Original subtitles

I've seen too many people taken down by this thing.

So when the time comes... That's my choice.

Lawrence Hartley's wife, Caitlin,

just passed away.

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.

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...

_

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.

- Synced & corrected by MementMori - -- www.addic7ed.com --

- 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.

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.

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.

I begged the Red Cross

to implement some sort of donor screening.

Why wouldn't they do it?

They were afraid of the backlash.

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.

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.

They were using science

to avoid spending money,

and ignoring all the warning signs.

There was a statement they kept repeating.

"No conclusive proof."

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.

No one's safety was dependent on that.

Some of Columbus's sailors, sir,

might have differed with you, but never mind.

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.

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.

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.

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.

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.

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.

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.

Mr. Kirpatrick.

Someone suggested we put a washbasin up here

because of all the officials

who come and wash their hands of responsibility.

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.

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.

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.

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.

"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.

"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.

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.

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.

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.

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.

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.

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.

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.

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.

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?

_

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.

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