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WWW.MY-SUBS.COM
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I've seen too many people
taken down by this thing.
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So when the time comes...
That's my choice.
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Lawrence Hartley's wife, Caitlin,
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just passed away.
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Unfortunately,
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we're not seeing much success
with this treatment.
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I'm requesting you resign.
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I think you need to
start coming to the CHS
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in an official capacity.
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Dust off that old law degree?
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Check out what "ADC" stands for.
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I have to tell the Red Cross.
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"Exhaustion of existing inventory,"
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that's one way of putting it.
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Handing out tainted blood
for another seven months
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- is another!
- The FDA ruled that
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Armour's process is adequate,
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so long as it's made
with screened plasma.
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Screw an inquiry! Seven more dead,
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six kids! There's no excuses.
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Are you gonna tell the world
what a screwed-up family we are?
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This was a mistake.
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You may now kiss the bride.
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We didn't get AIDS. They gave it to us.
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The open spaces called "agora"
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embodied the newfound
respect for social justice
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received through debate
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rather than imperial mandate,
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the most well-known
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being the ancient agora of Athens,
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depicted here.
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You probably recognize
that this is the root word
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for "agoraphobia,"
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which, as follows, is a
fear of open spaces.
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From the 18th century to
the 8th century B.C.,
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citizens would gather
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in the open court, or agora,
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to hear statements...
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She's studying to be an astrophysicist.
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... later, it would
serve as a marketplace
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where merchants would set
up stalls and shops...
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_
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Federal Health and Welfare Minister
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Mary Collins is on line one.
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I know who she is.
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_
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Mary, it's Horace.
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Horace, how are you?
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Fine, fine.
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I read your interview in The Globe.
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- _
- Always on top of everything.
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I do understand this will
make some people nervous,
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but I can't stress enough the
importance of this inquiry
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to our country.
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I need to make sure
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you know what you're
getting yourself into.
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Enough to know
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I'm not going to fully
understand the situation
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till I'm done.
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Can I take that as a yes?
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Yes.
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Is this you celebrating?
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I'll celebrate
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when those criminals get
what's coming to them.
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- Synced & corrected by MementMori -
-- www.MY-SUBS.com --
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- Good morning, Ms. Edwardh.
- Good morning.
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I requested the records
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of the Canadian Blood
Committee meetings.
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No word back yet. And this is
the latest travel schedule
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for the testimony road show.
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Looks like we're going
to start in Toronto,
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move to Vancouver, and then head east.
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Thank you very much, Jenny.
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Yes.
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There's no way we're gonna
make this deadline.
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September 30th is a joke.
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AIDS is only one part of this story.
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Hepatitis C keeps coming up.
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I don't think I'm exaggerating
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when I say this could take years.
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- What's this?
- Budget proposal.
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16 million?
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That's conservative.
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That's 13 million more
than they gave us.
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That's what it's going to cost.
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Are we going to get it?
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What choice do they have?
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This is the government
we're talking about.
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- _
- Hearings opened today
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into the tragedy of tainted blood,
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a tragedy that left more
than a thousand Canadians
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with HIV...
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It is not and will not be a witch hunt.
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It is not concerned with
criminal or civil liability.
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The focus of this inquiry
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is to determine whether or not
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Canada's blood supply is
as safe as it could be,
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and whether the blood
system is sound enough
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so that no future tragedy will occur.
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The victims of the tainted blood scandal
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are dying at a rate of three a week.
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Others may not live to see
the end of the inquiry,
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but both they themselves
and Justice Krever
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are determined to see
that they are heard.
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This is something I just can't believe,
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that, uh, I was given product
that's going to kill me,
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and kill my wife and destroy our family.
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I've flown all the way from Vancouver
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so that I can give this
to Justice Krever.
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Inside, um, I've written
my son Andy's story.
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He's gone now,
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and nothing is going to
bring him back, um...
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I struggle with that every day,
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but I have to say I'm just grateful
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that someone is finally listening...
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That's your friend Andy's mom, isn't it?
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Hello, my name is Lawrence Hartley,
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and I have been president of the
Canadian Hemophilia Society
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since 1986.
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I am also a hemophiliac who
is co-infected with HIV
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and Hepatitis C.
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This story is tragic, obviously,
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but the reason it is so tragic
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is because it could have been avoided.
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Those of us that depended
on blood products to live
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were seriously injured
by a Canadian system
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that just didn't seem to care.
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Now, I understand people want a
"triumph over tragedy" story,
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some kind of silver lining,
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but for those of us who
have lost someone,
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there is no end to the grief,
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and so we must speak here today
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about how to fix things for the future,
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but also know
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that nothing will ever
repair the damage done.
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No one wanted to recognize the problem.
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To recognize it would have meant
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taking on the immense
task of dealing with it.
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The doctors and nurses said
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they were relying on the Red Cross.
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The Red Cross pointed at
the Bureau of Biologics.
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No one was taking responsibility.
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We were treaters,
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and our overriding concern was
to treat our patients well.
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We knew very little about AIDS,
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but we knew a lot about hemophilia
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and the complications of bleeding.
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Not that I am trying to absolve anyone,
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but I think it's important to remember
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that we can't look back
and judge ourselves
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on what we didn't know at the time.
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AIDS was a difficult mystery to unravel.
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Furthermore, I think it can be too easy
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to scapegoat certain
people at the Red Cross
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when in fact it was the entire
blood system that failed.
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As early as 1981,
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there were reports of a
new disease in the U.S.,
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and there was no reason to expect
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it wouldn't reach Canada.
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The BoB asked the Red Cross
to monitor the situation.
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I'm a father of a hemophiliac,
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and we were never
warned about the danger
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through any official channels.
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I remember patients calling me
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about symptoms
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that now in hindsight, were
clearly connected to HIV.
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Did you get bulletins or updates
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of medical information
from the Red Cross
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or the Bureau of Biologics?
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Oh, no.
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No, nothing like that.
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There were no transfusion-
related cases of AIDS
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at the time,
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and the authorities, whom I trusted,
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were not very concerned.
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Clearly, the latency period of the virus
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created huge problems.
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It took a while for people
to actually start dying,
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and in the meantime,
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they were free to infect
the blood system.
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I begged the Red Cross
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to implement some sort
of donor screening.
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Why wouldn't they do it?
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They were afraid of the backlash.
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It was a religion.
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Because you had to volunteer,
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they thought that only
good people gave blood,
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and good people wouldn't have AIDS.
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It was... blind faith.
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16 months
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after the U.S. implemented
an AIDS pamphlet for donors,
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the Canadian Red Cross
finally jumped in.
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Dr. Perrault, in December of 1984,
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both you and Dr. Davey were informed
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that the issue was urgent,
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and that there was overwhelming evidence
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that these pamphlets were not
being used as instructed.
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Then in January,
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Dr. Derrick wrote the both of you
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and stated,
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"It has been acknowledged from the first
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that the pamphlet is
less than adequate."
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Well, I mean, this is a first edition.
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The wording is not necessarily ideal.
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The fact that it's less than perfect...
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There's a difference between
being less than perfect
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and less than adequate, isn't there?
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00:08:01,440 --> 00:08:03,470
Well, I can't speak for Dr. Derrick...
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The memo says, "acknowledged
from the first."
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That would be the beginning
of the use of this pamphlet.
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He writes, "While it is true
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there are no cases of AIDS in Canada
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which can be attributed
strictly to transfusion,
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it is certain that this
will occur eventually,
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possibly soon,
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and unless the CRC is seen
to be exerting every effort
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00:08:23,580 --> 00:08:25,260
to screen out high-risk donors,
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when this does happen,
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the credibility of the
Blood Transfusion Service
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will be badly damaged."
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00:08:30,970 --> 00:08:33,140
Did you share this view
that it was certain
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that cases of AIDS in Canada
would soon be attributed
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strictly to transfusion?
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I thought it likely, sir.
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They were using science
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to avoid spending money,
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00:08:43,080 --> 00:08:44,850
and ignoring all the warning signs.
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00:08:44,880 --> 00:08:46,680
There was a statement
they kept repeating.
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"No conclusive proof."
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00:08:49,050 --> 00:08:51,920
Dr. Davey, I suggest that
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00:08:51,950 --> 00:08:55,420
you saw your role in
all this as a skeptic.
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00:08:55,480 --> 00:08:57,360
But, in fact, you were skeptical
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00:08:57,390 --> 00:08:59,360
beyond reason.
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00:08:59,400 --> 00:09:03,430
I would describe my position
as critical, not skeptical.
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00:09:03,470 --> 00:09:06,199
I looked at evidence, assessed it,
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00:09:06,200 --> 00:09:07,970
and drew conclusions from it
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00:09:08,000 --> 00:09:10,399
compatible with the state
of knowledge at the time.
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00:09:10,400 --> 00:09:11,700
I suggest
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00:09:11,720 --> 00:09:14,880
that we are going to find
your critical position
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00:09:14,910 --> 00:09:16,680
to be wrong on every count.
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That always, you erred against safety,
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and that it cost us lives.
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00:09:21,300 --> 00:09:23,740
I'm not going to be
convinced by a statement
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just because it's a view
that's widely held.
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00:09:26,020 --> 00:09:29,290
It was at one time a
widely held view, sir,
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00:09:29,330 --> 00:09:30,690
that the Earth was flat.
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No one's safety was dependent on that.
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Some of Columbus's sailors, sir,
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00:09:38,940 --> 00:09:40,870
might have differed with
you, but never mind.
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00:09:46,800 --> 00:09:48,169
Look at what happened in Calgary
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00:09:48,170 --> 00:09:49,179
under Man Chiu Poon.
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He put his patients back on Cryo,
253
00:09:51,010 --> 00:09:54,679
and only 33% of his severe
patients contracted AIDS,
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versus I believe 90-95%
on a national basis.
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00:09:57,790 --> 00:09:59,340
And to his credit, when somebody said
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congratulations are in order,
257
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Dr. Man Chiu Poon said,
258
00:10:03,180 --> 00:10:06,030
"Everyone that is affected by HIV
259
00:10:06,060 --> 00:10:08,300
is a failure on our part."
260
00:10:08,340 --> 00:10:11,900
Dr. Perrault, would you agree
that by the fall of 1984,
261
00:10:11,920 --> 00:10:14,040
the risk of contracting
HIV from concentrate
262
00:10:14,070 --> 00:10:15,820
was greater than that
of cryoprecipitate?
263
00:10:15,840 --> 00:10:17,670
That was generally accepted.
264
00:10:17,710 --> 00:10:20,510
If you had a son who was a hemophiliac,
265
00:10:20,540 --> 00:10:22,020
would you have kept him on Cryo?
266
00:10:26,420 --> 00:10:28,450
I have thought of that many times,
267
00:10:28,480 --> 00:10:30,920
and some of the points would be his age,
268
00:10:30,950 --> 00:10:33,120
and level of activity
in school and whatnot.
269
00:10:33,160 --> 00:10:35,190
I think that an active
10-year-old or 12-year-old
270
00:10:35,220 --> 00:10:37,060
would have objected,
271
00:10:37,090 --> 00:10:40,160
although my preference
would have been Cryo.
272
00:10:41,300 --> 00:10:43,030
To be clear,
273
00:10:43,070 --> 00:10:46,130
you would have kept your own
son on cryoprecipitate?
274
00:10:46,170 --> 00:10:47,600
Yes.
275
00:10:51,720 --> 00:10:53,320
Some of the things
coming out in testimony
276
00:10:53,340 --> 00:10:54,880
are unbelievable.
277
00:10:54,910 --> 00:10:57,150
It's all we talk about in Ethics.
278
00:10:57,180 --> 00:10:58,400
I think it's fascinating.
279
00:10:58,440 --> 00:11:00,750
You know, you're gonna
make a good doctor,
280
00:11:00,780 --> 00:11:03,050
but you would have made
a truly great lawyer.
281
00:11:03,090 --> 00:11:04,620
Why do you say that?
282
00:11:04,650 --> 00:11:06,520
I can hear you building your case.
283
00:11:09,830 --> 00:11:11,790
Okay, fine.
284
00:11:11,830 --> 00:11:13,830
I think you should testify.
285
00:11:13,860 --> 00:11:15,630
I know you care,
286
00:11:15,660 --> 00:11:17,730
and I think you're gonna
regret it if you don't.
287
00:11:17,770 --> 00:11:19,170
Other people are standing up,
288
00:11:19,200 --> 00:11:20,720
and I'm glad they are.
289
00:11:20,800 --> 00:11:21,900
I'm happy for 'em.
290
00:11:21,940 --> 00:11:23,440
But in the end, I have to live with it.
291
00:11:23,470 --> 00:11:25,810
I don't see the need to relive it,
292
00:11:25,840 --> 00:11:28,480
even for a day.
293
00:11:28,510 --> 00:11:31,150
Being a victim doesn't diminish you.
294
00:11:31,180 --> 00:11:32,580
This is going to make things better.
295
00:11:32,600 --> 00:11:33,620
Is it?
296
00:11:33,630 --> 00:11:36,480
Well, it won't change what
happened to you, but...
297
00:11:36,520 --> 00:11:38,040
maybe in the future,
298
00:11:38,100 --> 00:11:39,850
it makes someone in power think twice
299
00:11:39,890 --> 00:11:41,860
before they put money
over people's lives.
300
00:11:41,890 --> 00:11:43,180
Maybe the attention gets help
301
00:11:43,200 --> 00:11:45,330
- for people who need it right now.
- I'm sorry.
302
00:11:45,360 --> 00:11:48,720
I don't feel a duty to make
a spectacle out of myself.
303
00:11:48,740 --> 00:11:51,370
I don't owe anybody my story.
304
00:11:55,970 --> 00:11:57,960
His name, his face,
305
00:11:57,980 --> 00:12:01,440
came to symbolize the
tragedy of tainted blood.
306
00:12:01,480 --> 00:12:03,160
Randy Conners, a hemophiliac,
307
00:12:03,200 --> 00:12:05,120
contracted HIV at a time
308
00:12:05,150 --> 00:12:07,520
when Canada's blood
supply was contaminated.
309
00:12:07,650 --> 00:12:09,680
He led a fight for compensation,
310
00:12:09,700 --> 00:12:12,820
and won respect for his
courage and determination.
311
00:12:12,860 --> 00:12:16,320
Today, at the age of 38,
Randy Conners died.
312
00:12:16,360 --> 00:12:18,800
His great regret was
that he wouldn't live
313
00:12:18,820 --> 00:12:21,840
to see the outcome of
the Krever inquiry.
314
00:12:21,860 --> 00:12:24,230
Randy Conners chose to die at home,
315
00:12:24,270 --> 00:12:26,900
and spent his last
hours with his family.
316
00:12:26,940 --> 00:12:29,040
As his life drew close to an end,
317
00:12:29,070 --> 00:12:31,510
Randy Conners focussed on one question.
318
00:12:31,540 --> 00:12:34,060
Why did the blood system
he relied on so much
319
00:12:34,080 --> 00:12:37,080
fail him and 700 other hemophiliacs?
320
00:12:41,180 --> 00:12:44,420
Um... my name is Jessica Hartley...
321
00:12:45,380 --> 00:12:48,120
and I'm 15 years old.
322
00:12:49,090 --> 00:12:54,190
I was seven when I found out
that my mom was dying of AIDS.
323
00:12:55,760 --> 00:12:58,730
I still really miss her.
324
00:12:58,760 --> 00:13:03,180
My mom got AIDS from my dad,
325
00:13:03,300 --> 00:13:06,400
and I know he feels really bad about it,
326
00:13:06,440 --> 00:13:09,840
but I know it wasn't his fault.
327
00:13:09,870 --> 00:13:11,920
He didn't know he had it.
328
00:13:12,020 --> 00:13:14,380
The people at the Red
Cross and the doctors
329
00:13:14,410 --> 00:13:16,080
didn't tell my dad that he could have it
330
00:13:16,100 --> 00:13:17,450
or that he could give it to my mom
331
00:13:17,480 --> 00:13:19,280
until it was too late.
332
00:13:19,320 --> 00:13:21,050
I don't think it's fair
333
00:13:21,080 --> 00:13:22,620
that I have to grow up without my mom,
334
00:13:22,650 --> 00:13:26,390
but I know that life isn't always fair.
335
00:13:28,930 --> 00:13:32,300
I'm very sad and very
angry that this happened,
336
00:13:32,330 --> 00:13:35,830
and I just hope that my
dad's going to be okay.
337
00:13:42,980 --> 00:13:44,000
It's amazing
338
00:13:44,010 --> 00:13:45,680
how he can sit through
something like that
339
00:13:45,700 --> 00:13:47,110
and not react.
340
00:13:47,140 --> 00:13:49,650
There wasn't a dry eye in the house.
341
00:13:49,680 --> 00:13:51,420
He is a judge.
342
00:13:51,450 --> 00:13:53,560
He needs to appear impartial,
343
00:13:53,570 --> 00:13:54,650
and he wants to make sure
344
00:13:54,690 --> 00:13:56,890
his report doesn't look biased.
345
00:13:56,920 --> 00:13:58,790
Yeah, but he's still a human being.
346
00:14:04,360 --> 00:14:07,300
I think it must be lonely.
347
00:14:08,630 --> 00:14:10,730
Your ALTs are up over 600.
348
00:14:10,770 --> 00:14:12,070
What can we do?
349
00:14:12,100 --> 00:14:14,300
Not much more than we're
doing already, I'm afraid.
350
00:14:14,340 --> 00:14:16,770
The AZT doesn't seem to be helping.
351
00:14:16,810 --> 00:14:19,750
No, given that he only has two T-cells.
352
00:14:19,780 --> 00:14:21,360
You really need to take it easy.
353
00:14:21,390 --> 00:14:23,480
Give the meds a chance.
354
00:14:25,020 --> 00:14:26,250
I can't quit now.
355
00:14:26,280 --> 00:14:28,620
The treatment for the Hep C failed.
356
00:14:28,650 --> 00:14:31,090
I'm sorry if this is morbid, but...
357
00:14:31,100 --> 00:14:32,120
if I'm going to die,
358
00:14:32,140 --> 00:14:34,100
I'd like to make a difference
with the time I have left.
359
00:14:34,140 --> 00:14:36,330
He didn't say you were dying.
360
00:14:38,320 --> 00:14:39,660
You're certainly not giving yourself
361
00:14:39,700 --> 00:14:41,000
a better chance to live.
362
00:14:44,170 --> 00:14:45,870
Every one of these files
363
00:14:45,900 --> 00:14:48,360
is for a patient who died of AIDS
364
00:14:48,540 --> 00:14:50,300
from tainted blood.
365
00:14:50,360 --> 00:14:53,480
They are not just pieces of paper,
366
00:14:53,510 --> 00:14:56,210
are they?
367
00:14:56,250 --> 00:14:58,680
Medical histories.
368
00:14:58,780 --> 00:15:01,780
Test results.
369
00:15:01,820 --> 00:15:05,000
They are human beings who are now dead.
370
00:15:05,080 --> 00:15:07,260
But it doesn't end here.
371
00:15:07,290 --> 00:15:09,160
Please, when you look at this,
372
00:15:09,220 --> 00:15:11,390
think of the people who
are not represented.
373
00:15:11,430 --> 00:15:16,200
They are called "secondary victims."
374
00:15:16,820 --> 00:15:19,670
Pauline Richards...
375
00:15:21,870 --> 00:15:24,470
She lost her uncle, a brother,
376
00:15:24,510 --> 00:15:26,520
and both of her sons.
377
00:15:26,550 --> 00:15:29,050
All in one year. Imagine that.
378
00:15:29,080 --> 00:15:30,640
Imagine the devastation
379
00:15:30,660 --> 00:15:32,170
of losing not one of your dear children,
380
00:15:32,180 --> 00:15:33,250
but both of them,
381
00:15:33,280 --> 00:15:36,320
and a good lot of the rest of
your family along with them.
382
00:15:36,350 --> 00:15:39,880
What, pray tell,
383
00:15:40,000 --> 00:15:42,100
is secondary about that?
384
00:15:42,160 --> 00:15:44,190
Dr. Furesz, the order that came
385
00:15:44,230 --> 00:15:47,240
from the Bureau of Biologics
in November of 1984
386
00:15:47,260 --> 00:15:49,140
was to switch to heated concentrates
387
00:15:49,170 --> 00:15:50,770
as soon as feasible.
388
00:15:50,800 --> 00:15:53,540
What monitoring did the
Bureau do after that
389
00:15:53,570 --> 00:15:55,840
to ensure the "as soon
as feasible" part?
390
00:15:55,870 --> 00:15:58,070
Everyone concerned met at
the Consensus Conference
391
00:15:58,110 --> 00:15:59,280
in December.
392
00:15:59,300 --> 00:16:01,740
We relied on the recommendations
that came out of that meeting.
393
00:16:01,780 --> 00:16:03,640
There was unanimous agreement.
394
00:16:03,700 --> 00:16:06,480
Our job was to approve the
safety of the product,
395
00:16:06,520 --> 00:16:09,999
not determine the practical
aspects of its distribution.
396
00:16:10,000 --> 00:16:11,040
Dr. Inwood,
397
00:16:11,050 --> 00:16:13,550
you represented the CBC
advisory sub-committee
398
00:16:13,580 --> 00:16:15,860
at the Consensus Conference in 1984.
399
00:16:15,890 --> 00:16:19,350
What did you hear Dr. Naylor
say on behalf of the Red Cross
400
00:16:19,380 --> 00:16:20,780
with respect to switching
all concentrates
401
00:16:20,800 --> 00:16:21,810
to heat-treated?
402
00:16:21,830 --> 00:16:23,930
He was unwilling to have
heat-treated concentrates
403
00:16:23,970 --> 00:16:25,530
immediately available in Canada.
404
00:16:25,570 --> 00:16:27,560
Was his unwillingness
related to the fact
405
00:16:27,580 --> 00:16:30,710
that he wanted first to use
up the untreated inventory
406
00:16:30,740 --> 00:16:31,910
in stock and on order?
407
00:16:31,940 --> 00:16:34,360
To do justice to the late Dr. Naylor,
408
00:16:34,400 --> 00:16:36,810
I suspect that what he
wanted to get across
409
00:16:36,850 --> 00:16:39,120
was that they would not be able to get
410
00:16:39,140 --> 00:16:41,160
any heat-treated material until April,
411
00:16:41,200 --> 00:16:43,260
and as a result, we would
have to continue to use
412
00:16:43,300 --> 00:16:45,330
non-heat-treated material,
but I can assure you,
413
00:16:45,340 --> 00:16:47,029
it was a matter of some
significant debate
414
00:16:47,030 --> 00:16:48,040
during the lunch hour.
415
00:16:48,060 --> 00:16:49,990
They certainly wanted to
finish off their older stocks
416
00:16:50,000 --> 00:16:51,010
at the same time.
417
00:16:51,860 --> 00:16:54,300
In the fall of '84, were you of the view
418
00:16:54,320 --> 00:16:56,600
that 100% of hemophiliacs
419
00:16:56,630 --> 00:16:59,599
had almost certainly been
infected with HIV already?
420
00:16:59,600 --> 00:17:02,200
I don't know if the studies showed 100%,
421
00:17:02,220 --> 00:17:03,540
but they showed a high percentage.
422
00:17:03,570 --> 00:17:05,660
We have the Bureau of
Biologics' position paper
423
00:17:05,680 --> 00:17:08,110
from the Consensus
Conference, Dr. Perrault.
424
00:17:10,950 --> 00:17:14,080
It says, and I quote,
425
00:17:14,120 --> 00:17:16,380
"Preliminary data from
Canadian studies indicate
426
00:17:16,400 --> 00:17:19,860
that over 55% of hemophilia patients
427
00:17:19,880 --> 00:17:21,420
who have received Factor 8
428
00:17:21,460 --> 00:17:23,090
have antibodies to this virus."
429
00:17:23,130 --> 00:17:27,760
Would you agree with me that
55% is a lot lower than 100%?
430
00:17:27,840 --> 00:17:30,080
If you say "all hemophiliacs,"
431
00:17:30,100 --> 00:17:31,800
55% is lower,
432
00:17:31,840 --> 00:17:33,970
but if you're only talking about severe,
433
00:17:34,000 --> 00:17:36,140
we're not comparing the same things.
434
00:17:36,170 --> 00:17:37,860
The point is, in the fall of '84,
435
00:17:37,880 --> 00:17:39,020
there was at least some chance
436
00:17:39,040 --> 00:17:40,780
to prevent infection in hemophiliacs
437
00:17:40,810 --> 00:17:42,880
who had not been previously
exposed, correct?
438
00:17:42,910 --> 00:17:45,180
That is entirely possible.
439
00:17:45,280 --> 00:17:46,980
Did you have a sense of urgency
440
00:17:47,020 --> 00:17:48,620
in November of 1984
441
00:17:48,650 --> 00:17:50,290
to get safer heat-treated product
442
00:17:50,320 --> 00:17:52,860
to Canadian hemophiliacs
knowing it might save lives?
443
00:17:52,890 --> 00:17:54,200
Yes, we did.
444
00:17:55,330 --> 00:17:56,750
Doctor, based on your data,
445
00:17:56,780 --> 00:17:58,820
what was the damage done by the delay
446
00:17:58,840 --> 00:18:01,040
in switching to
heat-treated concentrates?
447
00:18:01,060 --> 00:18:03,700
Between the time the
BoB ordered the switch
448
00:18:03,730 --> 00:18:06,400
and the July 1st, 1985 conversion,
449
00:18:06,440 --> 00:18:09,380
I can tell you that eight of my patients
450
00:18:09,400 --> 00:18:10,840
were infected with HIV.
451
00:18:10,870 --> 00:18:13,340
As well, given the fact
I was only tracking
452
00:18:13,380 --> 00:18:16,350
one sixth of the patients in Canada,
453
00:18:16,380 --> 00:18:18,900
I think it's safe to assume
there were more than that.
454
00:18:18,960 --> 00:18:21,080
You've indicated to us
throughout your testimony
455
00:18:21,120 --> 00:18:22,150
that there was no directive
456
00:18:22,190 --> 00:18:23,350
from the national Red Cross office
457
00:18:23,390 --> 00:18:25,750
to get rid of all its
non-heat-treated Factor 8?
458
00:18:25,790 --> 00:18:27,260
There was no such directive.
459
00:18:27,290 --> 00:18:29,860
I'd ask you to turn to tab 31...
460
00:18:30,790 --> 00:18:32,860
It is the Factor 8 inventory sheets
461
00:18:32,900 --> 00:18:33,900
from the national centre.
462
00:18:34,800 --> 00:18:38,070
On June 13th, 1985,
463
00:18:38,100 --> 00:18:39,280
there were 50,000 vials
464
00:18:39,300 --> 00:18:41,540
of safe heat-treated
product on the shelves.
465
00:18:41,570 --> 00:18:44,010
And yet, on that same day,
466
00:18:44,040 --> 00:18:47,010
98 vials of non-heat-treated product
467
00:18:47,040 --> 00:18:48,840
went to the Hospital for Sick Children.
468
00:18:48,860 --> 00:18:51,050
Dr. Perrault, it certainly seems
469
00:18:51,080 --> 00:18:52,410
that your dispensing centre
470
00:18:52,450 --> 00:18:54,880
was intent on distributing
its non-heat-treated product
471
00:18:54,920 --> 00:18:56,320
before the transition date.
472
00:18:56,380 --> 00:18:58,050
The information I was given
473
00:18:58,090 --> 00:19:01,290
was that the level of
inventory was required
474
00:19:01,320 --> 00:19:05,030
to make sure that we would not
be in a stop-and-go situation.
475
00:19:05,060 --> 00:19:07,600
A stop-and-go situation?
476
00:19:07,630 --> 00:19:09,740
There were 50,000 vials
477
00:19:09,770 --> 00:19:12,600
of safe, heat-treated
product on the shelves
478
00:19:12,620 --> 00:19:14,900
when you issued non-heat-treated product
479
00:19:14,920 --> 00:19:16,680
to the Hospital for Sick Children.
480
00:19:16,720 --> 00:19:18,250
I am telling you what I was told,
481
00:19:18,280 --> 00:19:19,980
and what I knew.
482
00:19:23,510 --> 00:19:25,620
What we were striving for
483
00:19:25,640 --> 00:19:27,720
was to make sure that we
could deliver the product
484
00:19:27,750 --> 00:19:29,920
on a sustained basis,
and not have to go back
485
00:19:29,930 --> 00:19:33,640
and say that suddenly
we are out of stock.
486
00:19:33,700 --> 00:19:35,120
Stop-and-go situation.
487
00:19:35,160 --> 00:19:37,620
Dr. Perrault, I have
just finished indicating
488
00:19:37,640 --> 00:19:40,500
that there was more than
enough safe product on hand
489
00:19:40,530 --> 00:19:43,130
when untreated product was
sent out to children!
490
00:19:43,170 --> 00:19:44,480
Are these the morals and ethics
491
00:19:44,500 --> 00:19:45,939
that guide your organization?
492
00:19:45,940 --> 00:19:48,900
Mr. Kirpatrick, this really
is not cross-examination.
493
00:19:48,920 --> 00:19:50,070
This is speech-making.
494
00:19:50,110 --> 00:19:51,460
Please stick with the facts.
495
00:19:54,840 --> 00:19:56,610
The fact is, Dr. Perrault,
496
00:19:56,650 --> 00:19:58,300
your organization
497
00:19:58,340 --> 00:20:00,920
sent tainted blood to children.
498
00:20:00,940 --> 00:20:02,660
Mr. Kirpatrick.
499
00:20:27,770 --> 00:20:30,930
Someone suggested we put
a washbasin up here
500
00:20:30,970 --> 00:20:31,980
because of all the officials
501
00:20:31,990 --> 00:20:35,100
who come and wash their
hands of responsibility.
502
00:20:35,180 --> 00:20:37,639
State your name for the record, please?
503
00:20:37,640 --> 00:20:39,310
Uh, Jim Krepke.
504
00:20:39,340 --> 00:20:41,920
My heart goes out to
you, Justice Krever.
505
00:20:41,980 --> 00:20:43,640
How do you distinguish between the truth
506
00:20:43,660 --> 00:20:44,719
and a statement made
507
00:20:44,720 --> 00:20:46,419
to protect oneself from liability?
508
00:20:46,420 --> 00:20:49,620
I know that I make
mistakes every single day,
509
00:20:49,650 --> 00:20:51,660
and I am willing to admit that freely.
510
00:20:51,700 --> 00:20:54,000
I make mistakes.
511
00:20:54,020 --> 00:20:56,690
But I've seen doctors and officials
512
00:20:56,700 --> 00:20:58,110
come and testify before you
513
00:20:58,140 --> 00:21:01,470
who apparently never made
a mistake in their life.
514
00:21:01,500 --> 00:21:02,700
In 1983,
515
00:21:02,720 --> 00:21:04,470
the Red Cross entered into a contract
516
00:21:04,500 --> 00:21:06,070
with Connaught Laboratories,
517
00:21:06,100 --> 00:21:08,140
the only licensed Canadian producer
518
00:21:08,170 --> 00:21:11,000
of Factor 8 concentrate, to
produce six million units.
519
00:21:11,060 --> 00:21:13,300
We've already covered some
of Connaught's deficiencies
520
00:21:13,340 --> 00:21:15,050
in producing Factor concentrate.
521
00:21:15,080 --> 00:21:17,250
There were some issues with quality,
522
00:21:17,280 --> 00:21:19,080
in particular, solubility
of the product.
523
00:21:19,100 --> 00:21:20,109
Canadian blood donations
524
00:21:20,110 --> 00:21:21,740
couldn't possibly supply enough plasma
525
00:21:21,750 --> 00:21:23,520
to produce that much concentrate,
526
00:21:23,540 --> 00:21:25,490
so Connaught started buying plasma
527
00:21:25,520 --> 00:21:28,190
from a company called Cryosan Ltd.
528
00:21:28,230 --> 00:21:29,840
They were essentially a blood broker,
529
00:21:29,860 --> 00:21:31,760
the largest supplier of plasma
in the world at the time.
530
00:21:31,800 --> 00:21:34,780
We were not aware of that until
the latter part of 1983.
531
00:21:34,800 --> 00:21:36,660
Mr. Weber, the volume of plasma required
532
00:21:36,680 --> 00:21:38,270
to fulfill such a large order
533
00:21:38,300 --> 00:21:39,740
changed the way Connaught did things.
534
00:21:39,770 --> 00:21:41,710
You decided it would be impractical
535
00:21:41,740 --> 00:21:43,020
to send your own employees
536
00:21:43,040 --> 00:21:45,460
to inspect the centres where
Cryosan collected blood?
537
00:21:45,600 --> 00:21:47,180
We decided it was acceptable
538
00:21:47,210 --> 00:21:49,250
to confirm if the supplier had a license
539
00:21:49,280 --> 00:21:51,050
from the U.S. Food and
Drug Administration
540
00:21:51,080 --> 00:21:53,120
and then review their
inspection reports.
541
00:21:53,150 --> 00:21:54,300
Yet even that protocol
542
00:21:54,320 --> 00:21:55,480
was not properly followed.
543
00:21:55,580 --> 00:21:58,960
Can I take you to the
Connaught document brief?
544
00:21:58,980 --> 00:22:01,480
I believe it's Exhibit 722.
545
00:22:01,960 --> 00:22:05,800
It is a letter, dated August 23rd, 1983,
546
00:22:05,830 --> 00:22:07,180
from Mr. Weber of Connaught
547
00:22:07,200 --> 00:22:08,280
to you, Dr. Davey.
548
00:22:08,300 --> 00:22:09,820
Can you please tell me what it says?
549
00:22:09,840 --> 00:22:11,640
It's regarding a recall incident
550
00:22:11,670 --> 00:22:14,910
related to U.S.-sourced plasma.
551
00:22:14,940 --> 00:22:15,970
We were not aware of the details
552
00:22:16,010 --> 00:22:17,540
of that particular collection centre.
553
00:22:17,580 --> 00:22:19,740
The shipping papers
accompanying the plasma
554
00:22:19,780 --> 00:22:22,879
simply referred to it
as "ADC Plasma Centre,
555
00:22:22,880 --> 00:22:23,889
Grady, Arkansas."
556
00:22:23,890 --> 00:22:25,840
And what does "ADC" stand for?
557
00:22:28,860 --> 00:22:30,890
Arkansas Department of Corrections.
558
00:22:33,120 --> 00:22:34,460
They were notifying you
559
00:22:34,500 --> 00:22:36,260
that blood had been collected
560
00:22:36,290 --> 00:22:38,960
from inmates at a correctional facility?
561
00:22:39,000 --> 00:22:42,300
- Correct.
- They were in fact paid a fee.
562
00:22:42,330 --> 00:22:44,000
I believe they were.
563
00:22:44,040 --> 00:22:45,840
Given the amount of drug use
564
00:22:45,880 --> 00:22:47,760
and unprotected sexual activity,
565
00:22:47,800 --> 00:22:50,640
could there possibly be a
higher risk pool of donors?
566
00:22:50,680 --> 00:22:52,060
I don't know the answer to that.
567
00:22:52,100 --> 00:22:55,480
So Dr. Furesz of the BoB
knew about the incident?
568
00:22:55,510 --> 00:22:56,580
Yes, in fact,
569
00:22:56,610 --> 00:22:58,010
he was the one that informed us.
570
00:22:58,050 --> 00:22:59,350
They had heard from the FDA.
571
00:22:59,380 --> 00:23:01,600
Yet you had to inform the Red Cross?
572
00:23:03,920 --> 00:23:07,460
Clearly, the system had broken down.
573
00:23:09,240 --> 00:23:10,990
I would just like to reiterate
574
00:23:11,030 --> 00:23:13,830
my sincere thanks and gratitude
575
00:23:13,870 --> 00:23:16,720
to the thousands of
people who in my lifetime
576
00:23:16,800 --> 00:23:19,240
donated blood on a voluntary basis.
577
00:23:19,260 --> 00:23:20,780
I'd also like to thank the volunteers
578
00:23:20,800 --> 00:23:22,160
and the workers at the Red Cross,
579
00:23:22,180 --> 00:23:23,810
dedicated professional people,
580
00:23:23,840 --> 00:23:27,260
who have treated me with nothing
but care and compassion.
581
00:23:27,280 --> 00:23:29,740
Their important, lifesaving work
582
00:23:29,780 --> 00:23:32,850
shouldn't be overlooked in all of this.
583
00:23:32,880 --> 00:23:35,720
I'd just also like to say that...
584
00:23:35,750 --> 00:23:39,220
I know that I have caused my family
585
00:23:39,320 --> 00:23:41,800
a great deal of pain,
586
00:23:41,820 --> 00:23:44,160
more than they ever deserve.
587
00:23:44,200 --> 00:23:45,240
Words are never enough,
588
00:23:45,260 --> 00:23:47,960
but for whatever part I am guilty,
589
00:23:48,000 --> 00:23:50,080
I am sorry.
590
00:23:51,570 --> 00:23:56,170
If you don't mind, I'd
like to read a poem
591
00:23:56,210 --> 00:24:00,520
given to me by the daughter
of another victim.
592
00:24:06,080 --> 00:24:09,590
"To Father.
593
00:24:09,620 --> 00:24:13,260
Teddy Bear, Teddy Bear,
can I lean on you?
594
00:24:13,290 --> 00:24:14,640
I'm hurt and confused,
595
00:24:14,660 --> 00:24:17,080
tell me what to do.
596
00:24:17,200 --> 00:24:19,660
It's been such a long time
since I've talked to you.
597
00:24:19,690 --> 00:24:21,160
In my advanced age,
598
00:24:21,200 --> 00:24:23,000
I thought I no longer needed you...
599
00:24:23,030 --> 00:24:24,770
so I put you away,
600
00:24:24,800 --> 00:24:25,979
stuffed you in the corner,
601
00:24:25,980 --> 00:24:27,540
and tried to go on with my life,
602
00:24:27,570 --> 00:24:28,960
which got harder.
603
00:24:29,020 --> 00:24:31,720
You sat in the corner for years on end,
604
00:24:31,750 --> 00:24:35,000
you watched my heart
break, and then it mend.
605
00:24:35,160 --> 00:24:38,000
You used to comfort me when I needed it.
606
00:24:38,080 --> 00:24:40,060
When I was angry, you took the hit.
607
00:24:40,080 --> 00:24:42,160
But my problems are bigger now,
608
00:24:42,220 --> 00:24:43,950
and you're worn down.
609
00:24:43,990 --> 00:24:45,899
I no longer smile.
610
00:24:45,900 --> 00:24:48,320
My lips are a constant frown.
611
00:24:48,660 --> 00:24:51,400
So Teddy Bear, Teddy Bear,
612
00:24:51,420 --> 00:24:52,860
can I lean on you?
613
00:24:52,900 --> 00:24:56,220
Work your magic, tell me what to do."
614
00:24:59,100 --> 00:25:01,220
Hi, Daddy.
615
00:25:03,640 --> 00:25:05,460
"Your loving daughter."
616
00:25:20,050 --> 00:25:21,510
Mr. Landry.
617
00:25:21,550 --> 00:25:23,150
Justice Krever.
618
00:25:23,180 --> 00:25:25,240
- You remember me?
- Yes, of course.
619
00:25:25,260 --> 00:25:27,520
I read both the archival
history you compiled
620
00:25:27,550 --> 00:25:28,560
and your book.
621
00:25:28,580 --> 00:25:30,590
I'm sorry, but it would
be inappropriate for me
622
00:25:30,620 --> 00:25:32,990
to discuss anything to do with
the inquiry at this time.
623
00:25:33,030 --> 00:25:34,430
I was, uh...
624
00:25:34,460 --> 00:25:36,000
I was hoping you might
agree to an interview.
625
00:25:36,030 --> 00:25:38,260
Well, given what I just said,
what purpose would it serve?
626
00:25:38,300 --> 00:25:40,180
We wouldn't have to talk
about any the details.
627
00:25:40,220 --> 00:25:42,200
I just think that everyone recognizes
628
00:25:42,240 --> 00:25:43,960
this is an enormous undertaking,
629
00:25:43,980 --> 00:25:45,440
and the public would be very interested
630
00:25:45,470 --> 00:25:46,960
in hearing what you're going through.
631
00:25:47,000 --> 00:25:48,840
You know, how... what you're
dealing with personally,
632
00:25:48,880 --> 00:25:50,080
how it's affecting you.
633
00:25:52,520 --> 00:25:53,980
I don't think so.
634
00:25:54,010 --> 00:25:55,239
Maybe when it's all done?
635
00:25:55,240 --> 00:25:56,260
Maybe.
636
00:25:56,320 --> 00:25:58,250
Justice Krever...
637
00:25:59,520 --> 00:26:03,890
Publicly shaming those
responsible is not enough.
638
00:26:03,920 --> 00:26:05,190
They deserve worse.
639
00:26:08,220 --> 00:26:11,870
Mr. Landry, you're angry,
and I understand that,
640
00:26:11,900 --> 00:26:13,130
but this inquiry is about
641
00:26:13,170 --> 00:26:16,320
getting to the bottom of
why this tragedy occurred.
642
00:26:16,360 --> 00:26:18,200
We must figure out what went wrong
643
00:26:18,220 --> 00:26:19,740
and recommend how to fix it.
644
00:26:19,770 --> 00:26:21,410
It can't be about punishment,
645
00:26:21,440 --> 00:26:23,480
or worse, revenge.
646
00:26:23,540 --> 00:26:24,980
With all due respect, sir,
647
00:26:25,000 --> 00:26:28,410
in this case, it should be.
648
00:26:31,690 --> 00:26:33,520
Have a good day.
649
00:26:35,540 --> 00:26:37,300
To have to look into the
faces of those parents,
650
00:26:37,320 --> 00:26:40,160
and tell them their child had
just tested positive for HIV?
651
00:26:40,190 --> 00:26:42,600
Once they started using
the heat-treated product,
652
00:26:42,620 --> 00:26:44,830
they thought the threat
of AIDS was behind them.
653
00:26:44,870 --> 00:26:49,940
I can feel the tension
and the anger inside me.
654
00:26:49,970 --> 00:26:53,210
The same sickness I felt
then, I feel it now.
655
00:26:53,240 --> 00:26:55,880
They asked me, "How could this happen?"
656
00:26:55,910 --> 00:26:58,280
I had no answer.
657
00:26:58,340 --> 00:27:01,120
The various manufacturers
of heat-treated Factor 8
658
00:27:01,160 --> 00:27:03,979
all had a... a slightly
different process
659
00:27:03,980 --> 00:27:05,890
for eliminating HIV from the plasma.
660
00:27:05,920 --> 00:27:07,250
Is it fair to assume
661
00:27:07,290 --> 00:27:09,600
that you recognized
that the Cutter process
662
00:27:09,620 --> 00:27:12,030
was more rigorous than the
Armour process at this point?
663
00:27:12,060 --> 00:27:13,590
There was indication that it might be.
664
00:27:13,630 --> 00:27:14,999
But you didn't do any
665
00:27:15,000 --> 00:27:16,179
actual testing yourself.
666
00:27:16,180 --> 00:27:18,330
You instead relied entirely
667
00:27:18,340 --> 00:27:19,430
on the CDC's studies.
668
00:27:19,470 --> 00:27:21,900
Did you ever see any
viral inactivation data
669
00:27:21,940 --> 00:27:23,980
- referrable to the Armour product?
- No.
670
00:27:24,000 --> 00:27:25,910
So you issued the notice of compliance
671
00:27:25,920 --> 00:27:26,930
without seeing any data
672
00:27:26,940 --> 00:27:28,440
referring to the Armour
product in particular?
673
00:27:28,480 --> 00:27:29,780
I'm not saying that.
674
00:27:29,800 --> 00:27:31,380
You've testified that you were aware
675
00:27:31,400 --> 00:27:32,620
of the European seroconversions
676
00:27:32,630 --> 00:27:34,080
from reading about them in the Lancet.
677
00:27:34,110 --> 00:27:37,180
Did you think to approach Armour,
678
00:27:37,220 --> 00:27:38,900
ask them what was happening?
679
00:27:38,920 --> 00:27:41,220
I don't recall there was any
indication in the article
680
00:27:41,260 --> 00:27:43,120
whether it was Armour or not.
681
00:27:43,160 --> 00:27:44,990
The Lancet article didn't say
682
00:27:45,030 --> 00:27:46,560
which company was responsible,
683
00:27:46,590 --> 00:27:48,730
but it specified the process.
684
00:27:48,760 --> 00:27:50,630
60 degrees, 30 hours.
685
00:27:50,660 --> 00:27:51,680
It was a simple deduction.
686
00:27:51,700 --> 00:27:52,830
I just read the product insert,
687
00:27:52,870 --> 00:27:54,710
and knew it was Armour
they were talking about.
688
00:27:55,320 --> 00:27:58,470
We'd only given my son one box.
689
00:27:58,510 --> 00:28:00,770
That could have been enough.
690
00:28:00,810 --> 00:28:04,310
We could have exposed him to AIDS.
691
00:28:05,580 --> 00:28:07,150
But given the questionable nature
692
00:28:07,180 --> 00:28:08,350
of Armour's heat-treating process,
693
00:28:08,380 --> 00:28:09,500
it could have been made safer
694
00:28:09,520 --> 00:28:11,320
by screening the plasma for HIV,
695
00:28:11,350 --> 00:28:12,620
and weeding out possible contaminants
696
00:28:12,650 --> 00:28:13,920
from the start.
697
00:28:13,950 --> 00:28:15,960
We did everything we could
698
00:28:15,980 --> 00:28:17,960
to make sure the product
from screened plasma
699
00:28:17,990 --> 00:28:19,980
made it to consumers
as soon as possible.
700
00:28:20,080 --> 00:28:23,800
However, prior to July 1, 1986,
701
00:28:23,830 --> 00:28:26,030
Dr. Naylor wrote to Cutter International
702
00:28:26,070 --> 00:28:28,370
asking them not to put
labels on their product
703
00:28:28,400 --> 00:28:31,580
indicating if it came
from screened plasma.
704
00:28:31,670 --> 00:28:33,340
Are we to assume that this is because
705
00:28:33,370 --> 00:28:34,470
you didn't want consumers
706
00:28:34,500 --> 00:28:36,810
to prefer one box of
concentrate over another
707
00:28:36,840 --> 00:28:38,340
and wreak havoc with your inventory?
708
00:28:38,380 --> 00:28:39,650
I don't recall the thinking.
709
00:28:40,510 --> 00:28:43,480
I don't know what Dr.
Naylor had in mind.
710
00:28:43,500 --> 00:28:45,300
It does seem to suggest
711
00:28:45,320 --> 00:28:47,680
that he thought it could lead users
712
00:28:47,700 --> 00:28:50,820
to request only Cutter screened product,
713
00:28:50,840 --> 00:28:52,730
which was not available
in adequate quantity
714
00:28:52,760 --> 00:28:54,260
at that time.
715
00:28:55,860 --> 00:28:58,920
I'm sorry, is it your answer
716
00:28:58,930 --> 00:29:00,900
that it would be
deleterious to the system
717
00:29:00,920 --> 00:29:02,240
for users to know
718
00:29:02,270 --> 00:29:04,020
if the product they were
taking was screened?
719
00:29:04,040 --> 00:29:05,840
I am just trying to
reason for Dr. Naylor.
720
00:29:05,870 --> 00:29:08,040
But... does that sound logical?
721
00:29:08,080 --> 00:29:09,460
That people shouldn't know the nature
722
00:29:09,480 --> 00:29:11,600
and relative safety of the
product they are taking?
723
00:29:11,620 --> 00:29:12,980
I'm just trying to reconstruct
724
00:29:12,990 --> 00:29:15,180
Dr. Naylor's line of thought.
725
00:29:15,220 --> 00:29:16,880
We were confident at the time,
726
00:29:16,920 --> 00:29:18,750
particularly with the Cutter process
727
00:29:18,790 --> 00:29:19,900
and its efficacy.
728
00:29:19,960 --> 00:29:21,540
Particularly with the Cutter process,
729
00:29:21,570 --> 00:29:23,400
but not Armour's, is
that what I'm to infer?
730
00:29:23,420 --> 00:29:26,430
No. We believed we were
supplying a safe product.
731
00:29:29,030 --> 00:29:30,080
You believed
732
00:29:30,100 --> 00:29:31,430
that if you pulled the Armour product,
733
00:29:31,470 --> 00:29:33,120
it would send the world
market into crisis.
734
00:29:33,140 --> 00:29:34,520
Yes, and there was no proof
735
00:29:34,530 --> 00:29:36,070
that seroconversions were occurring
736
00:29:36,100 --> 00:29:37,499
in the screened Armour product.
737
00:29:37,500 --> 00:29:38,520
To be clear,
738
00:29:38,550 --> 00:29:42,919
you actually issued a
letter to the Red Cross
739
00:29:42,920 --> 00:29:46,510
advising them to continue
to distribute it.
740
00:29:46,550 --> 00:29:48,050
Yes.
741
00:29:49,300 --> 00:29:51,420
Dr. Furesz,
742
00:29:51,450 --> 00:29:55,590
did the Red Cross ask for this letter?
743
00:29:56,760 --> 00:29:58,000
That could be.
744
00:29:58,100 --> 00:29:59,280
I asked...
745
00:29:59,300 --> 00:30:02,380
I begged both Perrault and
Davey to go against the BoB
746
00:30:02,400 --> 00:30:04,600
and withhold the Armour product.
747
00:30:04,630 --> 00:30:07,480
You know, forget that you have
permission to distribute it,
748
00:30:07,500 --> 00:30:09,570
and just... don't distribute it.
749
00:30:09,600 --> 00:30:11,070
And what did they say?
750
00:30:11,110 --> 00:30:13,040
That it was 20% of their supply.
751
00:30:13,070 --> 00:30:14,620
Seven people are dead
752
00:30:14,640 --> 00:30:17,580
because they took that product.
753
00:30:17,610 --> 00:30:18,980
Five of them were children.
754
00:30:21,310 --> 00:30:24,040
_
755
00:30:32,030 --> 00:30:34,790
I'm so sorry.
756
00:30:51,710 --> 00:30:52,980
He's gone.
757
00:31:03,820 --> 00:31:05,540
He didn't say so,
758
00:31:05,560 --> 00:31:07,830
but I saw it in his eyes.
759
00:31:07,860 --> 00:31:09,680
I'm going to regret not
giving him that bullet
760
00:31:09,700 --> 00:31:11,500
for the rest of my life.
761
00:31:27,310 --> 00:31:30,580
You'll get your chance one day.
762
00:31:34,800 --> 00:31:36,930
Happy anniversary.
763
00:31:36,970 --> 00:31:39,100
Happy anniversary.
764
00:31:46,660 --> 00:31:48,140
Something wrong?
765
00:31:49,080 --> 00:31:51,710
It's hard to believe
it's been five years
766
00:31:51,750 --> 00:31:53,880
since our first kiss.
767
00:31:53,920 --> 00:31:56,180
In this very spot.
768
00:31:57,960 --> 00:31:59,620
Remember when you said
769
00:31:59,660 --> 00:32:03,030
people who've been
dating for two years...
770
00:32:03,060 --> 00:32:06,700
... should absolutely know if
they want to get married?
771
00:32:08,460 --> 00:32:10,330
Okay.
772
00:32:10,370 --> 00:32:13,400
I knew that's what you were thinking.
773
00:32:16,660 --> 00:32:19,590
I'm really sorry this took so long.
774
00:32:21,660 --> 00:32:22,960
Shut up, what are you doing?
775
00:32:23,140 --> 00:32:24,300
Shut up?
776
00:32:24,330 --> 00:32:26,330
Yeah, that-that's what I said.
777
00:32:28,600 --> 00:32:29,670
No way.
778
00:32:29,700 --> 00:32:31,170
How long have you had that?
779
00:32:31,200 --> 00:32:32,980
That's what you're asking?
780
00:32:33,000 --> 00:32:34,410
You're supposed to say "yes."
781
00:32:34,440 --> 00:32:36,140
You haven't asked me anything yet!
782
00:32:36,160 --> 00:32:37,770
Right.
783
00:32:37,810 --> 00:32:39,480
Ruby Dae Kim...
784
00:32:41,110 --> 00:32:43,010
Will you marry me?
785
00:32:43,800 --> 00:32:44,850
Fuck yeah!
786
00:32:44,880 --> 00:32:46,350
Really? That's your answer?
787
00:32:46,360 --> 00:32:48,040
Five years, you haven't noticed I swear
788
00:32:48,050 --> 00:32:49,060
when I'm excited?
789
00:32:49,070 --> 00:32:51,190
That's gonna make this a tough
story to tell our kids.
790
00:32:58,160 --> 00:32:59,300
It wasn't you.
791
00:33:00,280 --> 00:33:03,020
I've always known you were the one.
792
00:33:03,050 --> 00:33:04,970
Always.
793
00:33:05,800 --> 00:33:08,260
If you don't want to do this...
794
00:33:08,360 --> 00:33:09,980
because I'm...
795
00:33:10,000 --> 00:33:11,780
Shut up, okay?
796
00:33:11,810 --> 00:33:13,150
Just shut up.
797
00:33:14,860 --> 00:33:17,780
No one knows what the future holds.
798
00:33:17,820 --> 00:33:19,540
You are who you are
799
00:33:19,560 --> 00:33:22,390
because of what you've been through.
800
00:33:22,420 --> 00:33:25,720
I could get hit by a bus tomorrow.
801
00:33:25,760 --> 00:33:28,390
You never look both ways.
802
00:33:29,330 --> 00:33:30,660
I love you.
803
00:33:30,700 --> 00:33:33,570
I love you too.
804
00:34:03,040 --> 00:34:04,460
What are you doing up?
805
00:34:08,630 --> 00:34:10,540
I want kids.
806
00:34:11,900 --> 00:34:13,370
It's not like we can...
807
00:34:13,410 --> 00:34:15,240
Conceive?
808
00:34:15,300 --> 00:34:17,280
I know.
809
00:34:18,500 --> 00:34:20,860
So what are you trying to say?
810
00:34:20,960 --> 00:34:23,180
- Adoption?
- I don't know.
811
00:34:23,220 --> 00:34:25,040
I know you hate when I bring this up,
812
00:34:25,060 --> 00:34:27,890
but we don't really
know how long I have.
813
00:34:27,920 --> 00:34:29,740
I certainly can't provide for you,
814
00:34:29,780 --> 00:34:31,390
much less a child,
815
00:34:31,420 --> 00:34:32,460
and there's a pretty good chance
816
00:34:32,490 --> 00:34:34,090
I won't be around to help you raise it.
817
00:34:34,130 --> 00:34:36,390
Look, I knew what you were gonna say,
818
00:34:36,430 --> 00:34:38,760
which is why I was just lying here
819
00:34:38,800 --> 00:34:40,200
not saying anything.
820
00:34:40,230 --> 00:34:41,740
I just woke up to take a pill
821
00:34:41,760 --> 00:34:43,680
to keep me from dying.
822
00:34:44,970 --> 00:34:47,310
Does that sound like good
father material to you?
823
00:34:47,340 --> 00:34:50,260
It doesn't change how I feel.
824
00:35:02,990 --> 00:35:05,100
What is it, what's wrong? Where's Paul?
825
00:35:05,180 --> 00:35:06,600
He couldn't get out of bed.
826
00:35:06,620 --> 00:35:09,380
He's supposed to cross
Perrault on Hep C today.
827
00:35:09,480 --> 00:35:10,930
He said you should do it.
828
00:35:10,960 --> 00:35:11,990
Me?
829
00:35:12,000 --> 00:35:13,770
You're more than capable.
830
00:35:13,800 --> 00:35:14,900
Look, um...
831
00:35:14,920 --> 00:35:16,670
he may not be in tomorrow, either.
832
00:35:16,700 --> 00:35:18,900
Listen, tell him to take
as much time as he needs.
833
00:35:18,940 --> 00:35:19,940
I'll stop by later.
834
00:35:19,970 --> 00:35:21,570
Let us know if there's
anything you need.
835
00:35:27,010 --> 00:35:28,110
- You got this.
- Right.
836
00:35:28,150 --> 00:35:30,020
- You got it.
- Yup, I do.
837
00:35:30,050 --> 00:35:31,750
250,000 patients
838
00:35:31,780 --> 00:35:33,620
are transfused in Canada per year.
839
00:35:33,650 --> 00:35:38,300
In 1986, 2.6% of the blood was
infected with Hepatitis C.
840
00:35:38,320 --> 00:35:41,630
That means that 5,000 to
6,000 people per year
841
00:35:41,660 --> 00:35:43,460
were being infected by our blood system.
842
00:35:43,500 --> 00:35:45,360
It's been suggested
that surrogate testing
843
00:35:45,400 --> 00:35:48,030
would have reduced that
number by up to 60%.
844
00:35:48,070 --> 00:35:49,700
Was it unethical of the Red Cross
845
00:35:49,740 --> 00:35:51,540
not to take steps that
would have prevented
846
00:35:51,570 --> 00:35:54,420
thousands upon thousands
of Hepatitis C infections?
847
00:35:54,440 --> 00:35:56,200
- We object to the question.
- Mrs. Sanders,
848
00:35:56,220 --> 00:35:58,010
I have previously asked your colleague
849
00:35:58,040 --> 00:35:59,980
to refrain from asking witnesses
850
00:36:00,010 --> 00:36:01,210
to make moral judgments.
851
00:36:01,250 --> 00:36:03,210
The purpose of these cross-examinations,
852
00:36:03,250 --> 00:36:04,720
as I've said from the outset,
853
00:36:04,750 --> 00:36:06,060
is the single purpose
854
00:36:06,090 --> 00:36:07,850
of helping me discharge my mandate.
855
00:36:07,890 --> 00:36:10,200
It does not help for you to
recriminate the witness.
856
00:36:10,220 --> 00:36:11,950
The question of whether
a decision they made
857
00:36:11,960 --> 00:36:13,660
was in their eyes, moral,
858
00:36:13,690 --> 00:36:15,660
goes to how the system was managed.
859
00:36:15,700 --> 00:36:17,700
I don't know what could
be more important
860
00:36:17,720 --> 00:36:18,729
than if this man believes
861
00:36:18,730 --> 00:36:20,220
that his actions were justifiable
862
00:36:20,240 --> 00:36:21,799
given the number of
human lives at stake.
863
00:36:21,800 --> 00:36:22,820
I will make the judgment
864
00:36:22,830 --> 00:36:24,920
as to whether actions were improper,
865
00:36:24,930 --> 00:36:26,370
immoral, or wrong.
866
00:36:26,410 --> 00:36:28,140
I do not need the help of the witness.
867
00:36:28,170 --> 00:36:29,510
I just want the facts.
868
00:36:29,540 --> 00:36:31,640
I think the witness' opinion
is material evidence.
869
00:36:31,660 --> 00:36:33,550
I do not, Mrs. Sanders.
870
00:36:34,760 --> 00:36:36,450
Thank you, Your Honour.
871
00:36:42,120 --> 00:36:44,260
I was the one who recommended
to the blood committee
872
00:36:44,290 --> 00:36:46,390
that we implement a study
of the effectiveness
873
00:36:46,430 --> 00:36:48,860
of surrogate testing for
Non-A, Non-B Hepatitis.
874
00:36:50,700 --> 00:36:52,730
Thank you, Dr. Perrault.
875
00:36:55,770 --> 00:36:57,680
Excuse me, Justice Krever,
876
00:36:57,700 --> 00:36:59,240
I have one more line of questioning.
877
00:36:59,260 --> 00:37:00,270
Proceed.
878
00:37:05,310 --> 00:37:07,180
Dr. Perrault, in 1986
879
00:37:07,210 --> 00:37:09,340
there were several
U.S. studies available
880
00:37:09,360 --> 00:37:11,350
regarding the success
of surrogate testing
881
00:37:11,380 --> 00:37:12,550
to weed out Hepatitis
882
00:37:12,580 --> 00:37:14,040
from entering our blood system.
883
00:37:14,060 --> 00:37:15,590
Are you saying that
overwhelming evidence
884
00:37:15,620 --> 00:37:16,900
was unreliable?
885
00:37:16,930 --> 00:37:18,200
We have heard repeatedly
886
00:37:18,220 --> 00:37:20,220
that relying on U.S. information
887
00:37:20,240 --> 00:37:21,960
can also be damaging,
888
00:37:21,990 --> 00:37:23,560
and I have testified
889
00:37:23,600 --> 00:37:26,130
that the Canadian and U.S.
systems were different.
890
00:37:26,170 --> 00:37:28,370
You cannot compare apples and oranges.
891
00:37:28,400 --> 00:37:31,340
Okay, well, let's compare this.
892
00:37:31,360 --> 00:37:33,970
What was the cost of the
study you proposed?
893
00:37:35,670 --> 00:37:36,940
I don't remember.
894
00:37:36,980 --> 00:37:40,060
According to this, roughly
two million dollars.
895
00:37:43,650 --> 00:37:45,320
That appears to be correct.
896
00:37:45,380 --> 00:37:47,420
That study delayed implementation
897
00:37:47,450 --> 00:37:49,390
of screening in Canada for four years,
898
00:37:49,420 --> 00:37:51,880
screening that would have
prevented tens of thousands
899
00:37:51,900 --> 00:37:53,460
of Hepatitis C infections.
900
00:37:53,490 --> 00:37:56,490
How much money was saved
during those four years?
901
00:37:57,430 --> 00:37:59,060
Dr. Perrault, do you not remember
902
00:37:59,100 --> 00:38:00,600
that figure either? I won't ask about
903
00:38:00,620 --> 00:38:02,100
the ethics of the decision.
904
00:38:02,130 --> 00:38:05,240
I'll just tell you that
it was $30 million.
905
00:38:05,270 --> 00:38:08,240
The provinces saved $30 million
906
00:38:08,300 --> 00:38:09,900
by stalling for four years
907
00:38:09,920 --> 00:38:12,940
while a two-year study was done.
908
00:38:12,980 --> 00:38:14,110
Those are the facts.
909
00:38:15,680 --> 00:38:17,080
I can only guess what it's going to cost
910
00:38:17,120 --> 00:38:20,020
to treat all those infected people now.
911
00:38:29,630 --> 00:38:32,500
My name is Alice Landry.
912
00:38:35,630 --> 00:38:38,540
Who am I? What do I know?
913
00:38:38,570 --> 00:38:40,870
I'm just a mother, right?
914
00:38:40,910 --> 00:38:42,620
I'm not an expert.
915
00:38:42,630 --> 00:38:46,410
I mean, all I know is I feel let down.
916
00:38:49,720 --> 00:38:51,450
I don't expect perfection,
917
00:38:51,480 --> 00:38:53,820
but you trust your doctor,
918
00:38:53,850 --> 00:38:56,080
the Red Cross, the government.
919
00:38:56,240 --> 00:38:57,690
All the bureaucratic bungling
920
00:38:57,720 --> 00:39:01,230
and the lethargic attitude
towards safety...
921
00:39:01,260 --> 00:39:02,330
they can deny it,
922
00:39:02,360 --> 00:39:03,960
but when we walk out of here,
923
00:39:04,040 --> 00:39:08,370
we carry AIDS with us
every minute, every day.
924
00:39:10,040 --> 00:39:13,070
This is not an academic exercise for us.
925
00:39:16,540 --> 00:39:18,780
This is a day-to-day reality.
926
00:39:19,750 --> 00:39:21,380
I will never forgive the people
927
00:39:21,410 --> 00:39:25,150
that made those deadly
decisions not to act.
928
00:39:25,180 --> 00:39:26,890
Cost won out over safety.
929
00:39:26,920 --> 00:39:30,860
I sit here today saying
this not out of revenge.
930
00:39:30,890 --> 00:39:33,220
Others may want that, but not me.
931
00:39:35,390 --> 00:39:39,060
I want my son to be okay.
932
00:39:39,100 --> 00:39:40,430
I can't give him back
933
00:39:40,470 --> 00:39:43,360
the years that have already been stolen.
934
00:39:43,400 --> 00:39:46,960
I just hope for a better future.
935
00:39:47,040 --> 00:39:50,410
I'm so grateful to the
woman in his life,
936
00:39:50,440 --> 00:39:54,550
who's given him some happiness
and sense of self-worth.
937
00:39:54,580 --> 00:39:56,920
My heart is full for her.
938
00:39:58,120 --> 00:40:01,920
I can never repay you for
what you've done for Peter.
939
00:40:02,860 --> 00:40:04,920
To my incredible daughter...
940
00:40:05,940 --> 00:40:09,680
I am in constant admiration
of your strength,
941
00:40:09,740 --> 00:40:10,780
of how you have withstood
942
00:40:10,800 --> 00:40:12,600
the tremendous burden placed upon you
943
00:40:12,620 --> 00:40:13,820
with such grace.
944
00:40:18,170 --> 00:40:21,370
On the other hand,
945
00:40:21,410 --> 00:40:23,800
I've watched my husband,
946
00:40:23,840 --> 00:40:25,240
a man who I married
947
00:40:25,260 --> 00:40:28,500
because he was thoughtful,
kind, and generous,
948
00:40:28,540 --> 00:40:30,900
become bitter, hateful, and vengeful.
949
00:40:33,520 --> 00:40:36,740
I've watched his relationship
with my son deteriorate.
950
00:40:37,960 --> 00:40:40,330
Because of this virus,
951
00:40:40,360 --> 00:40:42,890
I've watched my family
become unable to communicate
952
00:40:42,930 --> 00:40:45,930
about anything that gives
us happiness anymore.
953
00:40:47,580 --> 00:40:49,020
I'm not hopeful of anything
954
00:40:49,040 --> 00:40:53,970
other than maybe... if
the truth is heard,
955
00:40:54,010 --> 00:40:56,640
some justice will prevail,
956
00:40:56,660 --> 00:40:58,810
and a lesson will be learned.
957
00:41:03,950 --> 00:41:05,950
Thank you.
958
00:41:20,330 --> 00:41:21,880
This just came for us.
959
00:41:21,900 --> 00:41:23,970
Notification from Krever.
960
00:41:24,000 --> 00:41:25,270
He's naming us for misconduct
961
00:41:25,300 --> 00:41:26,670
in his written report.
962
00:41:26,710 --> 00:41:27,900
It's not a certainty,
963
00:41:27,920 --> 00:41:29,840
but, you know, it's possible.
964
00:41:29,900 --> 00:41:31,880
He has to warn us.
965
00:41:31,910 --> 00:41:33,040
Justifiable or not,
966
00:41:33,060 --> 00:41:34,650
our medical advisory committee
967
00:41:34,680 --> 00:41:37,760
limited the flow of
information to hemophiliacs.
968
00:41:39,650 --> 00:41:43,840
I'll get started on
drafting our response.
969
00:41:43,850 --> 00:41:45,490
Paul...
970
00:41:46,300 --> 00:41:48,990
This can wait until tomorrow.
971
00:41:49,030 --> 00:41:50,230
Go home.
972
00:41:50,260 --> 00:41:52,160
If it's any consolation,
973
00:41:52,200 --> 00:41:53,630
there's no doubt that the Red Cross,
974
00:41:53,670 --> 00:41:54,850
the BoB, and the provincial ministers
975
00:41:54,860 --> 00:41:55,870
all got them too.
976
00:41:55,900 --> 00:41:58,340
You think they're just
going to respond politely?
977
00:42:06,550 --> 00:42:08,800
_
978
00:42:08,900 --> 00:42:10,960
So much for our mandate.
979
00:42:11,120 --> 00:42:12,580
They're all filing suit.
980
00:42:12,620 --> 00:42:14,490
The Red Cross, the BoB,
981
00:42:14,520 --> 00:42:16,420
both provincial and federal governments.
982
00:42:16,460 --> 00:42:18,860
They're basically saying
we sandbagged them.
983
00:42:18,890 --> 00:42:21,560
You thought the letters
would set off a storm.
984
00:42:21,680 --> 00:42:24,360
I wrote them.
985
00:42:24,400 --> 00:42:26,360
The language was appropriate.
986
00:42:26,400 --> 00:42:28,800
It should have been stronger.
987
00:42:28,850 --> 00:42:30,200
Saying someone failed
988
00:42:30,210 --> 00:42:31,270
doesn't mean that they breached
989
00:42:31,300 --> 00:42:33,740
a criminal or civil standard of conduct.
990
00:42:33,770 --> 00:42:36,640
We didn't have a choice.
991
00:42:37,580 --> 00:42:40,420
I really didn't expect this.
992
00:42:41,740 --> 00:42:44,320
No...
993
00:42:44,380 --> 00:42:47,050
neither did I.
994
00:42:47,090 --> 00:42:48,420
It is most deplorable
995
00:42:48,440 --> 00:42:50,500
that the very government
that ordered this inquiry
996
00:42:50,520 --> 00:42:52,190
is now trying to stand in its way.
997
00:42:52,220 --> 00:42:53,860
They want to block all Canadians
998
00:42:53,890 --> 00:42:55,260
from getting to the
bottom of what happened
999
00:42:55,290 --> 00:42:58,760
because they are afraid of
what will be said about them.
1000
00:43:00,130 --> 00:43:02,130
The way I see it,
1001
00:43:02,170 --> 00:43:05,040
they buried my friends.
1002
00:43:05,070 --> 00:43:08,070
Now they are trying to bury the truth.
1003
00:43:09,120 --> 00:43:14,060
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