The Commission of Inquiry on the Blood System in Canada was a public investigation of the Canadian blood system, which had been contaminated with HIV and hepatitis C virus during the 1980s and lead to the infection of thousands of Canadians and Canada’s worst-ever preventable public health disaster. It is also commonly known as the Krever Report. It is now more than thirty years since the inquiry was established and Justice Horace Krever was named commissioner and sadly, on April 30, he passed away at the age of 94.
As part of my research for the series Unspeakable, which chronicles the tainted blood crisis in Canada, I had the incredible honour of interviewing Justice Krever a couple of times. He was gracious and every bit as impressive as you might expect.
During the testimony phase of the inquiry, members of the media and the hemophilia community noted that Justice Krever was very stoic while listening to testimony. Some took his lack of emotion as a sign that he was unsympathetic to the plight of victims of tainted blood. I asked him about it. He was aware of the prevailing opinion and understood why people felt the way he did. But he also took offence to the idea that he felt nothing. The testimony he was hearing day after day month upon month was excruciatingly tragic and in the case of those involved in wrongdoing, infuriating. Krever said of course he was deeply moved. But he steadfastly believed that in order for the outcome to be respected, he needed to appear impartial. He could not be seen as taking sides or the integrity of the inquiry would be jeopardized. So he kept his feelings to himself but I can assure you, they were there.
The Commission spent four years investigating the tainted blood tragedy, issuing its final report on November 21, 1997. Justice Krever fought a number of big legal battles with the very government that established the inquiry in the first place, principally over the right to name publicly those who had failed in their duties. In the process, it redefined the very role of public inquiries. It also began one of Canada’s most prolonged legal sagas, featuring almost $10 billion in legal claims, compensation, and a criminal investigation.
Coming in at a whopping 1,138 pages, perhaps the final report’s greatest achievement was a set of recommendations which overhauled the blood system in Canada and made it significantly safer for users of blood products. Despite his staggering accomplishment, Justice Krever repeatedly told me he was just doing his job and gave credit to everyone who worked on the inquiry as well as those who testified and fought for the bleeding community. The debt we owe him is immeasurable.
