Britain's Infected Blood Inquiry Report: Prime Minister's apology, and the benefits and perils of hindsight

 After the publication  yesterday of Britain's Infected Blood Inquiry Report, the UK's Prime Minister apologized to the nation. Here's the BBC story:

PM apologises after infected blood scandal cover-up  By Nick Triggle and Jim Reed, BBC News

"Prime Minister Rishi Sunak says he is truly sorry for the failures over the infected blood scandal, calling it a decades-long moral failure.

"He was responding to the public inquiry's report into the scandal, which has seen 30,000 people infected from contaminated blood treatments.

"It found authorities covered up the scandal and exposed victims to unacceptable risks.

"Mr Sunak described it as a "day of shame for the British state".

...

""Today's report shows a decades-long moral failure at the heart of our national life. I want to make a wholehearted and unequivocal apology."

"He said the attitude of denial was hard to comprehend and was to "our eternal shame".

...

Labour leader Sir Keir Starmer apologised too, describing it as one of the "gravest injustices" the country had seen and saying victims had "suffered unspeakably".

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I've now had the opportunity to read some of the (2000 page) report, and it leaves me in two minds.  On the one hand, as summarized in various news stories about the report, it deals with a long history during which British clinicians could have responded faster to growing evidence about hepatitis and HIV in the blood supply, and the various British governing coalitions could certainly have acknowledged earlier and more fully that people had been infected.

On the other hand, some of the harms to people who were infected by blood-borne pathogens are clearer in hindsight than they were at the times that they began to occur.

The cases of hemophila patients (many of them children, many of them at Treloar's, a school for disabled children including many with severe hemophilia) are particularly jarring.  Many of those children are no longer living, having been infected with HIV in the  1980's, before it was positively identified as the cause of AIDS (but after there was evidence that something in the blood carried the infection). The clotting factors (extracted from plasma pooled from many donors) that were being explored to treat hemophilia patients, are  (today standard treatments for hemophilia, but in the period covered by the report they were subjects of research, and were, tragically, infected with HIV, and hepatitis C before it's virus had been identified.

Here's a passage (from Vol. 1, p23) of the report that crystallizes why I think it's easier to assess blame in hindsight than it was at the time: (NANBH stands for non-A non-B Hepatitis, as Hep C was still something of a mystery.)

"By 1978 there were a number of reports showing that NANBH was linked to persistent liver damage. Amongst them was a paper published in September 1978 in The Lancet, authored by Dr Eric Preston and colleagues in Sheffield. In his oral evidence to the Inquiry, Dr Mark Winter said that this paper “blew out of the water instantly the idea that this [NANB hepatitis] was nothing to worry about because their study showed, as did other studies, that most of these patients had very significant chronic liver disease”. He thought doctors had been unwilling to think that NANBH might be a problem, because factor concentrate had brought “such spectacular benefits”: it was this reluctance to face the facts described in scientific journals that had prevented earlier acceptance of the seriousness of the problem."

The report also dwells on the difficulties that the UK faced in becoming self-sufficient in non-commercial plasma and clotting factor from domestic sources.  But self sufficiency is a world-wide problem today in states that depend on unpaid domestic donors. So it's not clear how culpable the British blood services should be considered on that account.

And it's a complicated question, because some of the U.S. commercial suppliers started heat treating their plasma to effectively destroy many pathogens, before this became common in the U.K.

The report states (Vol 1, p49)

"Some clinicians were reluctant to embrace commercial heat-treated products. There was as yet little direct evidence of how reliable the claims about commercial heat-treated products were in practice. Although there was no evidence of side-effects after a year of use in the US, heat-treated commercial products were not licensed for use in the UK until early in 1985. It is not difficult to see why clinicians may have preferred to wait for domestic product rather than change their treatment practices. Further, commercial products were believed to be more likely to carry hepatitis than domestic ones. Understandable though this reluctance may have been, it did not excuse continued use of unheated products beyond a short period into 1985."

So, British physicians were caught between desire for domestic plasma (from unpaid donors, which they believed was safer), and reluctance to use U.S. commercial plasma as it became the safer alternative.  And British plasma processors waited until 1985 to start producing their own heat treated plasma products. The results were tragic, but (unlike some of the later delays and evasions that the report spells out) I don't see that there is in every instance a clear case of blame.

The chair of the Infected Blood Inquiry is Sir Brian Langstaff , "a former judge of the High Court of England and Wales."  Judges have experience at hearing evidence, and may have some professional inclination to explain events in terms of guilt.  Not that there isn't plenty to apologize for.

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Here are all my posts on blood plasma.