Contaminated Blood

Contaminated Blood

This article is about the contaminated blood scandal. (No, madam, it’s not about mass immigration.) Seriously though, and it is very serious, more than 30,000 people were infected with HIV and or Hepatitis C after being given contaminated blood products in the 1970s and 80s. Over 3,000 died as a result. Many more had their lives ruined. But was there a conspiracy involved?

Yes, there was. But a second-degree conspiracy, designed to protect the guilty; the powerful, well-connected people responsible for those deaths and ruined lives.

The seven-year, highly expensive taxpayer-funded inquiry, with a team of 13 (four men and nine women) found that this tragedy could, and should, have been avoided. People requiring treatment or transfusions because of bleeding disorders, accident, during childbirth or surgery were supplied with contaminated blood. About 1,350 of them were infected with HIV and Hepatitis, a third of them children. Up to 32,000 more were infected with one or more of the Hepatitis viruses. Over 3,000, men, women and children, died.

The Inquiry found systemic, collective and individual failures to deal ethically, appropriately, and quickly with the risk of infections being transmitted in blood, and with infections when that risk materialised. Reasonable people might well conclude that this was criminal, and worthy of a corporate manslaughter prosecution.

That this could happen in a developed, allegedly civilised country is beyond belief. The reasons why it happened are truly shocking, though sadly not surprising to anyone who knows the NHS and how governance works in Britain. It has been known since at least the early 1940s that blood transfusions and use of plasma can transmit hepatitis, and that this could be fatal or result in serious long-term disease; liver failure, cirrhosis and cancer. By the early 1980s it was also known that whatever was causing AIDS was transmittable by blood and blood products. Surely therefore, every possible precaution should have been put in place to ensure that blood given to patients was free of contamination.

Not a bit of it. In fact, the reverse was the case. There was a failure to ensure that this country was self-sufficient in blood and blood products, suitable plants were neglected and left all but obsolete, purpose-built plants were used for other purposes. But no matter, the medical and political Establishment decided that it was acceptable to import blood from abroad, principally Austria and the US, understood even at the time to be less safe than British produced blood products, and with a “high risk of causing hepatitis” (direct quote from the Report).

To compound this negligence, the size of the donor pool used to manufacture blood products in Britain was increased, even though it was known that this would increase the risk of viral contamination. The Establishment then negligently failed to “ensure sufficiently careful and rigorous donor selection and screening”. They even allowed the collection of blood from prisons, despite there being a significantly higher incidence of Hepatitis B among prisoners. The American Red Cross had stopped collecting blood from prisons in 1971, yet British government policy through to 1984 was to encourage prisoners to donate blood as it was “believed to help with rehabilitation”.

There was a failure to research into how to kill viruses in blood products even though no new technology was required. People were treated with ever increasing volumes of blood concentrates, despite the known risk of viral transmission. No additional safeguards or safety measures were put in place.

Unbearably and infuriatingly, children were used as guinea pigs. Young boys at Treolar’s, a school in Hampshire meant to be a haven for at risk haemophiliac boys, were treated as objects of research. They were given multiple, riskier and unnecessary blood concentrates, much of it originating from blood donated by high-risk groups such as drug addicts, sex workers and prisoners in America, who were paid for their donation, even though the school’s clinicians were fully aware that this risked ‘causing AIDS’. The Americans had imported much of the blood from poor countries like Haiti.

No change however, was made in treatment procedures or the school’s approach to treatment except to regularly test the boys for aids – without their or their parent’s knowledge. The Report describes this as “unconscionable”. I call it criminal. Boys became ill as early as 1975, later to discover that they had been not only infected with Hepatitis, but also with HIV. Many died.

The political and medical Establishments routinely lied to the public, saying that blood did not carry AIDS or HIV, and that Hepatitis C was relatively mild and inconsequential. Knowing that this was untrue, and that foreign blood, especially from the USA, was more likely to be infected with both, they nevertheless decided, in 1984, to carry on importing commercially produced blood products. They did not tell people of the risk involved, and unethically and possibly illegally, treated them without informed consent.

And all the while they conducted research on patients without telling them or informing them of the risks. In fact, they often didn’t even bother to tell people that they had infected them, thus denying the infected the opportunity to seek treatment and, of course, risking passing on the infection to others.

All this was compounded by the utterly mendacious, inhuman and evasive response of the Establishment to those seeking to find out how they had been infected. Lying prolifically, the NHS, medical and scientific establishments, politicians and government officials made repeated use of inaccurate and misleading data. They did this ruthlessly and to such effect that the truth was hidden for decades. Documents were destroyed. Lie followed lie.

The whole ‘system’ was rotten. What system there was seems to have been designed to cause confusion and obfuscation. There was no overarching advisory committee on blood safety until the establishment of the Advisory Committee on the Virological Safety of Blood in 1989, almost 20 years after the contaminated blood saga began. Even then, though the need for such a committee was established in June 1988 it took until April 1989 before it got around to meeting.

Even when the truth could no longer be hidden, the NHS apparatchiks’ response was mealy-mouthed, mean-spirited and contemptuous. There were delays in giving the infected specialist treatment. Palliative care for those dying was patchy. Compensation was refused on the grounds that there was no fault, and long, bureaucratic delays were experienced in getting ex-gratia financial support to the infected.

The Inquiry concluded that much of the blame lay with successive governments, along with senior NHS management and a plethora of government committees, all staffed with well-paid bureaucrats, medical and non-medical, Sir this, Lady that, doctor, professor and so on. The report emphasises that many of the decisions that lead to this tragedy were those of the Government and the Department of Health and illustrates the institutional defensiveness of the NHS, government and civil service. It points out that the whole stinking mess was compounded by groupthink amongst civil servants and ministers, whose lack of transparency and candour had deadly consequences.

I try to avoid extremes of language and hyperbole, but the word vermin springs to mind. My dictionary defines vermin as ‘people considered loathsome or repulsive’. Yes. Sorry, but I can’t help it. Surely anger is the only reasonable response to this affair.

The Inquiry found, of course, that based on the available evidence (i.e. not destroyed?) “Ministers were not informed”. The report does not let them off the hook completely though, saying that “it is not the fault of ministers if civil servants do not bring matters to their attention. It is, however, the responsibility of ministers to demonstrate a degree of proactivity and to challenge. Viewed overall ministers appeared to have lacked curiosity in the early period of the developing public health crisis. No minister, for example, asked officials to investigate what other steps could be taken to protect people short of stopping the importation of concentrates.”

The committees and working groups so prevalent in the civil service, with acronyms like, MMWR; CBLA; CDSC; CSM(B); CSM; RTC; RTD and EAGRA, (CBA - Couldn’t Be Arsed – would have been appropriate) simply failed to do their jobs. They had, however, regular, cordial interactions with pharmaceutical companies. They were given gifts and their research was funded, as was the cost of attending international conferences. I doubt if they went cattle class.

A pharmaceutical company internal memo, dated May 1985, describes how the Chairman of the UK Haemophilia Centre Directors Organisation was sought out at an AIDS Conference in Atlanta. This chap, who features prominently – though not entirely to his credit - in the Report, asked if he could visit the company in San Diego. He had his flight, hotel and who knows what else was paid for. His wife went along as well.

Another eminent professor, one of the world's leading haematologists, recalled that the hospitality from pharmaceutical companies was: “overwhelmingly lavish … there would be the very best restaurants, the river cruises … all the paraphernalia of marketing products.” Asked why the companies were spending all that money, the answer was “Because they could gain influence with it.” There is more, but you get the drift.

This article starts by asking whether there has been a conspiracy. The Report’s answer was no, “not in the sense of a handful of people plotting in an orchestrated conspiracy to mislead, but in a way that was more subtle, more pervasive and more chilling in its implications.” So, there was a conspiracy. A conspiracy that involved more than a mere handful of people. The orchestrated plot involved more than that, including ministers, senior civil servants, a senior medics and NHS bureaucrats at the highest level.

The Terms of Reference of the Inquiry included whether there was a “cover-up”. The report chose to use the expression “hiding the truth” which is defined as “deliberate concealment … a lack of candour … the retelling of half-truths … and failing to tell people about the risks inherent in treatment or the alternatives to that treatment, that they had been tested for infection, or been used in research, or were suffering from a potentially serious and fatal disease.”

In what way is this not a conspiracy? It was not a conspiracy in the same way as the false man-made climate change and its cultist’s net zero, which seeks to change the world and the way we live, but it is a conspiracy nevertheless. In fact there were two conspiracies, the first to carry out dangerous research on an unsuspecting public, and a second to protect people who, in a sane society, would be regarded as criminals.

There was deliberate destruction of documents of relevance. The State’s Self-Sufficiency Report of 2006 was self-justifying, and its drafting had the effect of hiding significant information. Over decades successive governments made statements that were inaccurate, defensive and misleading.

And this only came out because many ordinary people, some made chronically ill, felt obliged to devote their time and their energies to investigating and campaigning, often at great personal cost. I salute those people and hope that those responsible are punished.

The Report includes the obligatory ‘Lessons to be Learned’ section. Basically, it suggests the obvious in regard to doing things properly, like giving paramountcy to patient safety, properly assessing risk, asking the right questions, minimising delays and so on, but it does not fully address the real cause of this scandal: the rotten culture, lack of accountability and contempt for the public that permeates all circles of government in Britain.

The report touches on this, saying that the status-quo should be challenged and that “all must beware of “sacred cows” – but only “in relation to medicine and clinical practice.” To be fair, it does recommend “candour and transparency between government and citizen” but only relates this to medical matters. The Report also recommends that “civil servants must ensure that the information given to ministers is accurate.” But if, at any time in the last century Sir Humphrey was asked, he would have assured us that it always is.

The report, to its credit, touches upon the culture and nature of the NHS and our system of government. It wants to see a rigorous duty of candour introduced across the Civil Service, one that “has teeth”. But the teeth recommended, consideration of a statutory duty, and that Ministers should be “subject to a duty beyond their current duty to Parliament under the Ministerial Code” seem less sharp than most of us would like, which is that such behaviour should be made unambiguously criminal – and that that those responsible should be punished accordingly.

There has been talk in the press of prosecutions, though some dismiss this by saying that a corporate manslaughter charge cannot be brought because the relevant law, the Corporate Manslaughter and Corporate Homicide Act was not introduced till 2007, too late to apply to the guilty men and women involved. However, prosecutions for manslaughter have been made before that law was introduced. Three company directors and four seamen involved in the Herald of Free Enterprise sinking in 1987 were prosecuted for manslaughter. The death toll in that disaster was a mere 193, tiny compared with that involved in the contaminated blood scandal.

There have been many more cases under the old law, but it was usually used against relatively lowly personnel and, so far as I can find, never against civil servants or the bosses of state-owned companies. Following the Ladygrove Road rail crash in 1999, in which 31 people died and 417 were injured, Network Rail was not prosecuted, only fined. The Railway Health and Safety Executive, though criticised, escaped unscathed. The driver of the train that crashed at Southall in 1997 however, was charged with manslaughter by gross negligence.

Around 72 people died when a council-owned block of flats, Grenfell Tower in Kensington and Chelsea, London, went on fire. To date, no prosecutions have been made and, disgracefully, the police say that they will not make any decision on prosecutions till the end of 2025. The Crown Prosecution Service says it will then need a full year after that to make any decisions. Meanwhile, accusations are being made of the destruction of evidence.

No doubt any decision about prosecuting those responsible for the 3,000 people who died because their blood was infected will be similarly delayed. When asked, PM Sunak said that there must be “justice and accountability”' for any wrongdoing and that, when asked about the possibility of criminal prosecutions, said: “Anyone, people, individuals, where there is evidence of wrongdoing, of course there must be justice and accountability for that”. He then went onto say, though, in the slithery style for which he and most politicians are renowned “But the report is very long, it is very comprehensive, and what I am committed to is the Government will now take the time to go through it properly and rigorously before responding in Parliament, and, of course, any individual cases will be a matter for the relevant authorities.”

I suspect that no decision will be made for a very long time. Both Labour and Tory politicians were involved. And is it only me who suspects that the passage of time means that the culpable individuals will be either dead or impossible to track down? And even if they are tracked down, expect to hear much about “lack of evidence of culpability” and an inability to discover a “guiding mind”. It’s started already.

Much has however, been made of the government’s newfound willingness be generous in compensating survivors and their families. No delay while the lengthy report is studied, analysed and kicked around in any number of committees for that. No, a multi-billion package is being talked about, with up to £10 billion of government money handed out, according to one headline.

But the government has no money, only what it takes from taxpayers or borrows in their name. No doubt they hope that all that money will induce campaigners to drop it all and go away to enjoy the money. So, as usual, who ends up being punished for all those avoidable deaths and all those ruined lives. That’s right, the long-suffering British taxpayer.