The Canadian Red Cross Tainted Blood Scandal spanned decades and to this day, individuals, families, groups and the nation feel its deadly impacts. The Canadian national blood supply was contaminated with two infectious viruses, Hepatitis-C and HIV during the late 1970s, 1980s and the early 1990s. This was the worst tragedy in Canadian medical history with over 20,000 Canadians infected after receiving blood or blood factors to treat their illnesses or during surgery.
1. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011
The Canadian Red Cross Tainted Blood Scandal
a sociological analysis
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2. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011
Abstract
The Canadian Red Cross Tainted Blood Scandal spanned decades and to this day, individuals,
families, groups and the nation feel its deadly impacts. The Canadian national blood supply
was contaminated with two infectious viruses, Hepatitis-C and HIV during the late 1970s, 1980s
and the early 1990s. This was the worst tragedy in Canadian medical history with over 20,000
Canadians infected after receiving blood or blood factors to treat their illnesses or during
surgery. Most of the people infected with HIV died. The Canadian Federal government
commissioned an Inquiry into the Blood System in Canada headed by Justice Horace Krever on
October 4, 1993. The report places blame on the Canadian Red Cross, the Federal government
and the Provincial governments for dysfunctional management, inadequate funding and failing
to act in a responsible manner. The Krever Commission report triggered sweeping changes
including the establishing the Canadian Blood Services agency to replace the Canadian Red
Cross Society to manage the blood supply system in Canada.
This paper provides a sociological analysis of the Canadian Red Cross Tainted Blood Disaster.
The paper covers the following topics (a) Background – the State of the Canadian Blood System,
Methods of Transmission and Infection, Detecting and Testing Blood Donations, Compensation
for Victims, Federal Commission of Inquiry, and Criminal Negligence and Responsibility (b)
Sociological Analysis – Disaster Categorization and Typology, Memory and Trauma, Toxic and
Non Toxic Threats, Individual and Collective Trauma, and Risk Amplification and (c) Conclusions
and (d) Appendix 1.
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Background
The State of the Canadian Blood System
The Canadian national blood supply managed by the Canadian Red Cross Society was
contaminated with two infectious viruses, Hepatitis-C and HIV during the late 1970s, 1980s and
into the early 1990s. The Canadian Red Cross ran the blood supply system since 1947. They
started out as a self-funded organization but over time began to rely more on government
subsidies. This was due to the increased demand for blood products in the Canadian Health
Care system. By 1974, the governments (federal and provincial) fully funded the blood service.
Justice Krever stated “The relationship between the Red Cross and the governments, and their
committees, was poorly defined and was often dysfunctional.” (Krever, 1997, p. 986) By the
1970s, Hepatitis was a known disease but only in its Hepatitis-A and Hepatitis-B forms. By the
end of this calamity, Hepatitis-C was identified and could be precisely tested for but not before
many people were infected with it by receiving blood transfusions and blood products. The
longer term impacts of Hepatitis-C are not fully understood but most patients develop ongoing
hepatitis as well as liver damage or liver cancer. While investigations into Hepatitis continued,
a new disease began to emerge. This turned out to be HIV and again the blood system proved
to be the infection media for AIDS. Infection with HIV inevitably leads to AIDS and eventually is
fatal. Justice Horace Krever specifically stated that “It is necessary to understand the historical
and institutional context in which those efforts were made. The description of that context is
focused, although not exclusively, on 1982, the year in which a relationship first was recognized
between infection with AIDS and the use of blood components and blood products. The most
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important measures to prevent or to minimize the risk of AIDS and Hepatitis-C were taken after
that year.” (Krever, 1997, p. 43)
Methods of Transmission and Infection
There were two main ways that people became infected with one or both viruses. The first
method was via blood transfusion usually in a hospital environment. The transfusions provided
patients with red blood cells, platelets and plasma and were usually given to surgery patients.
The second infection method occurred with patients receiving blood factor concentrates. The
main patients requiring these blood products were hemophiliacs. Once a test was created to
detect the HIV virus, and the symptoms of AIDS were showing up in homosexual men and
hemophiliacs with no history of homosexual behavior, the common factor became the blood
supply. By 1993, over 700 Canadian hemophiliacs were infected with HIV via blood
transfusions and receiving blood factors. Secondary infections occurred in some partners of
the people who unknowingly were infected by tainted blood products in both the United States
and Canada.
Detecting and Testing Blood Donations
In March 1985, the US Food and Drug Administration (USFDA) approved and licensed
companies to distribute HIV-antibody testing kits. By May 1985, all US blood and plasma
collection centers were testing donations for the presence of HIV. In August 1985, the
Canadian Blood Committee approved funding for testing of blood donations for the presence of
HIV-antibodies. It took until Nov 1985, for the Canadian Red Cross began testing all blood
donations for HIV. The USFDA recommended a dual test for Hepatitis-C in February 1986.
Some US blood fractionators actually start testing for Hepatitis-C in November 1985. In April
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1986, the American Association of Blood Banks decides to implement Hepatitis-C testing. In the
same month, the Canadian Red Cross rejects testing for Hepatitis-C pending more testing. “The
Canadian Red Cross decides tests might prevent a small number of cases at a cost of $20
million.” (CBC News, 2007) This is a key difference in the two blood systems response to
Hepatitis-C tainted blood supplies. It took 4 more years, June 1990, for the Canadian Red Cross
to begin testing for the Hepatitis-C HCV-antibody in blood products. But unscreened plasma
continued to be used for up to 2 more years before all blood products were tested. (CBC News,
2007) The Krever Commission reported that 95% of hemophiliacs who received blood products
before 1990 were infected with Hepatitis-C. (CBC News, 2007) Detailed time lines for both HIV
and AIDS from 1981 to 1994 (Krever, 1997, pp. xxi - xxviii) and Hepatitis from 1965 to 1995
(Krever, 1997, pp. xxix - xxxii) can be found in Volume 1 of the Krever Commission Report. The
CBC News site also provides a timeline from 1971 to 2007 explaining the milestones of virus
detection, blood services actions, government responses and the final outcome of criminal
negligence trials for Red Cross and government officials. (CBC News, 2007)
Compensation for Victims
The victims of the Canadian Tainted Blood Scandal have had a long road to seek compensation.
The Canadian Federal government announced a compensation package for 1,250 Canadians
who contracted HIV from tainted blood for a total amount on $150 million CAD on December
14, 1989. On March 27, 1998, Federal and Provincial Ministers of Health announced a new
compensation package worth $1.2 billion CAD for people who contracted Hepatitis-C between
the years 1986 and 1990. (CBC News, 2006) Their reasoning was that there was no valid test
before 1986 and that full scale tests began in 1990. Unfortunately, this excluded another
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20,000 Canadians who were infected outside that four year window. Due to the outrage,
British Columbia, Ontario and Quebec petitioned the Federal government to compensate all
victims who received tainted blood. The federal government voted down the motion on April
28, 1998 and stated that the file was closed. Ontario unilaterally provides an additional $200
million CAD for their impacted residents which has been estimated at 20,000 people. (CBC
News, 2006) So far the victims of the tainted blood scandal had not received any compensation
and many hundreds died waiting. Ontario and Quebec finally approve the March 1998
compensation deal in September 1999 – 18 months after it was announced. In the meantime,
the Canadian Red Cross announces $60 million CAD compensation for people infected before
1986 and after 1990. The Federal government decides to look at how to compensate victims
who were excluded in the 1998 compensation package. The Canadian House of Commons
unanimously passes a bill to add another 5000 people to the compensation package. In July
2006, a $1 billion CAD compensation package is announced by the Federal government to
address the 5,500 people infected with Hepatitis-C before 1986 and after 1990. Checks were
expected to be finally distributed to the victims in 2007.
Federal Commission of Inquiry
The Federal Government authorized a Commission of Inquiry in October of 1993 and appointed
Justice Horace Krever from the Ontario Court of Appeal to be the commissioner. The original
mission of the commission was to “review and report on the mandate, organization,
management, operations, financing and regulation of all activities of the blood system in
Canada, including the events surrounding the contamination of the blood system in Canada in
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the early 1980s.” (Krever, 1997, p. Appendix A 1081) Further, Justice Krever states in his report
that the commission would “examining, without limiting the generality of the inquiry:
• The organization and effectiveness of past and current systems designed to supply
blood and blood products in Canada
• The roles, views and ideas of relevant interest groups; and
• The structures and experiences of other countries, especially those with comparable
federal systems.” (Krever, 1997, p. 5)
Note, nothing was said about finding blame or bringing charges forward as part of the original
mandate of the commission. The commission had its deadlines extended twice and cost
taxpayers over $16 million CAD from an original budget of $2.5 million CAD. “As the inquiry got
to work on Nov. 22, 1993, Krever promised that he would not be concerned with criminal or
civil liability — but by November 1995, he said charges of misconduct might be brought forward
at some point and that he had an obligation to warn people they might be accused of
wrongdoing.” (CBC News, 2006)
Criminal Negligence and Responsibility
It was only as the Justice drafted his report that he was obliged to give notice to parties that
were mentioned in the report with comments that could be interpreted as misconduct. Justice
Krever notified a total of 95 people, corporations and governments on December 21, 1995.
Some of the organizations notified began legal proceedings in the Federal Court of Canada to
challenge the Commission’s jurisdiction and Justice Krever’s mandate in January 1996.
(Canadian Federal Court of Appeal, 1997) This action delays the release of the report until
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November 1997. In the end, 14 Red Cross officials and three federal officials are specifically
named for misconduct. (CBC News, 2007) In December 1997, the Royal Canadian Mounted
Police (RCMP) announces they are conducting a review of the report to see if a criminal
investigation is required. By February 1998, the RCMP launches a criminal investigation and
solicits help from the Canadian public.
In January 1999, a group of over 1000 hemophiliacs launch a $1 billion CAD lawsuit against the
Canadian Federal Government specifically for using blood purchased from United States jails.
On April 19, 2001, The Supreme Court of Canada delivers a negligence ruling against the
Canadian Red Cross. The Canadian Red Cross, four physicians and a US based pharmaceutical
company are charged criminally by the RCMP in November 2002. In a plea bargain, the
Canadian Red Cross pleads guilty to “distributing a contaminated drug” (CBC News, 2007) and is
fined a total of $5,000 CAD. (BBC News, 2005) All other six criminal charges are dropped. Dr.
Pierre Duplessis, CEO of the Canadian Red Cross Society issued a public apology on May 30,
2005 to the Canadian public. “We profoundly regret that the Canadian Red Cross Society did
not develop and adopt more quickly measures to reduce the risks of infection, and we accept
responsibility …” (Canadian Red Cross, 2005)
The four doctors, (Dr. Roger Perrault, the head of the Canadian Red Cross, Dr. John Furesz and
Dr. Donald Wark Boucher, both of Canada’s Health Protection Branch and Dr. Michael Rodell,
former Vice President of a New Jersey based pharmaceutical company were all acquitted for
their roles in the tainted blood scandal. (CBC News, 2007)
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Sociological Analysis
Disaster Categorization and Typology
In SOC 600 Module 1a, I proposed a structure to categorize the type of crisis. Using the three
words, Tragedy, Disaster and Catastrophe, I proposed an escalating continuum. When I think
about Tragedy, Disaster and Catastrophe, I think about differences of impact and scale for each
in a continuum of increasing magnitude. Tragedy has less impact and scale than Disaster which
in turn has less impact and scale than Catastrophe. Tragedy brings images of personal impact
and loss that begins on a small scale. Disaster evokes images of human as well as natural causes
that impact a group of people on a larger scale. Catastrophe implies a large number of people
or things impacted on a national level scale. Another categorization that we could apply to
these descriptions are: loss of life (human and natural) and loss of finances. There are times
when financial loss is not directly related to loss of life but inevitably loss of life is directly tied
to financial loss. (de Sousa, 2011)
Several weeks later in SOC 600 Module 2b, I incorporated Kai Erikson’s concept of collective
trauma and Pierre Bourdieu’s concept of “habitus”. (Britton, 2011) I added a further scale to
the definition “loss of habitus”. Habitus is “the set of socially learnt dispositions, skills and ways
of acting, that are often taken for granted, and which are acquired through the activities and
experiences of everyday life.” (Wikipedia, 2011) If an event has all 3 attributes of loss of life,
loss of finances and loss of habitus, it must be categorized as a catastrophe. (de Sousa, 2011)
The Canadian Red Cross Blood Scandal is a catastrophe base on the scales I defined. There was
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loss of life, finances and destruction of habitus particularly for the people (especially
hemophiliacs and their families) who trusted the blood system to be safe.
Using Barton’s Collective Stress Situation Typology, this disaster is classified as a national scope
of impact, gradual onset with long duration impact and low social preparedness. In fact, this
was a global catastrophe as every country that provided blood transfusions had the same
challenges. The difference was that most other countries acted sooner and erred on the side of
caution. The failure of the Canadian Red Cross and government health authorities (federal and
provincial) radically shook the confidence of the Canadian public. Donating and receiving
blood is considered a critical medical service by all Canadians but was not treated as such by
the Federal and Provincial governments. From underfunding to disconnected policies, the
governments put the Red Cross in a no win situation that was at odds with the mores of
Canadian culture. With the revelations of the Krever Inquiry, the habitus of trusting medical
authorities was severely damaged. This lack of trust remains today even though a new
organization has been responsible for the blood system for over 10 years. All levels of social
structures in Canada were impacted by the negligent actions of the Red Cross and the
governments in Canada. Hemophiliacs were particularly devastated as their disease requires
regular blood transfusions to help with bleeding. The damage to these individuals and their
families can never be compensated for. Dombrowsky’s quote “Disasters do not cause effects.
The effects are what we call a disaster” is very appropriate for what happened to the people
impacted by the Canadian Tainted Blood disaster. (Britton, 2011) The effects of delaying to test
donated blood and blood products caused untold damage and death to the lives of innocent
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people who sought out medical assistance and damaged the confidence in the medical system
in Canada.
A federal commission of inquiry was ordered in Sept 1993 headed by Justice Horace Krever to
investigate the Canadian Blood System. Early in 1994, the Inquiry learns that 95% of
hemophiliacs who used blood products before 1900 contracted Hepatitis-C virus. In November
1997, the Krever Inquiry releases its report condemning the Red Cross, and Federal and
Provincial governments for ignoring warnings and acting irresponsibly. The report estimates
that 85% of the 28,600 people infected with Hepatitis-C between 1986 and 1990 could have
been avoided. The result of the report was the creation of Canadian Blood Services to ensure
that the blood supply in Canada was treated as a national asset and that the organization had
all the authority to protect the safety of the blood supply.
Memory and Trauma
Kenneth Foote (2003), a cultural geographer, has examined how physical space is impacted by
tragic and violent American events. He states that there are four possible ways that societies
alter landscapes that are sites of violence and/or tragedy: sanctification, designation,
rectification and obliteration (Foote 1993: 7-16). (Britton, 2008, p. 10)
The Canadian Red Cross Tainted Blood Scandal, the landscape was altered in multiple ways.
The first was obliteration; the Canadian Red Cross was removed from managing the Blood
Supply in Canada and the provincial governments were also removed from funding. The
second action was rectification; the federal government created a national agency, Canadian
Blood Services, to be fully empowered to manage and protect the blood supply in Canada. The
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compensation to the victims, even though it was long delayed and took many court cases
eventually provided some rectification to the victims and their families. We could also argue
that designation also played a role in shaping the new Canadian Blood Services. Looking at the
Canadian Blood Services website we can see this by the statement on their About page:
“Canadian Blood Services is committed to blood safety. In addition to the effective
screening and testing processes, this pursuit of safety is reflected in every branch of its
organizational structure and in each management and operational decision that is
made.” (Canadian Blood Services, 1998)
This statement clearly reflects the need to ensure Canada’s blood supply is never put in
jeopardy again. Justice Krever’s report was the blueprint for the creation of the Canadian Blood
Services. In this way, we have learned from our mistakes in the past and planned for a better
future.
Finally, there is sanctification of the tragedy. On November 26, 2007, the Canadian Hemophilia
Society (CHS) launched a Commemoration of the Tainted Blood Tragedy, now an annual event.
They began a memorial forest by planting the first tree at the Canadian Blood Services (CBS)
office in Ottawa. Pam Wilton’s RN (President of CHS) speech on that day fits the Foote’s
sanctification model of altering our environment.
“The tree is a powerful symbol. Those who see it in this public place will recognize it as
a symbol of hope. Hope for those Canadians living with HIV and Hepatitis-C. And hope
for those needing a blood transfusion. Those who pass by it on their way into work at
CBS will be reminded of the vital work they do each and every day, and of the trust
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Canadians place in them to keep our blood system safe and secure.” (Canadian
Hemophilia Society, 2008)
Toxic and Non Toxic Threats
Erikson suggests that hazards can be categorized as toxic and non-toxic threats. Toxic threats
involve many involving technology results in contamination that impacts air, water, sea and
land in a negative way. Toxic threats involve more uncertain impacts compared to non-toxic
threats which are typically natural disasters. The Tainted Blood Scandal fits with Erikson’s Toxic
threats that “render innocuous or beneficial things dangerous” (Clarke & Short, 1993, p. 378)
There can be no doubt that the negligence of allowing the national blood supply to be
contaminated with HIV and Hepatitis-C viruses rendered “lifesaving” blood donations
dangerous. The Red Cross leadership decided to put more emphasis on ensuring there were
sufficient donors and protecting strained budgets than protecting the safety of the blood
supply. Krever called this a “delay in adopting preventative measures”. (Krever, 1997, p. 989)
“If the Red Cross had introduced appropriate risk-reduction measures promptly, without
awaiting full scientific proof, fewer persons would have been infected with HIV and hepatitis.”
(Krever, 1997, p. 990)
Clarke and Short reference four social science responses (Clarke & Short, 1993, p. 383):
• Social constructionism – the notion of objective risk is fundamentally flawed to begin
with
• Normalize the irrationality by showing that hardly anyone makes decisions rationally
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• Non experts are fact rational but in nonobvious ways that are neglected by traditional
approaches of probability theory and benefit/cost logic
• Fairness, competence and responsibility about how decisions are made concern people
Considering these responses, we can see how the Red Cross’s actions amplified the risk to the
blood supply. While the Red Cross was aware of blood testing, they were more focused on
financial stability (primarily due to the decentralized nature of funding from each province),
undue political influence by provincial authorities who insisted on keeping donations in each
province and a focus on keeping a strong blood donor turnout. Even in the face of strong
scientific evidence that restrictions on high risk donors and blood donation screening needed to
be implemented, the Red Cross ignored the information. This fits with the concept of
“normalizing the irrationality” by diverting focus away from the safety of the blood supply.
Another component was the dysfunctional relationship between the Red Cross and the
governments that funded them. “The relationship between the Red Cross and the
governments, and their committees, was poorly defined and was often dysfunctional.” (Krever,
1997, p. 989) This issue relates to Clarke and Short’s social science response “Fairness,
competence and responsibility about how decisions are made concern people”. Some of the
issues Justice Krever uncovered were:
• Defining the roles in the blood supply system
• Blood donations as a national resource
• Financing the blood supply system
• Operational independence
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Issues of provincial jurisdiction took over the management of the Canadian blood supply
causing shortages in certain urban areas. The provinces assumed funding for the blood supply
in each of their jurisdictions and then were reluctant to share excess due more to politics than
patient need. The Canadian Blood Committee which was made up of representatives of the
federal and provincial health ministries dictated policy to the Red Cross that caused shortages
in blood factor production and allowed for unsafe blood products to remain in the blood
system longer, causing more infections of HIV and Hepatitis-C in Canadians.
Individual and Collective Trauma
One particular group of Canadians were extremely sensitive to the tainted blood supply. These
were hemophiliacs who regularly relied on blood transfusions and supplies of blood factors
(especially blood factor VIII) to treat their disease and to stay alive. To get a perspective, over
1100 people were infected with HIV from blood transfusions; of which 700 of these people
were hemophiliacs or had other bleeding diseases. Approximately 700 to 800 people infected
with HIV from blood transfusions have passed away. Nearly 20,000 Canadians were infected
with Hepatitis-C with the majority being hemophiliacs (over 95%). (CBC News, 2007)
Clarke and Short provided quotes from Tierney and Bolton et al in their paper implying that the
poor suffer disproportionately during disasters. (Clarke & Short, 1993, p. 378) Erikson also
describes a similar understanding “But when one looks in on such scenes from a reflective
distance, it is obvious that human populations are spread out across the earth in such a way
that the most disadvantaged of them are the most likely to be located in harm’s way. So we are
not speaking here of a situation in which disasters seek out the vulnerable but a situation in
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which the vulnerable have already been herded into places where disasters are most likely to
take place.” (Erikson, 1976) There is a parallel here with hemophiliacs in Canada. They have a
rare disease that makes them reliant on the blood system to keep them alive. In many ways,
this dependence is like the “herding into places” that Erikson speaks of. When the one thing
that these people depended upon proved to be unsafe and deadly, their habitus was destroyed.
Think about how you would feel – betrayed, scared and vulnerable because the one thing you
depend on to stay alive is not safe. Imagine the horror of a hemophiliac patient each time they
receive a blood factors not knowing if it will infect them with a harmful virus or not. This level
of individual and collective trauma is extremely damaging. “Individual trauma results from
intense blows to an individual’s psyche that s/he is not equipped to react.” (Britton, 2008, p. 56)
Risk Amplification
Risk amplification refers to actions that increase the likelihood of a risk to occur and also
increase the level of damage inflicted. Risk attenuation refers to actions that decrease the
likelihood of a risk to occur and also decrease the level of damage inflicted. “If potential risks
are maximized, this process is called “risk amplification”; if they are minimized, there is “risk
attenuation” (Lombardi:253-253). A variety of social groups participate in risk amplification and
attenuation.” (Britton, 2011)
Kasperson et al wrote about a Conceptual Framework for Social Amplification of Risk. In their
work, the group identified that “hazards interact with psychological, social, institutional and
cultural processes in ways that may amplify or attenuate public responses to the risk or risk
event.” (Kasperson, et al., 1988, p. 177) Kasperson et al continue by describing the structure of
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the social amplification of risk. Amplification can occur in two stages; the transfer of risk
information and the society’s response mechanisms. Risk signals can be processed by
“individuals … the scientists who communicate the risk, the news media, cultural groups,
interpersonal networks and others.” (Kasperson, et al., 1988, p. 177)
As with any complex disaster, there were many messengers sending risk communications and
many receivers who interpreted them in various ways. The table in Appendix 1 provides a high
level summary of the risk amplification in this crisis. The publishing of the Krever report and the
creation of the Canadian Blood Services agency introduced risk attenuation strategies. Krever
Inquiry Recommendations: (Canadian Blood Services, 1998)
• donated blood is a public resource-Canadian Blood Services must act as a trustee of this public
resource for the benefit of all persons in Canada;
• safety of the blood supply system is paramount-the principle of safety must transcend other
principles and policies;
• the blood supply system should be operated in an open and accessible manner;
• the operator of the blood supply system should be independent and able to make decisions
solely in the best interests of the system;
• the provincial and territorial Ministers of Health should be the members of the corporation;
• the members of Canadian Blood Services should appoint an independent board of directors to
supervise the management of Canadian Blood Services and the members of the board shall
carry out their duties at arm's length from government; and
• the operation of Canadian Blood Services should be managed by both administrative and
medical personnel.
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Conclusions
The Canadian Red Cross Tainted Blood Scandal was the worst medical disaster in Canadian
history. This tragedy was national in scope and impact. Its gradual onset was due to many risk
amplification factors embedded in the Canadian Blood Supply System and the conflict between
federal and provincial politics. As a result almost 20,000 Canadians who received blood or
blood products were infected and so were some of their loved ones. The individual and cultural
impacts continue to influence our society. Due to a dysfunctional management structure,
conflicting value systems, insufficient funding, poor risk estimation and communication of risk,
thousands of innocent Canadians were infected with HIV and Hepatitis-C viruses. Most of the
people infected with HIV died and many of the Hepatitis-C victims are now suffering liver
damage and liver failure. Trust in the Canadian Blood Supply was destroyed as was the habitus
of Canadian hemophiliacs who rely on blood products to live. The Canadian Red Cross Society
was removed from managing the national blood supply system. A new federal agency,
Canadian Blood Services was created based on the findings of the Krever Inquiry.
Are we safe now? I leave the final words to Justice Krever from the Afterword of his report.
“Low as the risk may be of infection with HIV and the Hepatitis-C virus from today’s
blood supply, it is almost certain that infection will occur. When it does, the few
members of our society to whom the risk accrues and to whom the harm results must
be treated more compassionately than their predecessors were, and they must be given
suitable compensation without the necessity of proving fault.” (Krever, 1997, p. 1074)
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Appendix 1
Risk Amplification Matrix – Canadian Red Cross Tainted Blood Scandal
Risk Item Messenger Receiver Risk Impact
Description Amplification
Failure to create Canadian Blood Canadian Red Amplification – No one was
a national blood Committee Cross delays in clearly in charge
policy with no addressing safety or accountable
clearly defined issues for the safety of
roles the blood supply
Provincially Provincial Health Canadian Red Amplification – Provincial
funded blood Ministries Cross increased blood boundaries acted
supply systems shortages and as barriers so
discouraged disincentive to that blood
interprovincial implement risk donations were
transfers to meet reduction not treated as a
shortages strategies natural resource
Insufficient Canadian Blood Canadian Red Amplification – Red Cross was
funding of the Committee Cross provincial unable to
blood supply budgetary limits improve blood
system avoided allowing supply safety
for investments due to lack of
in blood safety funds
Provincial politics Provincial Health Canadian Red Amplification – Red Cross was
dictate suppliers Ministries Cross provincial unable to supply
of blood industrial policy safe factor VIII
fractionation forced the use of resulting in
particularly substandard infections of
factor VIII contractors hemophiliacs
Waiting for full Red Cross Transfusion Amplification – Thousands of
scientific proof Patients insistence by Red patients received
that HIV and Cross on full tainted blood
Hep-C were scientific proof products from
spread by blood delayed blood transfusions
transfusions testing
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Risk Amplification Matrix – Canadian Red Cross Tainted Blood Scandal (cont.)
Risk Item Messenger Receiver Risk Impact
Description Amplification
Underestimate Red Cross Canadian Public Amplification – Estimates of risk
actual risk values inaccurate vastly
and statement of risk understated the
communicated delayed risk true risk to the
that risk was reduction public
minimal for AIDS
Lack of funding Provincial Canadian Public Amplification – Recognition that
to monitor Ministries of no monitoring of patients were
disease Health transfused being infected
outbreaks patients was delayed
occurred significantly
Failure to Bureau of Red Cross Amplification – Unsafe blood
remove unsafe Biologics, Red Red Cross failed products were
products Cross to remove administered to
products and patients
were told to resulting in more
keep unsafe infections
products
Red Cross did Canadian Press Red Cross Amplification – Red Cross did
not promote Red Cross held to not educate the
restrictions for principles of public about the
HIV risk donors impartiality and groups that were
as it conflicted neutrality high risk for
with their contracting AIDS
principles
Red Cross Board Red Cross Canadian Public Amplification – Lack of medical
of Governors the board was expertise
lacked medical unqualified to introduced more
expertise run the blood risk into the
supply system blood system
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References
BBC News. (2005, May 31). Canada Red Cross used HIV blood. Retrieved Jun 25, 2011, from
BBC News: http://news.bbc.co.uk/2/hi/americas/4595039.stm
Britton, D. (2008). Elegies of Darkness: Commemorations of the Bombing of Pan Am 103.
Retrieved Jun 18, 2011, from Syaracuse University, In Dissertations & Theses:
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