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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.

Yet, in the end, despite gross ineptitude and willful blindness to the safety of patients, there was a single criminal prosecution: The Red Cross paid a $5,000 fine for distributing a contaminated drug. Four senior Red Cross and Health Canada officials were also charged, but they were acquitted.

The victims also trod a long, arduous path to obtain some justice and, after class-action lawsuits were launched, governments settled out of court and have paid out an estimated $5-billion in compensation.

The good news is Canada has a much safer blood system today. Canadian Blood Services is better administered, more transparent and regulated properly.

There has not been a single case of a patient infected by contaminated blood since the Krever report was tabled.

Yet, debates about blood safety persist, namely about the issue of paid plasma. The Krever report said all blood collected should be "voluntary and unpaid, except in rare circumstances."

Blood products are increasingly used, but Canada is not self-sufficient – only about 17 per cent of products such as intravenous immunoglobulin (IVIg) are made with plasma collected in Canada; the balance are imported, largely from the United States, where plasma donors are paid.

Now a private company, Canadian Plasma Resources, has set up shop in Canada, and it pays donors. Another company, Green Cross Biotherapeutics, is building a plant in Montreal to produce albumin and IVIg. Meanwhile, Canadian Blood Services is trying to bolster voluntary donations.

This is a complex issue, explored in depth in a recent Maclean's magazine article.

One of the lessons of the tainted-blood scandal is that the jingoistic belief that voluntary Canadian blood is inherently safer is wrong. At the same time, the enormous profits that can be made from blood products can incite manufacturers to seek out donors, even risky ones.

The key is having firm standards and forceful regulation – not areas where Health Canada has excelled.

To avoid another tainted-blood scandal, we need to be vigilant. We know our history, but also our limitations and, above all, we must debate the benefits and risks of our blood collection and distribution methods openly and vigorously.

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