Infected blood scandal: British medicine’s worst moment

Thirty thousand people in the UK were given infected blood products over two decades, resulting in 3000 deaths (doi:10.1136/bmj.q1179).1 The scandal has attracted descriptions to match: horrifying, an appalling medical tragedy, and the worst treatment disaster in the history of the NHS (doi:10.1136/bmj.q1143).2 The six year Langstaff inquiry into the scandal is a 2500 page indictment of doctors, governments, blood services, and researchers. The intervention was overpromoted, including in children, and long term harms were disregarded. If anyone needs an argument for caution and evidence based practice then this is it.

The balance of benefits and harms was spectacularly misjudged. The UK was slow to acknowledge the risks of a high risk intervention, slow to respond to the deep concerns of patients and carers, slow to organise a national inquiry, and slow to apologise to the people affected and compensate them. By contrast, the UK was quick to adopt an unproved commercial intervention, quick to roll it out widely, quick to experiment on children, and quick to be swayed by one influential clinician at the heart of the decision to use infected blood products and transfusions.

Arthur Bloom was lauded in his BMJ obituary of 1992 for his international work in haemophilia (doi:10.1136/bmj.305.6867.1495).3 But he led the adoption in the NHS of commercial blood products and transfusions infected with hepatitis C and HIV. Through his national leadership role and involvement in seemingly every relevant committee, Bloom prolonged the use of these hazardous products imported from the US. In 1983 the director of the US Communicable Disease Surveillance Centre concluded that “all blood products made from blood donated in the USA after 1978 should be withdrawn.” Bloom ensured that, unlike other countries, this wasn’t the case in the UK, which continued to import commercial products carrying chronic disease and death.

This abuse of vulnerable people extended to experimenting on pupils at the Lord Mayor Treloar College in Hampshire. Children with haemophilia boarded at the school, which had a NHS haemophilia centre on site (doi:10.1136/bmj.q1143).4 What should have been a pathway to better care became a death sentence. The children were included in research without their knowledge and without parental consent, echoing the Tuskegee syphilis study. Only 30 of the 122 pupils with haemophilia at the school from 1970 to 1987 now survive.

Some of the horrors of the infected blood scandal are mirrored in the story of vaginal mesh surgery: a commercial product quickly adopted by clinicians on the basis of uncertain evidence, contempt towards patient harms, and a slow professional and governmental response to the scandal. In this case, Sohier Elneil, a urogynaecologist, fought the establishment for the dangers of vaginal mesh surgery to be recognised; they eventually were by the Cumberledge review (doi:10.1136/bmj.m3099).5 “Where we are serving the health of women,” says Elneil (doi:10.1136/bmj.q1195), “there is still a lack of understanding about what women want.”6

The question now is whether we can truly learn from this. In 1998 a BMJ editorial on the Bristol heart surgery scandal, by the then editor in chief Richard Smith, famously declared: “All changed, changed utterly: British medicine will be transformed by the Bristol Case” (doi:10.1136/bmj.316.7149.1917).7 British medicine, however, is proving hard to transform.

The processes and safety measures for blood products and transfusions are now more robust (doi:10.1136/bmj.q1220),8 but, as the vaginal mesh scandal reminds us, the rush to advocate for, adopt, and roll out insufficiently proved interventions is one that doctors, health services, and politicians find hard to resist. The picture is now complicated further by social media led advocacy campaigns and patient lobbying groups demanding access to new therapies. The more substantive the intervention, the greater the risk to patients—and the greater the potential financial reward for the industry.

“History doesn’t repeat itself,” wrote Mark Twain, “but it often rhymes.” The rhyme here is an abuse of power, and it has become an unwelcome mantra. One solution lies in a world where the power of the Sohier Elniels among us to halt harmful therapies exceeds that of each and every Arthur Bloom to disseminate them recklessly.