Unspeakable s01e06 Episode Script

Krever (1993 - 1996)

1 I've seen too many people taken down by this thing.
So when the time comes That's my choice.
[DR.
MATTHEWS]: Lawrence Hartley's wife, Caitlin, just passed away.
[DR.
BRADLEY]: Unfortunately, we're not seeing much success with this treatment.
I'm requesting you resign.
I think you need to start coming to the CHS in an official capacity.
Dust off that old law degree? Check out what "ADC" stands for.
I have to tell the Red Cross.
"Exhaustion of existing inventory," that's one way of putting it.
Handing out tainted blood for another seven months - is another! - The FDA ruled that Armour's process is adequate, so long as it's made with screened plasma.
Screw an inquiry! Seven more dead, six kids! There's no excuses.
Are you gonna tell the world what a screwed-up family we are? This was a mistake.
You may now kiss the bride.
[JIM]: We didn't get AIDS.
They gave it to us.
The open spaces called "agora" embodied the newfound respect for social justice received through debate rather than imperial mandate, the most well-known being the ancient agora of Athens, depicted here.
You probably recognize that this is the root word for "agoraphobia," which, as follows, is a fear of open spaces.
From the 18th century to the 8th century B.
C.
, citizens would gather in the open court, or agora, to hear statements She's studying to be an astrophysicist.
later, it would serve as a marketplace where merchants would set up stalls and shops [INTERCOM BEEPS] Federal Health and Welfare Minister Mary Collins is on line one.
I know who she is.
Mary, it's Horace.
Horace, how are you? Fine, fine.
I read your interview in The Globe.
- - Always on top of everything.
I do understand this will make some people nervous, but I can't stress enough the importance of this inquiry to our country.
I need to make sure you know what you're getting yourself into.
Enough to know I'm not going to fully understand the situation till I'm done.
Can I take that as a yes? Yes.
Is this you celebrating? I'll celebrate when those criminals get what's coming to them.
- Good morning, Ms.
Edwardh.
- Good morning.
I requested the records of the Canadian Blood Committee meetings.
No word back yet.
And this is the latest travel schedule for the testimony road show.
Looks like we're going to start in Toronto, move to Vancouver, and then head east.
Thank you very much, Jenny.
- [KNOCKS] - [KREVER]: Yes.
There's no way we're gonna make this deadline.
September 30th is a joke.
AIDS is only one part of this story.
Hepatitis C keeps coming up.
I don't think I'm exaggerating when I say this could take years.
- What's this? - Budget proposal.
16 million? That's conservative.
That's 13 million more than they gave us.
That's what it's going to cost.
Are we going to get it? What choice do they have? This is the government we're talking about.
- - Hearings opened today into the tragedy of tainted blood, a tragedy that left more than a thousand Canadians with HIV It is not and will not be a witch hunt.
It is not concerned with criminal or civil liability.
The focus of this inquiry is to determine whether or not Canada's blood supply is as safe as it could be, and whether the blood system is sound enough so that no future tragedy will occur.
The victims of the tainted blood scandal are dying at a rate of three a week.
Others may not live to see the end of the inquiry, but both they themselves and Justice Krever are determined to see that they are heard.
This is something I just can't believe, that, uh, I was given product that's going to kill me, and kill my wife and destroy our family.
I've flown all the way from Vancouver so that I can give this to Justice Krever.
Inside, um, I've written my son Andy's story.
He's gone now, and nothing is going to bring him back, um I struggle with that every day, but I have to say I'm just grateful that someone is finally listening That's your friend Andy's mom, isn't it? Hello, my name is Lawrence Hartley, and I have been president of the Canadian Hemophilia Society since 1986.
I am also a hemophiliac who is co-infected with HIV and Hepatitis C.
This story is tragic, obviously, but the reason it is so tragic is because it could have been avoided.
Those of us that depended on blood products to live were seriously injured by a Canadian system that just didn't seem to care.
Now, I understand people want a "triumph over tragedy" story, some kind of silver lining, but for those of us who have lost someone, there is no end to the grief, and so we must speak here today about how to fix things for the future, but also know that nothing will ever repair the damage done.
No one wanted to recognize the problem.
To recognize it would have meant taking on the immense task of dealing with it.
The doctors and nurses said they were relying on the Red Cross.
The Red Cross pointed at the Bureau of Biologics.
No one was taking responsibility.
We were treaters, and our overriding concern was to treat our patients well.
We knew very little about AIDS, but we knew a lot about hemophilia and the complications of bleeding.
Not that I am trying to absolve anyone, but I think it's important to remember that we can't look back and judge ourselves on what we didn't know at the time.
AIDS was a difficult mystery to unravel.
Furthermore, I think it can be too easy to scapegoat certain people at the Red Cross when in fact it was the entire blood system that failed.
As early as 1981, there were reports of a new disease in the U.
S.
, and there was no reason to expect it wouldn't reach Canada.
The BoB asked the Red Cross to monitor the situation.
I'm a father of a hemophiliac, and we were never warned about the danger through any official channels.
I remember patients calling me about symptoms that now in hindsight, were clearly connected to HIV.
Did you get bulletins or updates of medical information from the Red Cross or the Bureau of Biologics? Oh, no.
No, nothing like that.
There were no transfusion- related cases of AIDS at the time, and the authorities, whom I trusted, were not very concerned.
[LAWRENCE]: Clearly, the latency period of the virus created huge problems.
It took a while for people to actually start dying, and in the meantime, they were free to infect the blood system.
[WILL]: I begged the Red Cross to implement some sort of donor screening.
Why wouldn't they do it? They were afraid of the backlash.
[LAWRENCE]: It was a religion.
Because you had to volunteer, they thought that only good people gave blood, and good people wouldn't have AIDS.
It was blind faith.
[WILL]: 16 months after the U.
S.
implemented an AIDS pamphlet for donors, the Canadian Red Cross finally jumped in.
Dr.
Perrault, in December of 1984, both you and Dr.
Davey were informed that the issue was urgent, and that there was overwhelming evidence that these pamphlets were not being used as instructed.
Then in January, Dr.
Derrick wrote the both of you and stated, "It has been acknowledged from the first that the pamphlet is less than adequate.
" Well, I mean, this is a first edition.
The wording is not necessarily ideal.
The fact that it's less than perfect There's a difference between being less than perfect and less than adequate, isn't there? Well, I can't speak for Dr.
Derrick The memo says, "acknowledged from the first.
" That would be the beginning of the use of this pamphlet.
He writes, "While it is true there are no cases of AIDS in Canada which can be attributed strictly to transfusion, it is certain that this will occur eventually, possibly soon, and unless the CRC is seen to be exerting every effort to screen out high-risk donors, when this does happen, the credibility of the Blood Transfusion Service will be badly damaged.
" Did you share this view that it was certain that cases of AIDS in Canada would soon be attributed strictly to transfusion? I thought it likely, sir.
[WILL]: They were using science to avoid spending money, and ignoring all the warning signs.
There was a statement they kept repeating.
"No conclusive proof.
" [PAUL]: Dr.
Davey, I suggest that you saw your role in all this as a skeptic.
But, in fact, you were skeptical beyond reason.
I would describe my position as critical, not skeptical.
I looked at evidence, assessed it, and drew conclusions from it compatible with the state of knowledge at the time.
I suggest that we are going to find your critical position to be wrong on every count.
That always, you erred against safety, and that it cost us lives.
I'm not going to be convinced by a statement just because it's a view that's widely held.
It was at one time a widely held view, sir, that the Earth was flat.
[CROWD MURMURING] No one's safety was dependent on that.
Some of Columbus's sailors, sir, might have differed with you, but never mind.
[CROWD MURMURING] Look at what happened in Calgary under Man Chiu Poon.
He put his patients back on Cryo, and only 33% of his severe patients contracted AIDS, versus I believe 90-95% on a national basis.
And to his credit, when somebody said congratulations are in order, Dr.
Man Chiu Poon said, "Everyone that is affected by HIV is a failure on our part.
" Dr.
Perrault, would you agree that by the fall of 1984, the risk of contracting HIV from concentrate was greater than that of cryoprecipitate? That was generally accepted.
If you had a son who was a hemophiliac, would you have kept him on Cryo? I have thought of that many times, and some of the points would be his age, and level of activity in school and whatnot.
I think that an active 10-year-old or 12-year-old would have objected, although my preference would have been Cryo.
To be clear, you would have kept your own son on cryoprecipitate? Yes.
[EMMA]: Some of the things coming out in testimony are unbelievable.
It's all we talk about in Ethics.
I think it's fascinating.
You know, you're gonna make a good doctor, but you would have made a truly great lawyer.
Why do you say that? I can hear you building your case.
Okay, fine.
I think you should testify.
I know you care, and I think you're gonna regret it if you don't.
Other people are standing up, and I'm glad they are.
I'm happy for 'em.
But in the end, I have to live with it.
I don't see the need to relive it, even for a day.
Being a victim doesn't diminish you.
This is going to make things better.
Is it? Well, it won't change what happened to you, but maybe in the future, it makes someone in power think twice before they put money over people's lives.
Maybe the attention gets help - for people who need it right now.
- I'm sorry.
I don't feel a duty to make a spectacle out of myself.
I don't owe anybody my story.
His name, his face, came to symbolize the tragedy of tainted blood.
Randy Conners, a hemophiliac, contracted HIV at a time when Canada's blood supply was contaminated.
He led a fight for compensation, and won respect for his courage and determination.
Today, at the age of 38, Randy Conners died.
[REPORTER]: His great regret was that he wouldn't live to see the outcome of the Krever inquiry.
Randy Conners chose to die at home, and spent his last hours with his family.
As his life drew close to an end, Randy Conners focussed on one question.
Why did the blood system he relied on so much fail him and 700 other hemophiliacs? Um my name is Jessica Hartley and I'm 15 years old.
I was seven when I found out that my mom was dying of AIDS.
[TEARFULLY] I still really miss her.
My mom got AIDS from my dad, and I know he feels really bad about it, but I know it wasn't his fault.
He didn't know he had it.
The people at the Red Cross and the doctors didn't tell my dad that he could have it or that he could give it to my mom until it was too late.
I don't think it's fair that I have to grow up without my mom, but I know that life isn't always fair.
I'm very sad and very angry that this happened, and I just hope that my dad's going to be okay.
[WILL, QUIETLY]: It's amazing how he can sit through something like that and not react.
There wasn't a dry eye in the house.
He is a judge.
He needs to appear impartial, and he wants to make sure his report doesn't look biased.
Yeah, but he's still a human being.
I think it must be lonely.
Your ALTs are up over 600.
What can we do? Not much more than we're doing already, I'm afraid.
The AZT doesn't seem to be helping.
No, given that he only has two T-cells.
You really need to take it easy.
Give the meds a chance.
I can't quit now.
The treatment for the Hep C failed.
I'm sorry if this is morbid, but if I'm going to die, I'd like to make a difference with the time I have left.
He didn't say you were dying.
You're certainly not giving yourself a better chance to live.
Every one of these files is for a patient who died of AIDS from tainted blood.
They are not just pieces of paper, are they? Medical histories.
Test results.
They are human beings who are now dead.
But it doesn't end here.
Please, when you look at this, think of the people who are not represented.
They are called "secondary victims.
" Pauline Richards She lost her uncle, a brother, and both of her sons.
All in one year.
Imagine that.
Imagine the devastation of losing not one of your dear children, but both of them, and a good lot of the rest of your family along with them.
What, pray tell, is secondary about that? Dr.
Furesz, the order that came from the Bureau of Biologics in November of 1984 was to switch to heated concentrates as soon as feasible.
What monitoring did the Bureau do after that to ensure the "as soon as feasible" part? Everyone concerned met at the Consensus Conference in December.
We relied on the recommendations that came out of that meeting.
There was unanimous agreement.
Our job was to approve the safety of the product, not determine the practical aspects of its distribution.
[EDWARDH]: Dr.
Inwood, you represented the CBC advisory sub-committee at the Consensus Conference in 1984.
What did you hear Dr.
Naylor say on behalf of the Red Cross with respect to switching all concentrates to heat-treated? He was unwilling to have heat-treated concentrates immediately available in Canada.
Was his unwillingness related to the fact that he wanted first to use up the untreated inventory in stock and on order? To do justice to the late Dr.
Naylor, I suspect that what he wanted to get across was that they would not be able to get any heat-treated material until April, and as a result, we would have to continue to use non-heat-treated material, but I can assure you, it was a matter of some significant debate during the lunch hour.
They certainly wanted to finish off their older stocks at the same time.
In the fall of '84, were you of the view that 100% of hemophiliacs had almost certainly been infected with HIV already? I don't know if the studies showed 100%, but they showed a high percentage.
We have the Bureau of Biologics' position paper from the Consensus Conference, Dr.
Perrault.
It says, and I quote, "Preliminary data from Canadian studies indicate that over 55% of hemophilia patients who have received Factor 8 have antibodies to this virus.
" Would you agree with me that 55% is a lot lower than 100%? If you say "all hemophiliacs," 55% is lower, but if you're only talking about severe, we're not comparing the same things.
The point is, in the fall of '84, there was at least some chance to prevent infection in hemophiliacs who had not been previously exposed, correct? That is entirely possible.
Did you have a sense of urgency in November of 1984 to get safer heat-treated product to Canadian hemophiliacs knowing it might save lives? Yes, we did.
Doctor, based on your data, what was the damage done by the delay in switching to heat-treated concentrates? Between the time the BoB ordered the switch and the July 1st, 1985 conversion, I can tell you that eight of my patients were infected with HIV.
As well, given the fact I was only tracking one sixth of the patients in Canada, I think it's safe to assume there were more than that.
[PAUL]: You've indicated to us throughout your testimony that there was no directive from the national Red Cross office to get rid of all its non-heat-treated Factor 8? There was no such directive.
I'd ask you to turn to tab 31 It is the Factor 8 inventory sheets from the national centre.
On June 13th, 1985, there were 50,000 vials of safe heat-treated product on the shelves.
And yet, on that same day, 98 vials of non-heat-treated product went to the Hospital for Sick Children.
Dr.
Perrault, it certainly seems that your dispensing centre was intent on distributing its non-heat-treated product before the transition date.
The information I was given was that the level of inventory was required to make sure that we would not be in a stop-and-go situation.
A stop-and-go situation? There were 50,000 vials of safe, heat-treated product on the shelves when you issued non-heat-treated product to the Hospital for Sick Children.
I am telling you what I was told, and what I knew.
What we were striving for was to make sure that we could deliver the product on a sustained basis, and not have to go back and say that suddenly we are out of stock.
Stop-and-go situation.
Dr.
Perrault, I have just finished indicating that there was more than enough safe product on hand when untreated product was sent out to children! Are these the morals and ethics that guide your organization? Mr.
Kirpatrick, this really is not cross-examination.
This is speech-making.
Please stick with the facts.
The fact is, Dr.
Perrault, your organization sent tainted blood to children.
[KREVER]: Mr.
Kirpatrick.
[CROWD MURMURING] [CLEARS THROAT] [SIGHS] Someone suggested we put a washbasin up here because of all the officials who come and wash their hands of responsibility.
- [SCATTERED CHUCKLES] - State your name for the record, please? Uh, Jim Krepke.
My heart goes out to you, Justice Krever.
How do you distinguish between the truth and a statement made to protect oneself from liability? I know that I make mistakes every single day, and I am willing to admit that freely.
I make mistakes.
But I've seen doctors and officials come and testify before you who apparently never made a mistake in their life.
[EDWARDH]: In 1983, the Red Cross entered into a contract with Connaught Laboratories, the only licensed Canadian producer of Factor 8 concentrate, to produce six million units.
We've already covered some of Connaught's deficiencies in producing Factor concentrate.
There were some issues with quality, in particular, solubility of the product.
Canadian blood donations couldn't possibly supply enough plasma to produce that much concentrate, so Connaught started buying plasma from a company called Cryosan Ltd.
They were essentially a blood broker, the largest supplier of plasma in the world at the time.
We were not aware of that until the latter part of 1983.
Mr.
Weber, the volume of plasma required to fulfill such a large order changed the way Connaught did things.
You decided it would be impractical to send your own employees to inspect the centres where Cryosan collected blood? We decided it was acceptable to confirm if the supplier had a license from the U.
S.
Food and Drug Administration and then review their inspection reports.
[EDWARDH]: Yet even that protocol was not properly followed.
Can I take you to the Connaught document brief? I believe it's Exhibit 722.
It is a letter, dated August 23rd, 1983, from Mr.
Weber of Connaught to you, Dr.
Davey.
Can you please tell me what it says? It's regarding a recall incident related to U.
S.
-sourced plasma.
We were not aware of the details of that particular collection centre.
The shipping papers accompanying the plasma simply referred to it as "ADC Plasma Centre, Grady, Arkansas.
" And what does "ADC" stand for? Arkansas Department of Corrections.
[GASPS AND MURMURS FROM CROWD] [PAUL]: They were notifying you that blood had been collected from inmates at a correctional facility? - Correct.
- They were in fact paid a fee.
I believe they were.
Given the amount of drug use and unprotected sexual activity, could there possibly be a higher risk pool of donors? I don't know the answer to that.
So Dr.
Furesz of the BoB knew about the incident? Yes, in fact, he was the one that informed us.
They had heard from the FDA.
Yet you had to inform the Red Cross? Clearly, the system had broken down.
I would just like to reiterate my sincere thanks and gratitude to the thousands of people who in my lifetime donated blood on a voluntary basis.
I'd also like to thank the volunteers and the workers at the Red Cross, dedicated professional people, who have treated me with nothing but care and compassion.
Their important, lifesaving work shouldn't be overlooked in all of this.
I'd just also like to say that I know that I have caused my family a great deal of pain, more than they ever deserve.
Words are never enough, but for whatever part I am guilty, I am sorry.
If you don't mind, I'd like to read a poem given to me by the daughter of another victim.
[CLEARS THROAT] "To Father.
Teddy Bear, Teddy Bear, can I lean on you? I'm hurt and confused, tell me what to do.
It's been such a long time since I've talked to you.
In my advanced age, I thought I no longer needed you so I put you away, stuffed you in the corner, and tried to go on with my life, which got harder.
You sat in the corner for years on end, you watched my heart break, and then it mend.
You used to comfort me when I needed it.
When I was angry, you took the hit.
But my problems are bigger now, and you're worn down.
I no longer smile.
My lips are a constant frown.
So Teddy Bear, Teddy Bear, can I lean on you? Work your magic, tell me what to do.
" Hi, Daddy.
[JIM, READING]: "Your loving daughter.
" Mr.
Landry.
Justice Krever.
- You remember me? - Yes, of course.
I read both the archival history you compiled and your book.
I'm sorry, but it would be inappropriate for me to discuss anything to do with the inquiry at this time.
I was, uh I was hoping you might agree to an interview.
Well, given what I just said, what purpose would it serve? We wouldn't have to talk about any the details.
I just think that everyone recognizes this is an enormous undertaking, and the public would be very interested in hearing what you're going through.
You know, how what you're dealing with personally, how it's affecting you.
I don't think so.
Maybe when it's all done? Maybe.
Justice Krever Publicly shaming those responsible is not enough.
They deserve worse.
Mr.
Landry, you're angry, and I understand that, but this inquiry is about getting to the bottom of why this tragedy occurred.
We must figure out what went wrong and recommend how to fix it.
It can't be about punishment, or worse, revenge.
With all due respect, sir, in this case, it should be.
Have a good day.
[LIZ]: To have to look into the faces of those parents, and tell them their child had just tested positive for HIV? Once they started using the heat-treated product, they thought the threat of AIDS was behind them.
I can feel the tension and the anger inside me.
The same sickness I felt then, I feel it now.
They asked me, "How could this happen?" I had no answer.
The various manufacturers of heat-treated Factor 8 all had a a slightly different process for eliminating HIV from the plasma.
Is it fair to assume that you recognized that the Cutter process was more rigorous than the Armour process at this point? There was indication that it might be.
But you didn't do any actual testing yourself.
You instead relied entirely on the CDC's studies.
Did you ever see any viral inactivation data - referrable to the Armour product? - No.
So you issued the notice of compliance without seeing any data referring to the Armour product in particular? I'm not saying that.
You've testified that you were aware of the European seroconversions from reading about them in the Lancet.
Did you think to approach Armour, ask them what was happening? I don't recall there was any indication in the article whether it was Armour or not.
[WILL]: The Lancet article didn't say which company was responsible, but it specified the process.
60 degrees, 30 hours.
It was a simple deduction.
I just read the product insert, and knew it was Armour they were talking about.
We'd only given my son one box.
That could have been enough.
We could have exposed him to AIDS.
[EDWARDH]: But given the questionable nature of Armour's heat-treating process, it could have been made safer by screening the plasma for HIV, and weeding out possible contaminants from the start.
We did everything we could to make sure the product from screened plasma made it to consumers as soon as possible.
However, prior to July 1, 1986, Dr.
Naylor wrote to Cutter International asking them not to put labels on their product indicating if it came from screened plasma.
Are we to assume that this is because you didn't want consumers to prefer one box of concentrate over another and wreak havoc with your inventory? I don't recall the thinking.
I don't know what Dr.
Naylor had in mind.
It does seem to suggest that he thought it could lead users to request only Cutter screened product, which was not available in adequate quantity at that time.
I'm sorry, is it your answer that it would be deleterious to the system for users to know if the product they were taking was screened? I am just trying to reason for Dr.
Naylor.
But does that sound logical? That people shouldn't know the nature and relative safety of the product they are taking? I'm just trying to reconstruct Dr.
Naylor's line of thought.
We were confident at the time, particularly with the Cutter process and its efficacy.
Particularly with the Cutter process, but not Armour's, is that what I'm to infer? No.
We believed we were supplying a safe product.
[PAUL]: You believed that if you pulled the Armour product, it would send the world market into crisis.
Yes, and there was no proof that seroconversions were occurring in the screened Armour product.
To be clear, you actually issued a letter to the Red Cross advising them to continue to distribute it.
Yes.
Dr.
Furesz, did the Red Cross ask for this letter? That could be.
[WILL]: I asked I begged both Perrault and Davey to go against the BoB and withhold the Armour product.
You know, forget that you have permission to distribute it, and just don't distribute it.
And what did they say? That it was 20% of their supply.
Seven people are dead because they took that product.
Five of them were children.
I'm so sorry.
[KISSING] He's gone.
He didn't say so, but I saw it in his eyes.
I'm going to regret not giving him that bullet for the rest of my life.
[SOBBING] You'll get your chance one day.
Happy anniversary.
Happy anniversary.
Something wrong? It's hard to believe it's been five years since our first kiss.
In this very spot.
Remember when you said people who've been dating for two years should absolutely know if they want to get married? Okay.
I knew that's what you were thinking.
[GASPS IN SURPRISE] I'm really sorry this took so long.
Shut up, what are you doing? Shut up? Yeah, that-that's what I said.
No way.
How long have you had that? That's what you're asking? You're supposed to say "yes.
" You haven't asked me anything yet! Right.
Ruby Dae Kim Will you marry me? Fuck yeah! Really? That's your answer? Five years, you haven't noticed I swear when I'm excited? That's gonna make this a tough story to tell our kids.
It wasn't you.
I've always known you were the one.
Always.
If you don't want to do this because I'm Shut up, okay? Just shut up.
No one knows what the future holds.
You are who you are because of what you've been through.
I could get hit by a bus tomorrow.
You never look both ways.
I love you.
I love you too.
[ALARM BEEPS] What are you doing up? I want kids.
It's not like we can Conceive? I know.
So what are you trying to say? - Adoption? - I don't know.
I know you hate when I bring this up, but we don't really know how long I have.
I certainly can't provide for you, much less a child, and there's a pretty good chance I won't be around to help you raise it.
Look, I knew what you were gonna say, which is why I was just lying here not saying anything.
I just woke up to take a pill to keep me from dying.
Does that sound like good father material to you? It doesn't change how I feel.
What is it, what's wrong? Where's Paul? He couldn't get out of bed.
He's supposed to cross Perrault on Hep C today.
He said you should do it.
Me? You're more than capable.
Look, um he may not be in tomorrow, either.
Listen, tell him to take as much time as he needs.
I'll stop by later.
Let us know if there's anything you need.
- You got this.
- Right.
- You got it.
- Yup, I do.
250,000 patients are transfused in Canada per year.
In 1986, 2.
6% of the blood was infected with Hepatitis C.
That means that 5,000 to 6,000 people per year were being infected by our blood system.
It's been suggested that surrogate testing would have reduced that number by up to 60%.
Was it unethical of the Red Cross not to take steps that would have prevented thousands upon thousands of Hepatitis C infections? - We object to the question.
- Mrs.
Sanders, I have previously asked your colleague to refrain from asking witnesses to make moral judgments.
The purpose of these cross-examinations, as I've said from the outset, is the single purpose of helping me discharge my mandate.
It does not help for you to recriminate the witness.
The question of whether a decision they made was in their eyes, moral, goes to how the system was managed.
I don't know what could be more important than if this man believes that his actions were justifiable given the number of human lives at stake.
I will make the judgment as to whether actions were improper, immoral, or wrong.
I do not need the help of the witness.
I just want the facts.
I think the witness' opinion is material evidence.
I do not, Mrs.
Sanders.
Thank you, Your Honour.
I was the one who recommended to the blood committee that we implement a study of the effectiveness of surrogate testing for Non-A, Non-B Hepatitis.
Thank you, Dr.
Perrault.
Excuse me, Justice Krever, I have one more line of questioning.
Proceed.
Dr.
Perrault, in 1986 there were several U.
S.
studies available regarding the success of surrogate testing to weed out Hepatitis from entering our blood system.
Are you saying that overwhelming evidence was unreliable? We have heard repeatedly that relying on U.
S.
information can also be damaging, and I have testified that the Canadian and U.
S.
systems were different.
You cannot compare apples and oranges.
Okay, well, let's compare this.
What was the cost of the study you proposed? I don't remember.
According to this, roughly two million dollars.
That appears to be correct.
That study delayed implementation of screening in Canada for four years, screening that would have prevented tens of thousands of Hepatitis C infections.
How much money was saved during those four years? Dr.
Perrault, do you not remember that figure either? I won't ask about the ethics of the decision.
I'll just tell you that it was $30 million.
The provinces saved $30 million by stalling for four years while a two-year study was done.
Those are the facts.
I can only guess what it's going to cost to treat all those infected people now.
My name is Alice Landry.
Who am I? What do I know? I'm just a mother, right? I'm not an expert.
I mean, all I know is I feel let down.
I don't expect perfection, but you trust your doctor, the Red Cross, the government.
All the bureaucratic bungling and the lethargic attitude towards safety they can deny it, but when we walk out of here, we carry AIDS with us every minute, every day.
This is not an academic exercise for us.
This is a day-to-day reality.
I will never forgive the people that made those deadly decisions not to act.
Cost won out over safety.
I sit here today saying this not out of revenge.
Others may want that, but not me.
I want my son to be okay.
I can't give him back the years that have already been stolen.
I just hope for a better future.
I'm so grateful to the woman in his life, who's given him some happiness and sense of self-worth.
My heart is full for her.
I can never repay you for what you've done for Peter.
To my incredible daughter I am in constant admiration of your strength, of how you have withstood the tremendous burden placed upon you with such grace.
On the other hand, I've watched my husband, a man who I married because he was thoughtful, kind, and generous, become bitter, hateful, and vengeful.
I've watched his relationship with my son deteriorate.
Because of this virus, I've watched my family become unable to communicate about anything that gives us happiness anymore.
I'm not hopeful of anything other than maybe if the truth is heard, some justice will prevail, and a lesson will be learned.
Thank you.
This just came for us.
Notification from Krever.
He's naming us for misconduct in his written report.
It's not a certainty, but, you know, it's possible.
He has to warn us.
Justifiable or not, our medical advisory committee limited the flow of information to hemophiliacs.
I'll get started on drafting our response.
Paul This can wait until tomorrow.
Go home.
If it's any consolation, there's no doubt that the Red Cross, the BoB, and the provincial ministers all got them too.
You think they're just going to respond politely? [CHUCKLES] So much for our mandate.
They're all filing suit.
The Red Cross, the BoB, both provincial and federal governments.
They're basically saying we sandbagged them.
You thought the letters would set off a storm.
I wrote them.
The language was appropriate.
It should have been stronger.
Saying someone failed doesn't mean that they breached a criminal or civil standard of conduct.
We didn't have a choice.
I really didn't expect this.
No neither did I.
It is most deplorable that the very government that ordered this inquiry is now trying to stand in its way.
They want to block all Canadians from getting to the bottom of what happened because they are afraid of what will be said about them.
The way I see it, they buried my friends.
Now they are trying to bury the truth.