A damning report about the tainted-blood scandal in Britain – the “worst treatment disaster” in the country’s history – has just been released, decades after Canada’s own reckoning.
The 2,567-page opus by Sir Brian Langstaff published last week came to conclusions that were eerily familiar for those who read then Ontario Court of Appeal justice Horace Krever’s relatively modest 1,138-page tome about our crisis, which was released in 1997:
- Officials knew that the HIV and hepatitis C pathogens were likely blood-borne, but were slow to implement screening and other precautionary measures;
- When testing became available, there were implementation delays;
- Blood products used principally by hemophiliacs were highly infected, but there was a reluctance to purchase products that were 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;
- Because of plasma shortages, products were purchased from blood brokers with dubious sources, such as U.S. prisons;
- There was little effort to reduce the use of blood transfusions, and patients were not told of the risks;
- Contact tracing was slow, so those who were infected were not notified promptly and they, in turn, infected their loved ones;
- When the severity of the blood scandal began to become clear, health officials and politicians worked to cover up the details.
Perhaps most importantly of all, both learned judges concluded that the devastation that resulted – 1,250 infected with HIV (including 380 children) and 26,800 with hepatitis C in Britain, and 2,000 Canadians infected with HIV and 30,000 with hepatitis C, along with unfathomable suffering and financial pain for so many hemophiliacs, transfusion recipients and their families – was largely, though not entirely, preventable.
In his report, Sir Brian concluded that there was no organized cover-up, in the sense of a vast orchestrated conspiracy to mislead. But cover up, officials did: “To save face and to save expense, there has been a hiding of the truth,” he wrote.
One of the most enlightening and damning aspects of the new infected-blood inquiry report is the insight it provides on how the governmental decision-making process contributes to this type of disaster.
Sir Brian said the way politicians and policy makers obtain and digest evidence they use as a basis for their decisions is deeply flawed. First of all, he wrote, evidence is embraced in a highly selective manner, often with an overreliance on select experts whose narrative aligns with the government’s. In Britain’s case, the report singles out the late hematology professor Arthur Bloom, the former chairman of the UK Haemophilia Centre Directors’ Organisation who systemically downplayed the risk of blood-borne pathogens for hemophiliacs.
Governmental decision-making is slow, often to the point of being obstructionist, which is particularly harmful when a pathogen – be it HIV, hepatitis C or COVID-19 – is blazing a trail of destruction.
Institutional defensiveness and the closing of ranks is also the norm, Sir Brian noted, meaning that even those with doubts are silenced.
The bureaucratic culture is incapable of admitting mistakes. As a result, errors are covered up rather than corrected, and typically, no lessons are learned. In the case of tainted blood, that included everything from deliberately misleading statements (read: lying) to the shredding of records.
Governments are also infected with the sickness of secrecy, which is particularly dangerous in the health field, as the tainted-blood scandal gruesomely demonstrated.
While some actions (and inaction) were unconscionable, many decisions were well-intentioned, albeit deadly – for example, the belief that hemophiliacs would have been deprived of life-saving treatments had they not received contaminated blood products.
But, as Sir Brian wrote, “this sadly does not diminish the appalling nature of what occurred.”
When the report was released, Prime Minister Rishi Sunak called it a “day of shame for the British state” and apologized unreservedly. It was a welcome statement, though it came a few decades too late.
The British government also announced the broad outline of a compensation plan for victims of tainted blood and their family members, one that could offer up to £2.5-million ($4.35-million) to individuals and cost a staggering £10-billion ($17.4-billion) in total. (To date, Canadian victims have received roughly $5-billion from various compensation plans.)
The ultimate irony here is that many deadly decisions were motivated by short-sighted cost-saving.
When Sir Brian’s report was released, British victims of tainted blood cheered and wept – just as Canadians had when Mr. Krever unveiled his findings. These are the emotions that come with long-awaited vindication. Massive tragedies such as tainted blood remind us that embracing prevention is essential financially, but it is important to remember that it is morally essential, most of all.