Canadian Red Cross Tainted Blood Scandal


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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.

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Canadian Red Cross Tainted Blood Scandal

  1. 1. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011 The Canadian Red Cross Tainted Blood Scandal a sociological analysis Leo de SousaLeo de Sousa 1
  2. 2. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011 AbstractThe 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 supplywas contaminated with two infectious viruses, Hepatitis-C and HIV during the late 1970s, 1980sand the early 1990s. This was the worst tragedy in Canadian medical history with over 20,000Canadians infected after receiving blood or blood factors to treat their illnesses or duringsurgery. Most of the people infected with HIV died. The Canadian Federal governmentcommissioned an Inquiry into the Blood System in Canada headed by Justice Horace Krever onOctober 4, 1993. The report places blame on the Canadian Red Cross, the Federal governmentand the Provincial governments for dysfunctional management, inadequate funding and failingto act in a responsible manner. The Krever Commission report triggered sweeping changesincluding the establishing the Canadian Blood Services agency to replace the Canadian RedCross 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, Compensationfor Victims, Federal Commission of Inquiry, and Criminal Negligence and Responsibility (b)Sociological Analysis – Disaster Categorization and Typology, Memory and Trauma, Toxic andNon Toxic Threats, Individual and Collective Trauma, and Risk Amplification and (c) Conclusionsand (d) Appendix 1.Leo de Sousa 2
  3. 3. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011 BackgroundThe State of the Canadian Blood SystemThe Canadian national blood supply managed by the Canadian Red Cross Society wascontaminated with two infectious viruses, Hepatitis-C and HIV during the late 1970s, 1980s andinto the early 1990s. The Canadian Red Cross ran the blood supply system since 1947. Theystarted out as a self-funded organization but over time began to rely more on governmentsubsidies. This was due to the increased demand for blood products in the Canadian HealthCare 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 theircommittees, was poorly defined and was often dysfunctional.” (Krever, 1997, p. 986) By the1970s, Hepatitis was a known disease but only in its Hepatitis-A and Hepatitis-B forms. By theend of this calamity, Hepatitis-C was identified and could be precisely tested for but not beforemany people were infected with it by receiving blood transfusions and blood products. Thelonger term impacts of Hepatitis-C are not fully understood but most patients develop ongoinghepatitis 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 provedto be the infection media for AIDS. Infection with HIV inevitably leads to AIDS and eventually isfatal. Justice Horace Krever specifically stated that “It is necessary to understand the historicaland institutional context in which those efforts were made. The description of that context isfocused, although not exclusively, on 1982, the year in which a relationship first was recognizedbetween infection with AIDS and the use of blood components and blood products. The mostLeo de Sousa 3
  4. 4. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011important measures to prevent or to minimize the risk of AIDS and Hepatitis-C were taken afterthat year.” (Krever, 1997, p. 43)Methods of Transmission and InfectionThere were two main ways that people became infected with one or both viruses. The firstmethod was via blood transfusion usually in a hospital environment. The transfusions providedpatients 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. Themain patients requiring these blood products were hemophiliacs. Once a test was created todetect the HIV virus, and the symptoms of AIDS were showing up in homosexual men andhemophiliacs with no history of homosexual behavior, the common factor became the bloodsupply. By 1993, over 700 Canadian hemophiliacs were infected with HIV via bloodtransfusions and receiving blood factors. Secondary infections occurred in some partners ofthe people who unknowingly were infected by tainted blood products in both the United Statesand Canada.Detecting and Testing Blood DonationsIn March 1985, the US Food and Drug Administration (USFDA) approved and licensedcompanies to distribute HIV-antibody testing kits. By May 1985, all US blood and plasmacollection centers were testing donations for the presence of HIV. In August 1985, theCanadian Blood Committee approved funding for testing of blood donations for the presence ofHIV-antibodies. It took until Nov 1985, for the Canadian Red Cross began testing all blooddonations 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 AprilLeo de Sousa 4
  5. 5. SOC 600 Sociology of Disasters – Research Paper Aug 12, 20111986, the American Association of Blood Banks decides to implement Hepatitis-C testing. In thesame month, the Canadian Red Cross rejects testing for Hepatitis-C pending more testing. “TheCanadian Red Cross decides tests might prevent a small number of cases at a cost of $20million.” (CBC News, 2007) This is a key difference in the two blood systems response toHepatitis-C tainted blood supplies. It took 4 more years, June 1990, for the Canadian Red Crossto begin testing for the Hepatitis-C HCV-antibody in blood products. But unscreened plasmacontinued 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 productsbefore 1990 were infected with Hepatitis-C. (CBC News, 2007) Detailed time lines for both HIVand 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. TheCBC News site also provides a timeline from 1971 to 2007 explaining the milestones of virusdetection, blood services actions, government responses and the final outcome of criminalnegligence trials for Red Cross and government officials. (CBC News, 2007)Compensation for VictimsThe 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 Canadianswho contracted HIV from tainted blood for a total amount on $150 million CAD on December14, 1989. On March 27, 1998, Federal and Provincial Ministers of Health announced a newcompensation package worth $1.2 billion CAD for people who contracted Hepatitis-C betweenthe years 1986 and 1990. (CBC News, 2006) Their reasoning was that there was no valid testbefore 1986 and that full scale tests began in 1990. Unfortunately, this excluded anotherLeo de Sousa 5
  6. 6. SOC 600 Sociology of Disasters – Research Paper Aug 12, 201120,000 Canadians who were infected outside that four year window. Due to the outrage,British Columbia, Ontario and Quebec petitioned the Federal government to compensate allvictims who received tainted blood. The federal government voted down the motion on April28, 1998 and stated that the file was closed. Ontario unilaterally provides an additional $200million CAD for their impacted residents which has been estimated at 20,000 people. (CBCNews, 2006) So far the victims of the tainted blood scandal had not received any compensationand many hundreds died waiting. Ontario and Quebec finally approve the March 1998compensation 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 before1986 and after 1990. The Federal government decides to look at how to compensate victimswho were excluded in the 1998 compensation package. The Canadian House of Commonsunanimously passes a bill to add another 5000 people to the compensation package. In July2006, a $1 billion CAD compensation package is announced by the Federal government toaddress the 5,500 people infected with Hepatitis-C before 1986 and after 1990. Checks wereexpected to be finally distributed to the victims in 2007.Federal Commission of InquiryThe Federal Government authorized a Commission of Inquiry in October of 1993 and appointedJustice Horace Krever from the Ontario Court of Appeal to be the commissioner. The originalmission of the commission was to “review and report on the mandate, organization,management, operations, financing and regulation of all activities of the blood system inCanada, including the events surrounding the contamination of the blood system in Canada inLeo de Sousa 6
  7. 7. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011the early 1980s.” (Krever, 1997, p. Appendix A 1081) Further, Justice Krever states in his reportthat 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 originalmandate of the commission. The commission had its deadlines extended twice and costtaxpayers over $16 million CAD from an original budget of $2.5 million CAD. “As the inquiry gotto work on Nov. 22, 1993, Krever promised that he would not be concerned with criminal orcivil liability — but by November 1995, he said charges of misconduct might be brought forwardat some point and that he had an obligation to warn people they might be accused ofwrongdoing.” (CBC News, 2006)Criminal Negligence and ResponsibilityIt was only as the Justice drafted his report that he was obliged to give notice to parties thatwere mentioned in the report with comments that could be interpreted as misconduct. JusticeKrever 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 tochallenge 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 untilLeo de Sousa 7
  8. 8. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011November 1997. In the end, 14 Red Cross officials and three federal officials are specificallynamed for misconduct. (CBC News, 2007) In December 1997, the Royal Canadian MountedPolice (RCMP) announces they are conducting a review of the report to see if a criminalinvestigation is required. By February 1998, the RCMP launches a criminal investigation andsolicits help from the Canadian public.In January 1999, a group of over 1000 hemophiliacs launch a $1 billion CAD lawsuit against theCanadian 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 theCanadian Red Cross. The Canadian Red Cross, four physicians and a US based pharmaceuticalcompany are charged criminally by the RCMP in November 2002. In a plea bargain, theCanadian Red Cross pleads guilty to “distributing a contaminated drug” (CBC News, 2007) and isfined 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 didnot develop and adopt more quickly measures to reduce the risks of infection, and we acceptresponsibility …” (Canadian Red Cross, 2005)The four doctors, (Dr. Roger Perrault, the head of the Canadian Red Cross, Dr. John Furesz andDr. 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 fortheir roles in the tainted blood scandal. (CBC News, 2007)Leo de Sousa 8
  9. 9. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011 Sociological AnalysisDisaster Categorization and TypologyIn SOC 600 Module 1a, I proposed a structure to categorize the type of crisis. Using the threewords, Tragedy, Disaster and Catastrophe, I proposed an escalating continuum. When I thinkabout Tragedy, Disaster and Catastrophe, I think about differences of impact and scale for eachin a continuum of increasing magnitude. Tragedy has less impact and scale than Disaster whichin turn has less impact and scale than Catastrophe. Tragedy brings images of personal impactand loss that begins on a small scale. Disaster evokes images of human as well as natural causesthat impact a group of people on a larger scale. Catastrophe implies a large number of peopleor things impacted on a national level scale. Another categorization that we could apply tothese descriptions are: loss of life (human and natural) and loss of finances. There are timeswhen financial loss is not directly related to loss of life but inevitably loss of life is directly tiedto financial loss. (de Sousa, 2011)Several weeks later in SOC 600 Module 2b, I incorporated Kai Erikson’s concept of collectivetrauma and Pierre Bourdieu’s concept of “habitus”. (Britton, 2011) I added a further scale tothe definition “loss of habitus”. Habitus is “the set of socially learnt dispositions, skills and waysof acting, that are often taken for granted, and which are acquired through the activities andexperiences 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 wasLeo de Sousa 9
  10. 10. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011loss of life, finances and destruction of habitus particularly for the people (especiallyhemophiliacs 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 scopeof impact, gradual onset with long duration impact and low social preparedness. In fact, thiswas a global catastrophe as every country that provided blood transfusions had the samechallenges. The difference was that most other countries acted sooner and erred on the side ofcaution. The failure of the Canadian Red Cross and government health authorities (federal andprovincial) radically shook the confidence of the Canadian public. Donating and receivingblood is considered a critical medical service by all Canadians but was not treated as such bythe Federal and Provincial governments. From underfunding to disconnected policies, thegovernments put the Red Cross in a no win situation that was at odds with the mores ofCanadian culture. With the revelations of the Krever Inquiry, the habitus of trusting medicalauthorities was severely damaged. This lack of trust remains today even though a neworganization has been responsible for the blood system for over 10 years. All levels of socialstructures in Canada were impacted by the negligent actions of the Red Cross and thegovernments in Canada. Hemophiliacs were particularly devastated as their disease requiresregular blood transfusions to help with bleeding. The damage to these individuals and theirfamilies 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 peopleimpacted by the Canadian Tainted Blood disaster. (Britton, 2011) The effects of delaying to testdonated blood and blood products caused untold damage and death to the lives of innocentLeo de Sousa 10
  11. 11. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011people who sought out medical assistance and damaged the confidence in the medical systemin Canada.A federal commission of inquiry was ordered in Sept 1993 headed by Justice Horace Krever toinvestigate the Canadian Blood System. Early in 1994, the Inquiry learns that 95% ofhemophiliacs who used blood products before 1900 contracted Hepatitis-C virus. In November1997, the Krever Inquiry releases its report condemning the Red Cross, and Federal andProvincial governments for ignoring warnings and acting irresponsibly. The report estimatesthat 85% of the 28,600 people infected with Hepatitis-C between 1986 and 1990 could havebeen avoided. The result of the report was the creation of Canadian Blood Services to ensurethat the blood supply in Canada was treated as a national asset and that the organization hadall the authority to protect the safety of the blood supply.Memory and TraumaKenneth Foote (2003), a cultural geographer, has examined how physical space is impacted bytragic and violent American events. He states that there are four possible ways that societiesalter 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 BloodSupply in Canada and the provincial governments were also removed from funding. Thesecond action was rectification; the federal government created a national agency, CanadianBlood Services, to be fully empowered to manage and protect the blood supply in Canada. TheLeo de Sousa 11
  12. 12. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011compensation to the victims, even though it was long delayed and took many court caseseventually provided some rectification to the victims and their families. We could also arguethat designation also played a role in shaping the new Canadian Blood Services. Looking at theCanadian 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 injeopardy again. Justice Krever’s report was the blueprint for the creation of the Canadian BloodServices. In this way, we have learned from our mistakes in the past and planned for a betterfuture.Finally, there is sanctification of the tragedy. On November 26, 2007, the Canadian HemophiliaSociety (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’ssanctification 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 trustLeo de Sousa 12
  13. 13. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011 Canadians place in them to keep our blood system safe and secure.” (Canadian Hemophilia Society, 2008)Toxic and Non Toxic ThreatsErikson suggests that hazards can be categorized as toxic and non-toxic threats. Toxic threatsinvolve many involving technology results in contamination that impacts air, water, sea andland in a negative way. Toxic threats involve more uncertain impacts compared to non-toxicthreats which are typically natural disasters. The Tainted Blood Scandal fits with Erikson’s Toxicthreats 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 becontaminated with HIV and Hepatitis-C viruses rendered “lifesaving” blood donationsdangerous. The Red Cross leadership decided to put more emphasis on ensuring there weresufficient donors and protecting strained budgets than protecting the safety of the bloodsupply. Krever called this a “delay in adopting preventative measures”. (Krever, 1997, p. 989)“If the Red Cross had introduced appropriate risk-reduction measures promptly, withoutawaiting 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 rationallyLeo de Sousa 13
  14. 14. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011 • 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 peopleConsidering these responses, we can see how the Red Cross’s actions amplified the risk to theblood supply. While the Red Cross was aware of blood testing, they were more focused onfinancial stability (primarily due to the decentralized nature of funding from each province),undue political influence by provincial authorities who insisted on keeping donations in eachprovince and a focus on keeping a strong blood donor turnout. Even in the face of strongscientific evidence that restrictions on high risk donors and blood donation screening needed tobe 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 thegovernments that funded them. “The relationship between the Red Cross and thegovernments, 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 theissues Justice Krever uncovered were: • Defining the roles in the blood supply system • Blood donations as a national resource • Financing the blood supply system • Operational independenceLeo de Sousa 14
  15. 15. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011Issues of provincial jurisdiction took over the management of the Canadian blood supplycausing shortages in certain urban areas. The provinces assumed funding for the blood supplyin each of their jurisdictions and then were reluctant to share excess due more to politics thanpatient need. The Canadian Blood Committee which was made up of representatives of thefederal and provincial health ministries dictated policy to the Red Cross that caused shortagesin blood factor production and allowed for unsafe blood products to remain in the bloodsystem longer, causing more infections of HIV and Hepatitis-C in Canadians.Individual and Collective TraumaOne particular group of Canadians were extremely sensitive to the tainted blood supply. Thesewere 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, over1100 people were infected with HIV from blood transfusions; of which 700 of these peoplewere hemophiliacs or had other bleeding diseases. Approximately 700 to 800 people infectedwith HIV from blood transfusions have passed away. Nearly 20,000 Canadians were infectedwith 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 thepoor suffer disproportionately during disasters. (Clarke & Short, 1993, p. 378) Erikson alsodescribes a similar understanding “But when one looks in on such scenes from a reflectivedistance, it is obvious that human populations are spread out across the earth in such a waythat the most disadvantaged of them are the most likely to be located in harm’s way. So we arenot speaking here of a situation in which disasters seek out the vulnerable but a situation inLeo de Sousa 15
  16. 16. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011which the vulnerable have already been herded into places where disasters are most likely totake place.” (Erikson, 1976) There is a parallel here with hemophiliacs in Canada. They have arare 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 thingthat 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 youdepend on to stay alive is not safe. Imagine the horror of a hemophiliac patient each time theyreceive a blood factors not knowing if it will infect them with a harmful virus or not. This levelof individual and collective trauma is extremely damaging. “Individual trauma results fromintense blows to an individual’s psyche that s/he is not equipped to react.” (Britton, 2008, p. 56)Risk AmplificationRisk amplification refers to actions that increase the likelihood of a risk to occur and alsoincrease the level of damage inflicted. Risk attenuation refers to actions that decrease thelikelihood of a risk to occur and also decrease the level of damage inflicted. “If potential risksare maximized, this process is called “risk amplification”; if they are minimized, there is “riskattenuation” (Lombardi:253-253). A variety of social groups participate in risk amplification andattenuation.” (Britton, 2011)Kasperson et al wrote about a Conceptual Framework for Social Amplification of Risk. In theirwork, the group identified that “hazards interact with psychological, social, institutional andcultural processes in ways that may amplify or attenuate public responses to the risk or riskevent.” (Kasperson, et al., 1988, p. 177) Kasperson et al continue by describing the structure ofLeo de Sousa 16
  17. 17. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011the social amplification of risk. Amplification can occur in two stages; the transfer of riskinformation 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 andmany receivers who interpreted them in various ways. The table in Appendix 1 provides a highlevel summary of the risk amplification in this crisis. The publishing of the Krever report and thecreation of the Canadian Blood Services agency introduced risk attenuation strategies. KreverInquiry 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 arms length from government; and • the operation of Canadian Blood Services should be managed by both administrative and medical personnel.Leo de Sousa 17
  18. 18. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011 ConclusionsThe Canadian Red Cross Tainted Blood Scandal was the worst medical disaster in Canadianhistory. This tragedy was national in scope and impact. Its gradual onset was due to many riskamplification factors embedded in the Canadian Blood Supply System and the conflict betweenfederal and provincial politics. As a result almost 20,000 Canadians who received blood orblood products were infected and so were some of their loved ones. The individual and culturalimpacts 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 thepeople infected with HIV died and many of the Hepatitis-C victims are now suffering liverdamage and liver failure. Trust in the Canadian Blood Supply was destroyed as was the habitusof Canadian hemophiliacs who rely on blood products to live. The Canadian Red Cross Societywas 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)Leo de Sousa 18
  19. 19. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011 Appendix 1Risk Amplification Matrix – Canadian Red Cross Tainted Blood ScandalRisk Item Messenger Receiver Risk ImpactDescription AmplificationFailure to create Canadian Blood Canadian Red Amplification – No one wasa national blood Committee Cross delays in clearly in chargepolicy with no addressing safety or accountableclearly defined issues for the safety ofroles the blood supplyProvincially Provincial Health Canadian Red Amplification – Provincialfunded blood Ministries Cross increased blood boundaries actedsupply systems shortages and as barriers sodiscouraged disincentive to that bloodinterprovincial implement risk donations weretransfers to meet reduction not treated as ashortages strategies natural resourceInsufficient Canadian Blood Canadian Red Amplification – Red Cross wasfunding of the Committee Cross provincial unable toblood supply budgetary limits improve bloodsystem avoided allowing supply safety for investments due to lack of in blood safety fundsProvincial politics Provincial Health Canadian Red Amplification – Red Cross wasdictate suppliers Ministries Cross provincial unable to supplyof blood industrial policy safe factor VIIIfractionation forced the use of resulting inparticularly substandard infections offactor VIII contractors hemophiliacsWaiting for full Red Cross Transfusion Amplification – Thousands ofscientific proof Patients insistence by Red patients receivedthat HIV and Cross on full tainted bloodHep-C were scientific proof products fromspread by blood delayed blood transfusionstransfusions testingLeo de Sousa 19
  20. 20. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011Risk Amplification Matrix – Canadian Red Cross Tainted Blood Scandal (cont.)Risk Item Messenger Receiver Risk ImpactDescription AmplificationUnderestimate Red Cross Canadian Public Amplification – Estimates of riskactual risk values inaccurate vastlyand statement of risk understated thecommunicated delayed risk true risk to thethat risk was reduction publicminimal for AIDSLack of funding Provincial Canadian Public Amplification – Recognition thatto monitor Ministries of no monitoring of patients weredisease Health transfused being infectedoutbreaks patients was delayed occurred significantlyFailure to Bureau of Red Cross Amplification – Unsafe bloodremove unsafe Biologics, Red Red Cross failed products wereproducts Cross to remove administered to products and patients were told to resulting in more keep unsafe infections productsRed Cross did Canadian Press Red Cross Amplification – Red Cross didnot promote Red Cross held to not educate therestrictions for principles of public about theHIV risk donors impartiality and groups that wereas it conflicted neutrality high risk forwith their contracting AIDSprinciplesRed Cross Board Red Cross Canadian Public Amplification – Lack of medicalof Governors the board was expertiselacked medical unqualified to introduced moreexpertise run the blood risk into the supply system blood systemLeo de Sousa 20
  21. 21. SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011 ReferencesBBC News. (2005, May 31). Canada Red Cross used HIV blood. Retrieved Jun 25, 2011, from BBC News:, D. (2008). Elegies of Darkness: Commemorations of the Bombing of Pan Am 103. Retrieved Jun 18, 2011, from Syaracuse University, In Dissertations & Theses:, D. (2011, May). SOC 600 Lecture 1 - What is a disaster? Syracuse, NY.Britton, D. (2011, Jun 12). SOC 600 Lecture 3- Culture, Society and Disaster. Syracuse, NY, USA.Britton, D. (2011, Jul 13). SOC 600 Lecture 4b Determination of Risk and Risk Communication. Syrucuse, NY.Canadian Blood Services. (1998). About Us. Retrieved Jul 25, 2011, from Canadian Blood Services: ut%20Us?OpenDocument&CloseMenuCanadian Blood Services. (1998, Jan 1). Krever Report. Retrieved Jun 25, 2011, from Canadian Blood Services: Krever?OpenDocumentCanadian Federal Court of Appeal. (1997, Sep 26). Canada (Attorney General) v. Canada (Commission of Inquiry on the Blood System). Ottawa, ON, Canada.Canadian Hemophilia Society. (2008). Winter 2008 Vol 43 No 1. Hemophilia Today, 4.Canadian Red Cross. (2005, May 30). Public Statement Transcript. Retrieved Jun 22, 2011, from Canadian Red Cross: News. (2006, Jul 25). Tainted Blood Scandal. Retrieved Jun 25, 2011, from CBC News: News. (2007, Oct 1). Canadas tainted blood scandal: A timeline. Retrieved Jun 25, 2011, from CBC News In Depth:, L., & Short, J. F. (1993). SOCIAL ORGANIZATION AND RISK: Some Current Controversies. Annual Review of Sociology, pp. Sousa, L. (2011, Jun 18). Comparing Buffalo Creek and Pan Am 103 - Catastrophe and Disaster. Vancouver, BC, Sousa, L. (2011, May 29). Is there a difference between disaster, tragedy and catastrophe? Vancovuer, BC, Canada.Erikson, K. T. (1976). Everything in its Path. New York: Simon and Schuster Paperbacks.Kasperson, R. E., Renn, O., Slovic, P., Brown, H. S., Emel, J., Goble, R., et al. (1988, Jan 8). The Social Amplification of Risk: A Conceptual Framework. Risk Analysis, 8(2), 177- 187.Krever, H. (1997). Commision of Inquiry on the Blood System in Canada: Final Report 3 vols. Ottawa: Miinster of Supply and Services.Wikipedia. (2011, Jun 3). Habitus (sociology). Retrieved Jun 11, 2011, from Wikipedia: de Sousa 21