Canadian Red Cross Tainted Blood Scandal

SOC 600 Sociology of Disasters – Research Paper Aug 12, 2011

Leo de Sousa

1

The Canadian Red Cross Tainted Blood Scandal

a sociological analysis

Leo de Sousa


Leo de Sousa

2

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.


Leo de Sousa

3

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


Leo de Sousa

4

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


Leo de Sousa

5

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


Leo de Sousa

6

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


Leo de Sousa

7

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


Leo de Sousa

8

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)


Leo de Sousa

9

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


Leo de Sousa

10

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


Leo de Sousa

11

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


Leo de Sousa

12

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


Leo de Sousa

13

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


Leo de Sousa

14

• 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


Leo de Sousa

15

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


Leo de Sousa

16

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


Leo de Sousa

17

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.


Leo de Sousa

18

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)


Leo de Sousa

19

Appendix 1

Risk Amplification Matrix – Canadian Red Cross Tainted Blood Scandal

Risk Item Description

Messenger Receiver Risk Amplification

Impact

Failure to create a national blood policy with no clearly defined roles

Canadian Blood Committee

Canadian Red Cross

Amplification – delays in addressing safety issues

No one was clearly in charge or accountable for the safety of the blood supply

Provincially funded blood supply systems discouraged interprovincial transfers to meet shortages

Provincial Health Ministries

Canadian Red Cross

Amplification – increased blood shortages and disincentive to implement risk reduction strategies

Provincial boundaries acted as barriers so that blood donations were not treated as a natural resource

Insufficient funding of the blood supply system

Canadian Blood Committee

Canadian Red Cross

Amplification – provincial budgetary limits avoided allowing for investments in blood safety

Red Cross was unable to improve blood supply safety due to lack of funds

Provincial politics dictate suppliers of blood fractionation particularly factor VIII

Provincial Health Ministries

Canadian Red Cross

Amplification – provincial industrial policy forced the use of substandard contractors

Red Cross was unable to supply safe factor VIII resulting in infections of hemophiliacs

Waiting for full scientific proof that HIV and Hep-C were spread by blood transfusions

Red Cross Transfusion Patients

Amplification – insistence by Red Cross on full scientific proof delayed blood testing

Thousands of patients received tainted blood products from transfusions


Leo de Sousa

20

Risk Amplification Matrix – Canadian Red Cross Tainted Blood Scandal (cont.)

Risk Item Description

Messenger Receiver Risk Amplification

Impact

Underestimate actual risk values and communicated that risk was minimal for AIDS

Red Cross Canadian Public Amplification – inaccurate statement of risk delayed risk reduction

Estimates of risk vastly understated the true risk to the public

Lack of funding to monitor disease outbreaks

Provincial Ministries of Health

Canadian Public Amplification – no monitoring of transfused patients occurred

Recognition that patients were being infected was delayed significantly

Failure to remove unsafe products

Bureau of Biologics, Red Cross

Red Cross Amplification – Red Cross failed to remove products and were told to keep unsafe products

Unsafe blood products were administered to patients resulting in more infections

Red Cross did not promote restrictions for HIV risk donors as it conflicted with their principles

Canadian Press Red Cross Amplification – Red Cross held to principles of impartiality and neutrality

Red Cross did not educate the public about the groups that were high risk for contracting AIDS

Red Cross Board of Governors lacked medical expertise

Red Cross Canadian Public Amplification – the board was unqualified to run the blood supply system

Lack of medical expertise introduced more risk into the blood system


Leo de Sousa

21

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: http://www.proquest.com.libezproxy2.syr.edu

Britton, 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: http://www.bloodservices.ca/CentreApps/Internet/UW_V502_MainEngine.nsf/page/About%20Us?OpenDocument&CloseMenu

Canadian Blood Services. (1998, Jan 1). Krever Report. Retrieved Jun 25, 2011, from Canadian Blood Services: http://www.bloodservices.ca/CentreApps/Internet/UW_V502_MainEngine.nsf/page/FAQKrever?OpenDocument

Canadian 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: http://www.redcross.ca/article.asp?id=13578&tid=001 CBC News. (2006, Jul 25). Tainted Blood Scandal. Retrieved Jun 25, 2011, from CBC News:

http://www.cbc.ca/news/background/taintedblood/index.html CBC News. (2007, Oct 1). Canada's tainted blood scandal: A timeline. Retrieved Jun 25, 2011,

from CBC News In Depth: http://www.cbc.ca/news/background/taintedblood/bloodscandal_timeline.html

Clarke, L., & Short, J. F. (1993). SOCIAL ORGANIZATION AND RISK: Some Current Controversies. Annual Review of Sociology, pp. 375-99.

de Sousa, L. (2011, Jun 18). Comparing Buffalo Creek and Pan Am 103 - Catastrophe and Disaster. Vancouver, BC, Canada.

de 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: http://en.wikipedia.org/wiki/Habitus_(sociology)

Documents

Canadian Red Cross Tainted Blood Scandal