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Documents from the mid-1980s reveal that the French agency that later carried out key investigations into the ‘contaminated blood’ affair was aware at the time that blood products were contaminated with HIV.

Staff at the General Inspectorate for Social Affairs (IGAS) not only failed to sound the alarm, but published a report in 1985 stating — misleadingly — that French blood products were of “satisfactory quality” and “much better than previously”.

Lucas: headed investigative agency that failed to acknowledge its awareness of problems in 1985. Credit: AFP/E. CABANIS

In an interview with Nature, Michel Lucas, who recently retired as head of IGAS, confirmed that this had been the situation at the time. But he denies that IGAS was at fault, and vigorously refutes allegations that the agency's involvement influenced his later handling of two major inquiries into the contaminated blood affair.

As head of IGAS, Lucas was the author of an inquiry carried out in 1991 into the decision-making process during the mid-1980s, when blood became contaminated with HIV. The results of the inquiry directly shaped both the current trial of three former ministers, and trials of more than 30 transfusion officials and government advisers.

A verdict is expected next week in the trial of former prime minister Laurence Fabius, former minister of social affairs and solidarity Georgina Dufoix, and her secretary of state, Edmond Hervé. They are charged with involuntary homicide and endangering life, and of negligence in handling the risk of transmission of AIDS in the blood supply in 1985.

The 1991 inquiry into the contaminated blood affair made no mention of IGAS's 1985 review of the National Blood Transfusion Centre (CNTS). This review endorsed the blood centre's commercial strategy — and made no mention of AIDS.

In cross-examination last week, Gérard Welzer, a legal adviser to Hervé, suggested that Lucas might have omitted mention of the 1985 report in his 1991 inquiry because he was “scared at some point to be questioned” about its apparently reassuring conclusions.

Lucas told a parliamentary inquiry in 1992 that the conclusions of the 1985 report concerning the quality of blood products were based on an analysis commissioned by IGAS from the National Health Laboratory. Had the IGAS investigator then had knowledge of contamination, he told the inquiry, “much greater vigilance would have been paid to the analyses carried out by the laboratory”.

But documents obtained by Nature show that the rapporteur of the IGAS report, a Mme Broyelle, was in fact present at a meeting of the Consultative Commission of Blood Transfusion on 20 June 1985, at which the contamination of blood products with HIV was discussed at length.

The minutes of the meeting state, for example, that “It must be known that the possibility of not having contaminated lots is very low ⃛ under these conditions, it is indispensable that seronegative haemophiliacs are treated with heat-inactivated products.”

According to the minutes, Broyelle, who has since died, “called the attention of the fractionating centres to new manufacturing procedures whose guarantees of safety vis-à-vis transmissible diseases need to be closely examined”.

Asked to comment on the minutes, Lucas initially argued that the report was released in May 1985, before this meeting took place.

But the report remained open for comment by IGAS until the end of July 1985. The final report was sent to Dufoix on 19 September 1985 with a covering note from Lucas stating that the “development of the CNTS over the past few years has been extremely satisfying in technical terms”.

Lucas subsequently suggested that the IGAS rapporteur might have failed to realize the importance of the discussions at the meeting. “Those who received information in the early 1980s didn't always realize its significance, ” he added, arguing that responsibility lies with those who gave the information and had a better knowledge of the consequences — and that the report's conclusions were not contested by CNTS officials.

Lucas says he had always instructed his inspectors “to bring to his attention any important facts that arose at meetings they attended”. One reason the discussion at the 20 June 1985 meeting was not brought to his personal attention, he suggests, was that he was in hospital during the summer of 1985.

Asked why IGAS's 1991 inquiry made no reference to the agency's 1985 report, Lucas said that the remit of the inquiry was merely to analyse the decision-making process in the mid-1980s. The IGAS report was therefore irrelevant, he argues, as it played no role in the decision making.

The report “would only have been relevant if IGAS itself had learnt that the blood was contaminated, ” says Lucas, arguing that, although Broyelle may have been aware of the dangers at the time, IGAS itself was not.

But the main reason, he adds, was that, if he had explained why the conclusions of the 1985 IGAS report were misleading, he would have been obliged to have accused the National Health Laboratory of having misled IGAS.

This would have conflicted with the remit of the 1991 inquiry, which was only to describe the course of events — not to seek to attribute responsibility to individuals.

Lucas says he was reassured — now, it appears, falsely — by the fact that the conclusions of the 1985 report were based on an analysis of the quality of blood products commissioned by IGAS from the National Health Laboratory. It was because of this, he adds, that he saw no reason to ask further questions.

It was only in 1991, he says, that he learnt that the analyses carried out by the national laboratory had not included testing the blood products for HIV, even though it had been informed that the products were contaminated with HIV.

Lucas argues that IGAS was misled by both the laboratory and the Directorate General of Health. “They should have told me [about the contamination] before the mission started.”

Lucas also argues that any interpretation of the events must take into account the heavy workload under which IGAS was operating at the time. But he concedes that the conclusions of the 1985 report are ultimately “the responsibility of IGAS, and eventually mine”.

Lucas also accepts that, when he became aware of the 1985 meeting during his 1991 inquiry, he realized that this could pose a potential problem for the agency. But he firmly rejects allegations that this influenced his actions in any way.

He dismisses allegations of conflict of interest as a bid to distract attention from the central allegations in the contaminated blood affair. Some protagonists are pursuing this aspect, he suggests, to support what he describes as an untenable argument, namely that in the affair “everyone is responsible and therefore no-one is guilty”.