IIt was one of the worst medical disasters of our time. Around 30,000 people who needed the help of the NHS to stay alive were given treatment that devastated their health, cost the lives of almost 3,000 people and will be responsible for even more deaths. Finally, today, half a century later, the six-year Langstaff inquiry has delivered a verdict on the tainted blood scandal – and it is devastating.
The list of errors and misjudgments is extraordinary and it is clear that the arrogance of the medical profession played a major role, as did the greed of the pharmaceutical companies and the underhandedness of the politicians. So many heads should roll, but many of the most guilty individuals are dead.
There was some hope that the report would call for prosecution of those responsible, supporting cases against individual NHS and government figures. That’s it, but the conclusions are harsh and the pleas for large compensation for the victims cannot be answered. The government is expected to announce a compensation package tomorrow.
The government has also been challenged by Sir Brian Langstaff to implement his recommendations or provide a good reason why this has not happened within a year. It would be a shame if this goal is not achieved.
If there’s a sense of deja vu, it’s not surprising. In recent years, one scandal after another has emerged, revealing decades later that ordinary people have not only been terribly wronged, had their lives ruined or curtailed, but have subsequently been denied explanation or justice for years . Look at the post office scandal, look at Hillsborough. There have been more and there will be more unless governments and other public authorities tell the truth when mistakes have been made.
It will be difficult to set things right for the infected blood patients. The compensation will help, but comes much too late. Prosecutions for corporate manslaughter will be difficult.
Many of those infected with hepatitis and HIV viruses through infected blood had hemophilia. They were blameless, yet they were ignored and cast aside as if they were unworthy, doubly stigmatized by their original vulnerability and the viruses they had contracted. There were many children among them. The story of what happened at Treloar school, which had a haemophilia centre, is deeply disturbing. Only 30 of the 122 children with hemophilia who attended the school between 1970 and 1987 survived. The children were guinea pigs who, among other things, received prophylactic doses of factor VIII concentrates that were deliberately too high or too low and were often, as we now know, infected with HIV.
In retrospect, it is difficult to understand the decisions made in the 1970s and 1980s. The fundamental undertaking of all physicians is, “First, do no harm.” Yet the risk of hepatitis in blood products had been known since the Second World War. In 1952, the World Health Organization warned that it was a serious problem and recommended measures to minimize the risk, including the careful selection of donors.
Doctors knew, or should have known when they started using factor VIII, a blood-clotting product derived in part from prisoners paid to donate blood in the US, that there was a high risk it would transmit hepatitis, given injecting drug use Amongst them. Cutter Laboratories, a subsidiary of Bayer, when applying for a license for its product Koate in the 1970s specifically stated the following: “Since the presence or absence of hepatitis virus in Koate concentrate cannot be proven with absolute certainty, the presence of such a virus can be assumed.” Doctors and the governments they advised argued that the benefits to patients who could die from haemorrhage outweighed the risk of hepatitis, underestimating the damage to the liver that hepatitis B and later the even more virulent C would cause. Patients developed cirrhosis and fatal liver cancer.
That complacency carried over into HIV. In 1982, when AIDS was taking off, there were warnings from the United States that factor VIII might contain the virus. The WHO advised countries to source blood from their own populations. In 1983, Health Secretary Kenneth Clarke told Parliament that there was “no conclusive evidence” that AIDS, which was then always fatal, was transmitted through blood products.
Yet these fundamental misjudgments, which destroyed health and lives, often killing children or parents who left young orphans behind, were not the end. Much could have been done to help the survivors live the best lives possible, but it didn’t. Instead, we heard the running of feet and the whirring of shredding machines as the establishment scrambled to cover up its involvement in the tragedy. The investigation found that many crucial documents went missing or were destroyed, from the medical records of individuals to the papers of ministers and, in the mid-1990s, of the Advisory Committee on the Virological Safety of Blood.
It would be totally shocking if we hadn’t been here before. But shockingly, it’s not uncommon. Mistakes are made, bad and careless decisions are made, and those in authority will not confess. That in itself is not only immoral. The result is much more suffering for those wronged and their families.
The Hillsborough families are campaigning for a new law that no country should need, but it appears Britain does. The Hillsborough bill would impose a duty on government agencies and officials to tell the truth about things that have gone wrong and to proactively cooperate with investigations. The families also want government funding for survivors at inquests – they have struggled to fund lawyers, while government agencies have had heavy legal representation. The government has instead signed a charter in which officials commit themselves to transparency and openness.
Keir Starmer has promised that Labor will do that introduce the Hillsborough Act. It might have helped the post office staff and infected blood patients get the justice and compensation they deserved decades earlier. At the very least, it might make those in positions of power think harder about the people affected by their decisions – and hopefully hesitate a little longer before turning on the shredding machine.