Tuesday, February 26, 2019

Always on my mind (Musings on infected blood inquiries)

Stay tuned - Updates likely to occur

The idea for this blog has roots in the UK Infected Blood Inquiry now in the news and the CBC's Unspeakable, an 8-part television series (Jan. 9-Feb. 27) about Canada's 'tainted blood scandal' of the 1980s-90s.

I will not go into too much detail as some topics discussed are emotional minefields for folks, eliciting strong opinions. The purpose is to offer food for thought and leave it to you, the reader, to think about the issues, according to your background and experience.

The title derives from a 1969 ditty that Willie Nelson covered with much success in 1982.

As you read, please monitor your reactions, since what we think and how we react to events largely depends on the emotional baggage we each carry. As one example of many, my reaction to blood inquiries is shaped by having worked for Canada's first blood supplier (Canadian Red Cross) for 13 years and for decades as a transfusion science educator. Also my views are shaped by being a bit of a contrarian who tends to challenge orthodox opinions of transfusion medicine's 'biggies' (thought leaders).

First, inquiries into infected blood tragedies are not concerned with criminal or civil liability. Supreme Court Decision of Canada (Attorney General) v. Canada (Commission of Inquiry on the Blood System) specifies
Second, the same Supreme Court decision specifies
Note that inquiries can make findings of misconduct if they fall within the inquiry's terms of reference. If the same is true for the UK's inquiry, then folks looking for criminal and civil blame to be assigned will be disappointed. But misconduct that occurred or actions that failed standards of conduct will be identified and open to further investigation by the justice system.

Given that memories fail and records disappear over time, especially sensitive ones, and self-interest makes few reveal their errors, based on Canada's experience, criminal prosecution is next to impossible. But civil suits, requiring a lower standard of proof beyond a reasonable doubt, may succeed.

As in most legal matters, credibility of witnesses is crucial where no hard evidence exists. It's complicated because of self-interest. Few,if any, admit, 'I screwed up and made a bad decision, I'm partly to blame. Forgive me.' Those involved are far more likely to say, ' I did the best I could under difficult conditions. I didn't know all the facts or what would happen. No one did. Hindsight is 20-20.'

From Canada's experience, an added key factor is that so many different players are involved, sometimes operating in silos, with no one ultimately responsible, that it's easy to claim, 'Not my responsibility.' All very convenient and I suspect Canada's blood system still has this fatal flaw despite its transmogrification, post-Krever.

Not being a lawyer, I hesitate to include this section but include it as food for thought. Here's how I see Canada's justice system, its purpose and principles. Note: My opinions may well differ with those of many Canadians, particularly regarding incarceration and punishment.
  • Ensures public safety by protecting society from those who violate the law. Defines unacceptable behaviours and the nature and severity of punishment for a given offence. 
  • Presumes innocent until proven guilty and those charged have the right to legal representation and a fair trial. Burden of proof is on the prosecution and defendant must be proven guilty beyond a reasonable doubt. 
  • Acts as a deterrent to criminals, with incarceration being the last resort, reserved for the most serious offenses and where mitigating factors do not exist.
  • Purpose is not to punish offenders but to act with compassion and rehabilitate, if possible. Fact: Most people who come in contact with criminal justice system are vulnerable or marginalized individuals who struggle with mental health and addiction issues, poverty, homelessness, and prior victimization. (See 'What we heard - Transforming Canada's criminal justice system,' Further Reading)
TIDBIT: When I read news items or information on the UK Blood Inquiry, it's my impression, rightly or wrongly, that, as in Canada, many victims and their families are out for blood so to speak. They clearly want those whose professional misconduct and negligence  - unproven but it's how they see it - led to loved ones being infected brought to justice and punished. In other words, the NHS and its medical professionals and officials seem to have been prejudged as guilty. (Further Reading)

Analogies are offered to stimulate thought.

#1. Tragic Humboldt bus crash (Further Reading)
On April 6, 2018 sixteen people were killed and thirteen injured when a bus carrying members of the Humboldt Broncos, a Canadian junior hockey team, struck a semi-trailer truck. The driver passed four signs warning about the upcoming intersection yet the semi-trailer went through a large stop sign with a flashing red light.

The driver of the semi-trailer, 29-year-old Jaskirat Singh Sidhu was charged with 16 counts of dangerous operation of a motor vehicle causing death and 13 counts of dangerous operation of a motor vehicle causing bodily injury.On January 8, 2019, Sidhu pleaded guilty to all charges.

The Crown is asking for a sentence of 10 years with a 10-year driving prohibition. Sentencing is March 22, 2019. It's possible Sidhu could be deported after serving his sentence.

Sidhu followed his girlfriend to Canada in 2013 and is now a permanent resident. He's a newlywed who grew up on a farm in India and earned a commerce degree. He worked at a Calgary liquor store before he started driving a truck. He started work at a small trucking company only three weeks before the crash, after undergoing a week of training and spent two weeks driving a double-trailer with the owner before driving on his own.

Canada and its provinces, except for Ontario, have no compulsory training for new 'class 1' truck drivers and no mandatory training standards.

TIDBIT: Sad but it seems Sidhu will take the full blame for his horrific error, despite mitigating circumstances, namely the entire trucking driver safety system failed. Trucking companies and governments now say they'll do better, but they suffer no consequences, only the ill-trained driver of the truck. Sidhu is the scapegoat.

Reminds me that Canadian Red Cross was the scapegoat of Canada's 'tainted blood tragedy.' The newly created CBC and Héma-Québec operated with many of the same transfusion professionals because you cannot educate and train new experts overnight.

Truck companies can save money by offering minimal training and put unsafe drivers of large semi-trailers behind the wheel. Only one provincial government required mandatory training or considered standardized training. Of course, now some provincial governments have but it will be a pathetic patchwork, ignoring that semis regularly drive across provincial borders.

Did the justice system provide a deterrent to prevent a tragedy like the Humboldt bus crash from happening? If a similar tragedy occurs, will it all fall on the driver again?  Will the justice system rehabilitate the dysfunction system that played a key role in the crash?

#2. Sexual abuse by Roman Catholic clergy (Further Reading)
Happened globally in 20th and 21st centuries, and likely for centuries before that. Scandal is so well exposed it needs no documentation, though see Further Reading. Clearly a systemic problem, yet who is held accountable?

Bishops transferred known offending priests to other jurisdictions to abuse more children. Everyone in the Church worked to protect the Church at the expense of children, and now it turns out, even nuns were abused.

Who is ever held accountable other than the odd defrocked clergyman? Who in the Catholic Church's patriarchal hierarchy should be held accountable and what would justice for victims, providing a deterrent to future crimes, and making the public and society safe entail?

Does 'We did the best we could in difficult circumstances, wanting to protect both the perpetrators and victims equally' cut it, because there's good people on both sides (to use a Trumpism)?

Healthcare, including transfusion medicine, supposedly has adopted a quality system that promotes a blame-free culture where individuals are able to report errors or near misses without fear of reprimand or punishment. (Further Reading, Culture of Safety)
"The culture of individual blame still dominant and traditional in health care undoubtedly impairs the advancement of a safety culture. One issue is that, while "no blame" is the appropriate stance for many errors, certain errors do seem blameworthy and demand accountability. In an effort to reconcile the twin needs for no-blame and appropriate accountability, the concept of just culture is now widely used.  
A just culture focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (e.g., slips), at-risk behavior (e.g., taking shortcuts), and reckless behavior (e.g., ignoring required safety steps), in contrast to an overarching "no-blame" approach still favored by some. " 
Yet the blame game still exists in medicine, as exemplified by the Dr. Bawa Garba case in the UK (Further Reading), although the injustice was ultimately rectified.

A key part of human nature is to want to know and understand why things happen. Humans (we Homo sapiens) have done it since we emerged as Great Apes, along with orangutans, gorillas, and chimpanzees. Later in our history it's one reason astrology emerged.

If bad things happen, it's natural to assign blame. Take footie (soccer in NA). If a team loses 1-0 because of a goal from a penalty kick due to the referee penalizing our player, many fans see it as the refs fault, it wasn't a penalty, the opponent dived. Definitely not that our club couldn't score even one goal.

And it's much more satisfying and easy to grasp if we can assign blame to fellow humans as opposed to some amorphous system failure. Another factor at play: if we look for something, we often find it. For example, can be as simple as being a new VW Beetle owner and suddenly noticing them everywhere. Or more relevantly, if I suspect that a person is a misogynist, I may interpret their perhaps innocent words and actions as misogynistic.

When I told a good pal that I considered writing this blog, she encouraged me (as she always does) and suggested I include what a desire for revenge does to a person.

Good example exists in the CBC's Unspeakable series, in the character Ben Landry, to me a fictionalized version of one of two book authors (along with Krever Report) the series is based on: Vic Parson, who wrote Bad Blood: The Tragedy of the Canadian Tainted Blood Scandal. In the fictionalized version, Landry's behaviour drives away his wife and son with hemophilia and misses out on celebrating the birth of his grandson.

It's a given that hatred and the desire for revenge eats away at people and can destroy their lives if left unchecked. Know this from personal experience of a relative who physically abused his wife and sexually abused many children. Revenge seldom, if ever, gives the solace we need.

Just want folks to think about what would constitute justice for victims of infected blood scandals around the globe. Are thousands of deaths from HIV and HCV the fault of no one, just a system failure that no one could prevent? No one can be faulted for decisions because they didn't know enough? If preventable errors were made, what does justice look like?

Chose this ditty because it fits how I feel about the blog's issue. To me, transfusion professionals always had patient well-being on their minds yet they failed them, as the lover admits in this song:
COMMENTS: As always, your comments are appreciated and welcome. See below.

Canada's blood scandal 
If you view only one resource, make it this one. From Canada's blood tragedy: Tragedy of Factor VIII concentrate (19:14 mins. well worth watching. See Randy Conners words at 18 min. mark)
Criminal Justice System Purpose
UK Infected Blood Inquiry News 
Humboldt Broncos bus crash
Catholic Church Sexual Abuse
No Blame Culture
Bawa-Garba Case

Saturday, February 02, 2019

I've been everywhere (MLS grads in the Klein era)

Updated: Feb. 2019 (Major re-write)

Folks, the article below by a University of Alberta graduate in Medical Laboratory Science (MLS) was written 22 years ago. I have her permission to include it in a blog. I think it's timely because it documents -using one example- what happened to Alberta's health professionals under Ralph Klein in the 1990s, now touted as a fiscal hero by UCP's Jason Kenney.

IMPORTANT: I alone am responsible for the blog. The MLS grad agreed I could use her article in a blog, whose content was unspecified.

Although somewhat political, I decided to include it in the 'Musings on Transfusion Medicine' blog series as it relates to one of several students who got work in New Zealand's Blood Service and to education for medical laboratory technologists/scientists.

The student in question was lucky in her decision to get a university degree in MLS because it gave her international mobility. So many  of Alberta's excellent medical laboratory technologists with diplomas did not have that option.

As someone who was asked by many with diplomas what their options were when jobs in Alberta all but disappeared under Klein, it was hard to tell them the reality. Many were experienced and talented but it mattered not. Unlike MLS grads, the USA wasn't possible because of NAFTA requiring a BSc in jobs the USA needed. To work as a technologist you also needed to be certified by ASCP or similar. In contrast, most MLS grads had opted to obtain ASCP certification upon graduating so had no USA barriers to employment for what they were educated and trained to do.

Getting MLS grads accredited to work in NZ and qualified for work visas was difficult. First, I sent the entire MLS curriculum to the NZ certification body to prove the program was equivalent to NZ's, which had adopted a university entry level and called graduates medical laboratory scientists or biomedical scientists. Getting MLS's program accredited was the easy part.

Second, the job had to be on a skill shortage list, plus candidates needed a job offer from a recognized employer, in this case the NZ Blood Service. Other criteria were age, health and character requirements. Much more was required, including booking plane flights before acceptance by the NZ Canadian embassy was guaranteed. I well recall the incredible bureaucratic nightmare the MLS students endured to go Down Under.

These MLS grads, my 'kids' as I call them,were brave pioneers, undertaking a grand adventure. Thanks to PC Premier Klein, dozens of other grads uprooted them selves from their homes and families and moved to the USA where they were treasured as fabulous health professionals.

For example, out of the blue I was contacted by a maker of blood bank software (Wyndgate, now part of Haemonetics) who explained they'd done a software demo for the NZBS and were so impressed by the Canadian MLS grads, they hoped other grads would be willing to travel to California to work for them. As it turned out two MLS grads did, including this graduate, a grad of the post-diploma BSc program.

1. Having experienced Klein's health care cuts in Alberta, which we still are recovering from, I'm no fan of politicians like UCP Kenny who bow down to the god of decreasing a deficit. Especially when they put that above the welfare of health professionals and diss them for being pampered public service workers.

2. Seeing the fossil fuel energy sector whine about lost jobs and decreased profits, after so many good years of mega-profits, makes me chuckle at the irony. Yes, I have empathy for those who have lost their jobs. In the good years many folks, regardless of education level, earned $100K+ in the oil patch, worked hard, long hours and lived the good life.

Medical lab technologists spent much effort, time and big-$ to get an education. Oil-patch dudes, who portray themselves as pull-themselves-up-by-the-bootstraps macho-men and now whine, are portrayed as victims of the governing Alberta NDP of all things by the opposition UCP, not victims of the glut of oil and falling prices.

Meanwhile, in the 1990s public sector workers like my young MLS grads just got on with making the best of a bad situation at great personal trauma and expense. Yet the conservative UCP refers to health care professionals and others in the public sector as pampered, spoiled elites. Really?

3. To me, the most important lesson is please get the most education you can. Because it not only opens your eyes and mind, it gives you the opportunity to be the best you can, to contribute the most you can, and to be prepared when disaster strikes. As it did in Alberta in the Klein years.


My name is Kathy Swainston. I graduated from the Medical Laboratory Technology program at NAIT in June of 1989. Over the next three years I worked in both a small hospital setting in Jasper and in a larger centre, the Red Deer Regional Hospital. It was while I was sharing the Student Supervisors position in Histology at RDRH that I decided that I needed to return to school. I had attended university for two years before going to NAIT and I felt that I needed to complete my university degree.

At first I explored the post-diploma degree that UBC offers, before I realized that [Med Lab Sci at] the University of Alberta could offer me the same option much closer to home. I had already made the decision to leave my job, even though the future of health care in Alberta was very much up in the air at the time. In September of 1992, I was once again enrolled in university. The next two years involved a lot of hard work, but it was worth it.

The first year was tough, but not as tough as for the four year university student. Because of my training at NAIT, I was given credit for the labs that accompanied most of the courses that I took that first year. That first year got me back up to speed in all of the five disciplines of laboratory work. It also introduced me to a first year biochemistry class, which I thoroughly enjoyed and an introductory statistics class, which I endured.

As part of the degree you are required to complete a 3-or-6 credit research project. I found the experience extremely valuable. I chose to do a 6 credit pro- ject titled 'Characterization of the gene(s) that allow avirulent phase Ill Bordetella pertussus to grow on nutrient agar.' I enjoyed my time in the laboratory working on my own and learning to troubleshoot the problems that arose. I was able to experience first hand what it would be like should I decide to pursue graduate studies.

We were also required to take a course called 'Communication and Analysis of Biomedical Information.' It was set up in two stages; one part involved the research and presentation of a medical case-study to my peers. This gave me the opportunity to present my findings as a lecture to classmates and instructors. It was a great way to practice speaking in front of a group of people, which is harder than it appears.

The second part of the course involved doing a literature review of a selected topic relevant to laboratory medicine and writing a review paper in a format suitable for publishing in a scientific journal. This entailed lots of time in the library looking through journals and using on-line services such as Medline to search for articles. l chose to review 'Extraction, Amplification, and Study of Mitochondrial DNA from Ancient Remains.'

In the second year you could take advanced courses in the disciplines you most enjoyed. Some courses gave an in-depth look at instrumentation and troubleshooting, very valuable in today's laboratory. We had the opportunity to examine the management side of things, which was an eye-opener. We were exposed to the latest techniques in genetic testing and other technologies, such as flow cytometry. All in all received a very well rounded education.

l graduated in the Spring of 1994 with a BSc in Medical Laboratory Science. In the end pursuing a post- diploma degree has given me more knowledge and confidence in my work. l am more confident in conveying my ideas and knowledge to others and am a better technologist because of my experience.

Having a BSc in Medical Laboratory Science has allowed me the opportunity to explore the job market in the United States, Saudi Arabia, and other Commonwealth countries. Because of the degree and the generous help of the staff in Medical Laboratory Science at the U of A, l am now living and working in New Zealand along with five other MLS graduates.

The instructors in Medical Laboratory Science not only teach, but provide valuable help when searching for a job post-graduate. l would like to take this opportunity to praise their effort and thank them all.

For technologists looking to further their education, l would definitely recommend the post-diploma degree at the University of Alberta.

l would like to thank Pat Letendre for her help in editing this article.

Kathy Swainston, RT, BSc (MLS) Hamilton, New Zealand
Published in the ASMLT Spectrum, Jan. 1997

Decided to use very old ditty by Canadian legend Hank Snow. What happens to health professionals when politicians value money above people. Tragedy is a career killer for those without international mobility. For those with mobility it's still traumatic.
As always comments are welcome. See those below.