDS, because it wanted somebody else on the hook in case of another public relations disaster. In addition, its relationship with the Canadian Blood Committee, the joint federal-provincial agency that funded the blood program, had soured because of conflicts over money and procedure. Consequently, the funding for the virus-screening program was not approved until August 1985 and implementation was delayed until November for what were explained as scheduling reasons.

Once the AIDS test became available, the Red Cross was supposed to test its blood stores and notify both donors and recipients of tainted products. However, the provinces took no leadership in this issue and "the federal government disregarded invitations for it to act," leaving the Red Cross on its own, says Mr. Justice Krever. Consequently, the Red Cross had no "look-back" (recipient identification) and "trace-back" (donor identification) policies until 1987. By 1988, only 20% of look-backs had been completed.

Hemophiliacs, the Canadians most vulnerable to blood mismanagement, were not yet out of the woods just because HIV screening had been adopted. Hemophiliacs require regular doses of "factor concentrates" made from donated blood; these concentrates cause clotting and prevent the hemophiliac from bleeding to death if he is cut or needs surgery. Given the state of the blood supply, hemophiliacs regularly had to choose between risking death by refusing treatment and risking death from AIDS or hepatitis. By 1985 some 800 Canadian hemophiliacs had been infected by tainted blood products.

In the early 1980s researchers discovered that heat-treating killed a variety of viral agents, such as hepatitis. In October 1984 researchers in the U.S. discovered that it also killed the AIDS virus in factor concentrates. Accordingly, the Red Cross planned to convert to heat-treated products. However, in those days, shortages of factor concentrates regularly became crises; the Red Cross thus decided that it would use up its store of untreated products rather than let them go to waste. This saved the agency some money and forestalled the possibility of a shortage. On two occasions, the Red Cross deliberately misled hemophiliacs and their doctors, not telling them that improved products were available, because the agency feared a rush on heat-treated products.

Moreover, writes Mr. Justice Krever, it took eight months to get the safe products into service. Dr. Davey testified that the Red Cross needed the Canadian Blood Committee's permission to purchase more expensive products from the U.S. Mr. Justice Krever says that the Red Cross did not really need permission, but acrimony flared up between the agencies whenever the Red Cross spent substantial sums without prior approval. In addition, the Red Cross took flak from the committee every time it made decisions that hurt the interests of an Ontario blood-products manufacturer.

The federal Bureau of Biologics ordered that the transition to heat-treated products take place "as soon as possible" and then disappeared from the process. But Mr. Justice Krever notes that the bureau had the authority to insist that blood donors be told the symptoms of AIDS; to require donors to be asked if they belonged to a high-risk group or if they had the symptoms of AIDS; and to ask that high-risk donors be excluded from donating. The bureau did none of those things, even though its only job was to ensure the safety of blood products for Canadians.

Mr. Justice Krever concludes his report with a description of the consequences of the tragedy. Of the 1,148 who got AIDS through blood transfusions before 1985, 627 had died by 1993, and of the 521 then still living with the virus, 274 were showing AIDS symptoms. Between 1986 and 1990, after the introduction of heat-treated products and the AIDS screening test, 28,600 people were infected with hepatitis C by blood transfusions. If adequate screening techniques, which were available in 1986, had been introduced then, 85% of those infections would have been prevented.

Mr. Justice Krever estimates that the number of people needlessly infected with hepatitis C between 1980 and 1986 is much higher, driving the total number of preventable infections to over 60,000. Three quarters of Canada's 2,500 hemophiliacs now have hepatitis C, which causes fatal illnesses such as cirrhosis and liver cancer in 15% to 20% of sufferers.

But "statistics are impersonal and abstract," observes Mr. Justice Krever, so he recorded anecdotes from the victims. A 55-year-old man was given a transfusion in 1983 without his knowledge and discovered 10 years later that he and his wife had AIDS. In 1985, a premature infant was given a tablespoon of blood for reasons still unknown, and seven years later, coughing relentlessly, he died of AIDS. A mildly hemophiliac boy was given untreated blood factor concentrates in 1985, instead of a safer product the family requested, developed AIDS and died in 1993. In 1989 a 40-year-old woman received a tiny transfusion during dental surgery and was diagnosed with hepatitis C the following year.

An AIDS-infected hemophiliac writes, "Some of us were so frightened and confused that we did not even kiss, hug or touch our children for three years for fear of contaminating them." People who contracted AIDS from transfusions have been receiving about $30,000 annually in compensation. Mr. Justice Krever recommends that the government provide no-fault compensation for those infected with hepatitis C. About $3-billion worth of class action lawsuits have been filed by hepatitis C victims. After the report's November 26 release, Health Minister Allan Rock apologized profusely on behalf of the federal government and promised to consult with the provinces about compensation.

Mr. Rock's apologies and those of current Red Cross president Gene Durin rang hollow in many quarters. For years the Red Cross has denied any responsibility for the debacle. It paid Drs. Perrault and Davey $100,000 and $50,000 respectively to testify at the inquiry. (Dr. Derrick is deceased.)

As justice minister in 1996, Mr. Rock led a coalition of the Red Cross, the federal government, six provincial governments, five pharmaceutical firms, and 64 individuals in asking the Federal Court of Canada to prevent Mr. Justice Krever from naming names in his report. They were afraid that civil and criminal sanctions would result. After a delay of 20 months, the Supreme Court ruled that he might name names, and he has—but his report does not finger any politicians.

This could be because in 1989 the Canadian Blood Committee's executive director, Dr. Jo Hauser, ordered that all records of blood committee meetings from 1982 to 1989 be destroyed. This order was given 15 days after an access-to-information request for the materials was filed. The records, detailing the decisions of provincial and federal health ministers as represented by their deputy health ministers, were potentially incriminating.

The RCMP are looking into the incident, along with the rest of the report, to see whether criminal charges are warranted. Lindee David, executive director of the Canadian Hemophilia Society, reports that the society has filed a complaint with the RCMP. "The senior political figures, the health ministers of the day, were never called to testify," she says. "What were the bases of some of those decisions? We just don't know."

Civil suits against blood systems and governments have been successful to varying degrees in different parts of the world, and most governments have initiated compensation programs. Besides compensation, Mr. Justice Krever has recommended that a new, independent blood agency be created and that the Red Cross be excluded from the system. He also believes that governments should increase their funding and tighten their regulatory watch.

Ottawa has been working on a new system since March 1996, but Reform health critic Grant Hill is not impressed. "Who will ensure that [Mr. Justice Krever's recommendations] are implemented?" he asks, pointing out that several faces from the old regime are appearing in the new one. "I call it an old skeleton in new clothes."

As a doctor, a citizen and a long-time believer in the Red Cross, he says "I feel betrayed by what happened. I was let down and the people who contracted diseases were let down even more. This is what happens when political correctness takes precedence over public health."

—Les Sillars

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