It was nothing short of a "national public health disaster." In the 1980s, thousands of Canadians were exposed to HIV and hepatitis C through contaminated blood products. Today they finally learn exactly how it happened. Judge Horace Krever, who led an inquiry into the disaster, concludes the Canadian Red Cross and provincial and federal governments are to blame. In this CBC News report, Health Minister Allan Rock responds to the Krever Report.

• In November 1985 the Canadian Red Cross Society began testing all donated blood for the presence of the antibody to HIV, the virus that causes AIDS.
• The test had been available since March 1985 and was already in use in both the United States and Australia.
• According to one estimate, about 133 cases of HIV transmission via blood products took place between March and November of 1985.

• As of December 1989 about 1,250 Canadians – many of them hemophiliacs – were known to have contracted HIV through blood products.
• Between 12,000 and 60,000 Canadians are thought to have contracted hepatitis C, a deadly disease that affects the liver, through blood products.
• A test to screen blood for hepatitis C was available in 1986, but the Red Cross did not begin using it on donated blood until 1990.

• A commission of inquiry into the tainted-blood crisis was announced in September 1993. Justice Horace Krever, an Ontario judge with experience in both medical and legal spheres, was named as commissioner.
• Preliminary and public hearings in the inquiry took over two years. The commission heard from 474 people and 89 written submissions.
• Krever's final report was delayed by legal challenges from parties aiming to prevent him from charging anyone with misconduct.

• An interim report came out in February 1996, but the legal challenges went all the way to the Supreme Court. In September 1997 the Supreme Court ruled that Krever could draw conclusions about who was at fault for the tainted blood crisis – something that had not originally been in the inquiry's mandate.
• Two months later, Krever's final report came out. He had been directed to avoid language that could be a finding of civil or criminal liability.

• Krever's report suggested the Canadian blood system should be governed by five principles:
- Blood is a public resource.
- No one should be paid to donate blood or plasma.
- Canada should collect enough blood and components to satisfy its own needs.
- Citizens should have free and universal access to blood components and products.
- Safety of the blood supply is paramount.

• Krever recommended that every Canadian who contracted HIV or hepatitis C through the transmission of tainted blood products receive government compensation. However, not all such individuals were eligible for compensation under the various government plans announced in the 1990s.
• In April 2005 the House of Commons passed legislation that would compensate all recipients of tainted blood.
• For more on Canada's contaminated blood crisis, see the CBC Archives topic Krever Report: Canada's Tainted Blood Disaster.

• In April 1996, the provincial and federal ministers of health met to begin the reform of the Canadian blood system. They agreed that a safe, integrated, accountable and transparent national blood system was needed.
• Canadian Blood Services, the new system, began operations in September 1998.
• The province of Quebec did not agree to be part of a national blood system. Instead, it set up its own parallel provincial service, Héma-Québec.

• In 2002, after five years of investigation, the RCMP laid 32 charges in the scandal. Among those charged were the Canadian Red Cross Society, a pharmaceutical company and four individuals.
• The Red Cross pleaded guilty to a lesser charge in May 2005 and was fined $5,000. The organization apologized in the courtroom and agreed to donate $1.5 million to the University of Ottawa for a scholarship fund for family members of those affected.

Medium: Television
Program: The National
Broadcast Date: Nov. 26, 1997
Host: Peter Mansbridge, Reporter: Susan Harada
Guest(s): Gene Durnin, Clay Serby
Duration: 2:47