In the late 1970s and early 1980s, Canada’s blood system infected approximately 1200 people with the HIV virus and another 12 000 people with hepatitis C. Many of the victims were hemophiliacs and people who had received blood during routine operations. At that time, we had less knowledge than we do now about these viruses and many of those who had been infected did not know they had received contaminated blood. Some people unknowingly passed on the viruses to their spouses and family members. As a result, by the 1990s it was estimated that the number of infected people had increased substantially and exponentially. The staggering number of victims—almost 3000 deaths to date—illustrated that the blood system had failed the very people it was supposed to protect. In response, many people began calling for a judicial inquiry into Canada’ blood system.

In 1993 Justice Horace Krever was appointed to head a Royal Commission of Inquiry with the mandate to investigate the management and operation of the blood system in Canada, including the events surrounding the contamination of the blood system. After nearly four years of a public judicial inquiry, Justice Krever issued his much-awaited report on November 26, 1997. In addition to being a significant historical event with serious social and political implications, the Krever Inquiry serves as an important case study of the role and process of a judicial inquiry in a democratic society.

For some people, Krever’s findings and recommendations provided a sense of relief, but for many, there remains a deep sense of bitterness and anger. The most recent statistics show that about 2000 Canadians contracted the HIV virus from tainted blood and blood products and tens of thousands were infected with hepatitis C. At the time of this writing, the latter group, which had not been eligible for a compensation package, is awaiting results of a proposal for a settlement.

Krever’s report also frustrated some critics because, although Krever had fought for, and won, the right to name names and assign blame, he did not do so. The right to assign blame was a small victory that came about despite numerous court challenges from agencies that had been entrusted with the responsibility of blood collection and distribution. The most notable of these was the Red Cross. Krever’s victory, however, was not without repercussions. The legal manoeuvring delayed the Report and by the time Krever revealed his 50 recommendations for revamping the blood system, many had already been embraced by politicians, and acted upon. After 353 witnesses, 50 000 transcript pages of testimony, and more than $16-million of taxpayers’ money, Krever’s report assigned no blame. Now that the inquiry is finished, there has been some debate about the value of the Report and the inquiry process. Some have suggested that the real enduring value of the Report is the methodical way it dissects a Canadian tragedy.

Maclean’s magazine called the Report a “horrific haunting tale of bungling and negligence.” One example the Report cited is lax monitoring by the Bureau of Biologics, the blood regulatory arm of Health Canada. The Report indicated the Bureau failed to ensure a system of checks was in place in the early 1980s when Canada faced a serious plasma shortage. Canadian health authorities pressured Toronto-based Connaught Laboratories, Canada’s largest manufacturer of blood products, to buy blood products in the United States. Krever noted that the higher overall incidence of HIV infection in the United States and the American practice of collecting plasma in prisons increased the risk of disease for Canadian hemophiliacs.

The RCMP announced it is closely examining the Krever Report to decide if a criminal investigation is warranted. Many survivors, and their families and advocates including the Hepatitis C Society, are now demanding that criminal charges be laid against those responsible. As the Red Cross prepares to divest itself of the responsibility of blood collection, numerous class-action suits are being brought forward by thousands of Canadians who contracted the HIV virus or hepatitis C. The question remains as to who will assume the legal responsibilities of the Red Cross.