The Politics of BSE

The Politics of BSE

Richard Packer

The Politics of BSE

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The Politics of BSE

Richard Packer Permanent Secretary at the Ministry of Agriculture, Fisheries and Food (MAFF), 1993–2000

© Richard Packer 2006 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2006 by PALGRAVE MACMILLAN Houndmills, Basingstoke, Hampshire RG21 6XS and 175 Fifth Avenue, New York, N.Y. 10010 Companies and representatives throughout the world. PALGRAVE MACMILLAN is the global academic imprint of the Palgrave Macmillan division of St. Martin’s Press, LLC and of Palgrave Macmillan Ltd. Macmillan® is a registered trademark in the United States, United Kingdom and other countries. Palgrave is a registered trademark in the European Union and other countries. ISBN-13: 978–1–4039–8529–3 ISBN-10: 1–4039–8529–4 This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. A catalogue record for this book is available from the British Library. A catalog record for this book is available from the Library of Congress. 10 9 8 7 6 5 4 3 2 1 15 14 13 12 11 10 09 08 07 06 Printed and bound in Great Britain by Antony Rowe Ltd, Chippenham and Eastbourne

Contents List of Figures and Tables

viii

List of Abbreviations

ix

Chronology

xi

Introduction

1

1 The Cattle and Ancillary Industries Agriculture in Britain The animal feed sector Slaughterhouses The rendering industry Head-boning plants Mechanically recovered meat (MRM) Knackers and hunt kennels Gelatine Other industries Consumers

7 7 8 9 10 10 11 11 12 12 12

2 Science and Research Introduction Advances up to 1986 The current theory

14 14 14 20

3 Slaughterhouses Public attitudes The state of the UK slaughterhouse sector in the 1980s/early 1990s The decision to establish a national meat hygiene service The putting in place of the MHS Assessing the reasons for support for and opposition to the MHS

23 23 23 27 28 30

4 A Chronicle of Events until 20 March 1996 The period up to early 1988 1988: first policy responses 1988 onwards: independent scientific advice to government; the Southwood Committee, the Tyrrell Committee and SEAC 1989: the decision to impose the human SBO ban Late 1989 to early 1990: pressure for an animal SBO ban Other developments in 1990 Late 1990: new evidence leads to an animal SBO ban Taking stock: the protective measures in place from Autumn 1990

33 33 36

v

41 50 55 58 64 66

vi

Contents

A relatively quiet period: late 1990 to 1994 1994: a reassessment of the success of the animal health controls From 1 April 1995: the establishment of the meat hygiene service transforms the situation SEAC concludes that cases of CJD in young people reflect exposure to BSE

66 77 80 90

5 The Establishment and Conduct of the BSE Inquiry The establishment of the Inquiry The conduct of the Inquiry

99 99 102

6 The Findings of the BSE Inquiry Section I: the origin of the disease and the science Section II: Southwood Committee Section III: the overall government response Section IV: the actions of commercial enterprises Section V: the detailed government response Section VI: communication of risk Section VII: ‘contingency planning’ Summary of the main findings of the BSE Inquiry

108 108 111 113 114 114 123 125 126

7 Consideration of the Inquiry’s Findings The status and standing of the Report Section I: the origin and science of the disease Section II: the Southwood Committee Section III: the overall government response Section IV: the actions of commercial enterprises Section V: the detailed government response Section VI: communication of risk Section VII: ‘contingency planning’ Further comments

129 129 130 131 133 134 135 143 146 153

8 Events after 20 March 1996: (A) The Period of Conservative Government until 1 May 1997 The first two weeks after the announcement From Easter (5–8 April) until the Florence Agreement (21 June 1996) From Florence (21 June 1996) to the End of the Conservative Administration (1 May 1997) 9 Events after 20 March 1996: (B) The Labour Government from 1 May 1997 Onwards The period up to the election After the election Taking stock Setbacks for the prospects for UK beef exports A proposal for a revised certified herd scheme resubmitted: consideration is given to an additional export scheme

158 158 172 187 208 208 208 211 211 212

Contents vii

Cattle-traceability: choosing a location for the headquarters of the British Cattle Movement Service (BCMS) Progress on lifting the ban Beef on the bone The BSE Inquiry The date-based scheme: Blair’s frustration boils over The cattle movement service is launched Worries about the possible transmission of vCJD via blood transfusions EU rules to protect the public from BSE: BSE outside the UK The press, the government machine and the strange interest of Mr Anthony Bevins 10 Conclusions Conclusions as regards BSE Conclusions as regards politics Long-term effects of the BSE crisis and lessons to be learned Index

212 217 218 221 222 227 227 229 232 245 245 246 247 251

List of Figures and Tables Figures 4.1 BSE cases in Great Britain confirmed by passive surveillance, by month and year of clinical onset 4.2 Confirmed cases of BSE in Great Britain with known dates of birth, by month of birth 9.1 BSE cases in Great Britain confirmed by active surveillance, by month and year of slaughter

68 69 233

Tables 9.1 BSE: selected international statistics

viii

232

List of Abbreviations BABs

Born after the ban. Cattle succumbing to BSE after it became illegal to include ruminant protein in ruminant feed. BCMS See CMS. BSE Bovine Spongiform Encephalopathy. A TSE in cattle. CAP Common Agricultural Policy of the European Union. CHS Certified Herd Scheme. Permitted exports. CJD Creutzfeld–Jacob Disease. A neurological disease of man discussed in Chapter 2. CJDSU CJD Surveillance Unit, located in Edinburgh. CMO Chief Medical Officer for England. There are separate CMOs for each of Northern Ireland, Scotland and Wales. CMS (British) Cattle Movement Service. CVL Central Veterinary Laboratory, the main veterinary laboratory within MAFF located in Weybridge, Surrey. CVO Chief Veterinary Officer, the most senior vet within the State Veterinary Service. The CVO is a MAFF official. DBS Date Based Scheme. Another scheme permitting UK exports of beef. DoH Department of Health. EHO Environmental Health Officer, an enforcement officer employed by local authorities. ELISA A chemical test for the presence of specified substances, for example animal protein or even bovine protein. Can be very sensitive. EU European Union. FCO Foreign and Commonwealth Office. IEHO Institute of EHOs. LA Local Authority. MAFF Ministry of Agriculture, Fisheries and Food. MBM Meat and Bonemeal. A protein residue which with tallow is derived from processing animal carcasses normally after the meat has been removed. MHS Meat Hygiene Service. Body established on 1 April 1995 for enforcing rules in slaughterhouses, originally part of MAFF. MLC Meat and Livestock Commission, a quango for advancing the interests of the meat industry. MRM Mechanically Recovered Meat. Meat recovered from the bones left following normal butchery in slaughterhouses. NFU National Farmers’ Union of England and Wales. There are separate unions for Scottish and Northern Irish farmers and a Welsh union which caters mainly for small, Welsh-speaking farmers. NPU Neuropathogenesis Unit. A government research institute outside MAFF located in Edinburgh. ix

x List of Abbreviations

SBO

Specified Bovine Offal. Parts of bovines which it is believed can harbour BSE infectivity and which from 1989 have been removed from carcasses and kept from human consumption. Later SBO became SBM (‘Material’ instead of ‘Offal’). This book uses SBO throughout. ScVC The European Commission’s Scientific Veterinary Committee, an expert advisory committee. SE A spongiform encephalopathy not (yet) proved to be transmissible as in TSE. SEAC Spongiform Encephalopathy Advisory Committee. The government’s independent scientific advisory committee on BSE, members of which were appointed jointly by the Minister of Agriculture and Secretary of State for Health. Earlier versions of SEAC were known as the Southwood and Tyrrell committees after the name of the chairmen. SVC Standing Veterinary Committee. A committee of officials from member states which meets under a chairman from the European Commission and decides on many technical veterinary matters. It was the SVC which decided on the export ban on UK beef in 1996. SVS State Veterinary Service. The group of vets in MAFF under the CVO. TSE Transmissable Spongiform Encephalopathy. A group of diseases including BSE in cattle and CJD in man discussed in Chapter 2. UKASTA United Kingdom Agricultural Supply Trade Association, a trade association for animal feed manufacturers. vCJD A type of CJD in young people apparently caused by exposure to BSE. VIS Veterinary Investigation Service. A part of MAFF consisting of a number of veterinary laboratories covering the whole country, though over time their number has been reduced. One of their tasks is to check dead animals for disease.

Chronology 1986 November 1987 11 July December 1988 21 April 18 July 8 August 1989 27 February 13 June 1990 3 April 10 May 16 May 8 June 24 September

A spongiform encephalopathy in a bovine, BSE, first identified by examination of an infected brain at CVL. Information on new disease first published in the Veterinary Record. MAFF epidemiologist concluded that MBM derived from ruminants was implicated in the spread of BSE. Government established an independent scientific advisory committee chaired by Sir Richard Southwood. Order prohibiting the use of ruminant protein in ruminant feed, the ‘feed ban’, came into force. Slaughter/compensation scheme for animals showing clinical symptoms came into force. Southwood Report published: Tyrrell heads successor. Human SBO ban announced which came into force on 13 November. SEAC established following on from Tyrrell. Discovery of SE in a cat. John Gummer fed daughter, Cordelia, a beefburger. Council of Agriculture Ministers agreed rules for export of UK cattle and beef to rest of EU. Announced that laboratory transmission of BSE to a pig had been achieved. Animal SBO ban brought in straight away. Prohibited use of SBO in any animal feed.

1991 27 March 1992 4 March 9 March 1993 14 July

First BAB announced. Announced that BSE had been transmitted to marmosets. John Gummer announced the intention to create a national Meat Hygiene Service. 100,000th case of BSE. xi

xii Chronology

1994 2 November

Human SBO ban extended following experimental results.

1995 1 April

SBO required to be stained with a distinctive dye.

15 August 15 December 1996 20 March

27 March 3 April 21 May 11 June 21 June 16 December 1997 31 July

MHS takes over slaughterhouse enforcement from local authorities. Extensive extra controls on SBO including requiring dedicated lines for rendering SBO. Manufacture of MRM from bovine spinal column banned. Government announced that SEAC had concluded that the occurrence of CJD in young people was probably due to exposure to BSE before the 1989 SBO ban. EU export ban introduced. 30-months scheme announced. John Major announced policy of non-cooperation in the EU in response to export ban. Export ban lifted for gelatine, tallow and semen. Framework for lifting export ban agreed at Florence European Council. Non-cooperation ceased. Backlog of animals under 30-months scheme cleared.

16 December 22 December

Announced that a GB cattle tracing organization would be established at Workington. SEAC first recommended all UK blood for use in transfusions be leucodepleted. Beef on the bone banned. Announcement of BSE Inquiry under Lord Phillips.

1998 16 March 28 September

Limited exports from Northern Ireland restarted. Cattle-tracing system launched.

24 October

1999 1 August

16 December 17 December

Scheme (Date-Based Export Scheme) allowing some exports of UK beef came into effect. Leucodepletion of UK blood for use in transfusions made obligatory. BSE Inquiry concludes oral hearings. Beef on the bone ban lifted.

2000 26 October

Report of BSE Inquiry published.

2004 16 March

Recipients of blood transfusions banned from giving blood.

1 November

Introduction

BSE (Bovine Spongiform Encephalopathy or Mad Cow Disease) is still with us in that animals regularly succumb to the disease, though in much smaller numbers than was the case a few years ago. Sadly young people are still dying of the human form of the disease, variant Creutzfeld–Jacob Disease (vCJD) believed to result from past exposure to BSE in food or in some other way, though the numbers appear to be declining. Occasionally an outbreak in some country where the disease was previously unknown, such as that in the USA in 2004/05, makes the newspapers, normally because trading partners have immediately banned imports of cattle and beef from that country. New scientific advances on the nature of BSE and its sister diseases regularly appear in the scientific press and occasionally make the general media. However, the public interest and alarm that this excites now is a very pale shadow of what happened a decade ago. Then government policy on BSE was discussed – and often denounced – with real passion. BSE came to public notice towards the end of the 1980s and gained increasing salience throughout the first half of the 1990s. Throughout this period every new twist in the story produced an explosion of media interest with each peak in the cycle higher than the last. Virtually without exception comment was negative and highly critical of all concerned, especially the public authorities. This process reached its crescendo in March 1996 when it was announced that the government’s independent scientific advisers had concluded that cases of a new form of CJD in young people probably resulted from exposure to BSE years earlier. BSE remained a major issue for some time thereafter not least because it became mixed up with the UK’s difficult relationship with the European Union (EU) via the EU beef ban and the UK’s retaliatory non-cooperation policy. Nevertheless interest slowly diminished with the last major peak of interest occurring in autumn 2000 when the official BSE Inquiry published its findings. Throughout the crisis the media coverage was unrelentingly critical. It became almost universally accepted that the crisis stemmed from serious policy failures and that government secrecy, cover-ups and mendacity were the main causes and culprits of the whole wretched saga. In case memories have faded and it might be thought I am exaggerating, let us consider an article by the respected journalist Andrew Rawnsley published in the 1

2

The Politics of BSE

Observer on 22 November 1998. His first paragraph consisted of 24 words. Among them were ‘secretive civil service’, ‘mendacious politicians’, ‘greedy farmers’, ‘complacency’, ‘incompetence’, ‘buck-passing’ and ‘cover-ups’. He went on to refer to ‘more than twenty former Ministers associated with the gravest failure of public administration in post-war history’. He implied ‘deregulation’ was to blame in part. ‘The BSE scandal is Suez, the poll tax and thalidomide rolled into one.’ ‘We might hope for condign punishment of the guilty men.’ He claimed Tory Ministers had misled Parliament about past risks. He concluded by asserting that Nick Brown the then Minister of Agriculture had been captured by his Permanent Secretary (me) who had (inevitably) poisoned his mind against the proposed Food Standards Agency. At the time Rawnsley’s observations were not dissimilar in tone to those of other commentators. However, the claims he and others made were very serious ones and we will examine them carefully against the evidence. Some aspects of the popular explanations for the perceived failures of policy on BSE became so embodied in public thought that they even infected government itself. In December 1999 the Home Office circulated to other government departments including the Ministry of Agriculture, Fisheries and Food (MAFF) draft speaking notes for the second reading in the House of Commons of the Freedom of Information Bill, one of the Labour government’s manifesto pledges. On the first page the draft stated: Madam Speaker, there are just three letters which spell out more starkly than anything else what can happen when the default setting is for secrecy not openness… Those three letters are BSE. BSE – three letters which serve as a constant reminder of how the previous government’s… approach to a looming problem was to get their heads down, and try to keep Parliament and the public in the dark. This was at the time a fairly standard criticism of the Conservative government’s handling of BSE and would probably have seemed unremarkable to most people. The difficulty was that it was already known to be untrue to anyone who had followed the deliberations of the BSE Inquiry which had finished hearing evidence the previous month. It was apparent from the trend of their hearings (all held in public) that apart from one incident in 1987 secrecy was not an issue. Confident claims that BSE had been bedevilled by excessive official secrecy had been made to the Inquiry at an earlier stage but no evidence had been produced to support them apart from the minor case mentioned. This incident was instructive. Over a period of years it had become firmly established in the public mind that policy on BSE had been defective in a number of fundamental ways, for example by the existence of ‘a culture of secrecy’ to the extent that a major department of state assumed it was true even though they knew nothing about the matter. In the event, MAFF commented on the draft speaking notes to the effect that the references to BSE were misguided for the reasons given above and they were

Introduction 3

deleted. This was fortunate for the Home Office which would otherwise have justified to Parliament their flagship policy by a claim which opponents could later have pointed out had been refuted by an enquiry (the BSE Inquiry) they had themselves instituted. But if one popular perception accepted by virtually all, even parts of government, was in fact wrong, what about the others? This is one of the questions which it is the purpose of this book to answer. It will be shown that many other popular perceptions are equally wrong, but that, nevertheless, mistakes were made and we will analyse their malign effects in due course. In brief, BSE was undoubtedly a national trauma but public perceptions of many aspects of the saga are well wide of the mark. This book sets out the facts distinguishing them from the fantasies which, as we have already seen, are especially prevalent in the area. It is the first book to cover all the ground, covering both the politics and the science.

Book layout and structure I have tried to structure this book to be as helpful as possible to readers who are not necessarily expert in agriculture, in science or indeed in politics. Chapters 1 to 3 give relevant background in these three areas, while throughout I have treated matters with the minimum degree of detail needed properly to understand what went on. Until 20 March 1996 scientific opinion, with scarcely a qualified dissentient, was that BSE was unlikely to have implications for human health. On that day it was announced that the UK government’s independent scientific advisers had concluded that cases of a new form of CJD in young people were probably the result of their exposure to BSE some years previously. Thus before 20 March 1996 policy-makers were operating in a world where BSE was believed not to pose a threat to human health, while from 20 March the opposite was true. Obviously policy-making was very different before and after 20 March. Moreover, the BSE Inquiry, which we will need to examine in some detail, was concerned with the period up to 20 March 1996 only. It is, therefore, a natural cut-off date. Accordingly, in the following text I first trace events from the first known cases of BSE in the mid-1980s up until 20 March 1996 and then consider the establishment, procedures and conclusions of the Inquiry (including any defects in any of those). I then discuss developments after 20 March first under the Conservatives and then under Labour. In general I have let the facts speak for themselves and I hope that in the main they do so. However, on occasion, particularly where I believe the BSE Inquiry has misread the evidence, I have explained at rather more length why I take a different view since readers are likely to be especially careful in considering claims of that kind. It would not be right to set out conclusions before the evidence on which they are based, though as I have already made clear one theme of this book is that a number of common beliefs about the handling of the BSE epidemic are simply wrong. I come to them in due course. I would add one point, however, at this stage.

4

The Politics of BSE

It is naïve1 to expect that the ‘real’ truth about political crises is that they result from major, intentional wrongdoing by those in public office or those working for them.2 While such cases arise they do so only very rarely and, to put my cards on the table, did not occur in the case of BSE. However, that is precisely what has often been alleged about BSE; a careful reading of the literature will find frequent references to ‘lies’, ‘cover-ups’ and the like. The real questions are likely to be more subtle and nuanced. For BSE they include such points as whether policy decisions were sound in the light of what was known at the time and whether those concerned were appropriately frank about the risks to the public. These are real issues the answers to which can lead to significant praise and criticism. However, if we judge that someone made a mistake after an investigation of this type we are not automatically claiming he or she was a villain of darkest dye. We do not need to frighten ourselves with goblins.

Conventions employed What is now the European Union (EU) was previously known successively as the European Economic Community (EEC) and the European Community (EC). For convenience I use the term EU throughout even where, strictly, this is anachronistic. The enquiry headed by Lord Phillips (as he became subsequently) described itself as ‘The BSE Inquiry’. Except where the context clearly shows otherwise, references to the ‘Inquiry’ are to this body. When referring to other investigations I refer to ‘enquiries’. I treat the Inquiry as a collective requiring a plural verb. I refer to qualified veterinary surgeons by the colloquial but brief designation ‘vets’.

Sources Much the best source for all matters until 20 March 1996 is the Report of the BSE Inquiry,3 in the shape of both its voluminous Report and the evidence submitted to it and preserved on the internet.4 After that date there is no source of comparable authority. One needs to rely on Hansard, newspapers, departmental notices and the like. I was conscious from 20 March 1996 that I was living through momentous times and took notes, sometimes detailed ones. I have a copy of my engagement diary for the period 1995–2000.

Personal involvement I was Permanent Secretary at MAFF from 1993 to 2000, and it may help to say a few words about the position of Permanent Secretary. He or she is normally the official head of the department in question5 obviously under the Minister. He or she6 is responsible for managing the department and some incumbents devote almost all of their energies to this task. However, he also has two other principal functions which will concern us. First he is the most senior adviser on policy and

Introduction 5

second he has personal responsibility in relation to the expenditure of public funds. He fulfils these latter responsibilities as the Accounting Officer. In this capacity he must ensure that value for money is obtained for all expenditure and that all the department’s financial actions and expenditure meets the highest standards of propriety. On these financial responsibilities the Permanent Secretary/Accounting Officer is responsible not only to his own Minister but also to the Treasury and to Parliament7 via the powerful Public Accounts Committee (PAC), always chaired by a senior member of the Opposition. Permanent Secretaries are regularly grilled by this committee on any and all aspects of departmental expenditure and if they are wise they make enormous efforts to prepare themselves for the occasion, since their performance will impinge on their reputation. There is a special though rarely used mechanism which Accounting Officers can and must use if they believe that financial proposals are unsatisfactory in terms of propriety and/or value for money. They can object and formally seek a direction from the Minister – that is a written order – to proceed with the matter in question. Without such a direction the Accounting officer can instruct officials not to proceed. The Accounting officer’s request for a direction and the Minister’s reply must be copied to the Treasury and the National Audit Office which reports to Parliament and is thus close to the PAC. There is clearly a potential tension here. The Permanent Secretary works for the Minister yet he can, indeed has the specific responsibility to, thwart the latter’s wishes in potentially embarrassing circumstances if he judges they do not meet certain standards. As we shall see this can lead to problems. As Permanent Secretary I participated in many of the more important discussions and incidents which occurred when BSE was a major issue. When I took up post I quickly found that to act effectively on BSE I needed to examine who had done what previously (that is before 1993) and why. Also, since Ministers were officially debarred from taking any role in the BSE Inquiry’s processes, I had to authorize departmental submissions to it in 1998 and 1999 covering the period before as well as after 1993. I therefore gained a solid grounding in the history of the disease back to its beginning in the mid-1980s. It also helps that my university degrees are in a scientific subject (chemistry). I believe that the history of BSE is fascinating and in some ways instructive even if – indeed because – the facts are different from popular perceptions. I also believe, perhaps immodestly, that I am in as good a position as anyone to write an account which needs to cover events, the political dimension and the science. Readers will judge for themselves whether this represents self-knowledge or self-delusion. The word ‘politics’ covers a host of matters from major issues of elevated principle to minor matters of interest to a few individuals only. This is because politics is a reflection of human nature, which while sometimes aspiring to the heavens is often concerned mainly with self. Accordingly, sometimes this book moves suddenly between the large and lofty and the small and rather grubby. I make no apology; it would not be an accurate account without both dimensions.

6

The Politics of BSE

Notes 1 In present UK circumstances. Elsewhere in time and space matters may be/have been different. 2 I acknowledge that, as I revise these pages in 2005, some might consider that the current High Court case involving Railtrack perhaps refutes this claim. However, whatever the merits of that case the proposition as put remains true. 3 Report, evidence and supporting pages of the Inquiry into the emergence and identification of Bovine Spongiform Encephalopathy (BSE) and variant Creutzfeld–Jacob Disease (CJD) and the action taken in response to it up to 20 March 1996. Stationery Office 2000. 4 At www.bseinquiry.gov.uk 5 Some larger departments have more than one Permanent Secretary, but if so one will be designated as the most senior. 6 I use ‘he’ subsequently to save repetition. 7 Departmental expenditure is authorized by specific Parliamentary votes.

1 The Cattle and Ancillary Industries

It will help in considering the emergence of BSE and the response of the government to the epidemic to have some concept of the industries concerned and how they are organized.

Agriculture in Britain Very broadly as we move eastwards across Britain average rainfall lessens and soil fertility increases. As one consequence the importance of arable farming (crops) also increases as we move eastwards. Thus the importance of cattle and sheep1 farming increases as we move the other way – westwards. Agriculture has been profoundly changed by the scientific revolutions of the last two hundred years, the pace of change seeming to get ever faster. However, not all sectors have been equally affected. Arable farming has been most affected, while dairy farming, too, has been very much altered by improved animal genetics, nutrition and milking techniques. The farming of beef cattle and sheep has been perhaps the least altered though even here observers from a century ago would be surprised by what they found. BSE is primarily a disease of cattle2 and in 1986 – when BSE was identified – the total UK cattle population was over 12 million spread over 120,000 farm holdings. Many thousands of people were economically involved in cattle (including dairy) farming and many more in the related ancillary industries. Cattle are big business. In 1986 the output of milk and cattle was valued at over £5 billion at 1990 prices and this figure does not include the large value added by a host of ancillary industries. All aspects of agriculture and trade are covered by the EU Treaties; hence it is primarily EU rules that apply in these areas and there is little scope for independent national action. In particular the production of and trade in milk and beef3 falls within the ambit of the common agricultural policy (CAP). The CAP is renowned for high prices and production subsidies;4 nevertheless, at times of crisis there are inevitably demands that support should be increased. Hence the politics of the CAP impinges on policy on BSE. 7

8

The Politics of BSE

Fortunately milk has never been implicated in the spread of BSE so I will therefore mention only the industries based on the processing of cattle carcasses and not those concerned with the processing of milk. In 1986 about two-thirds of beef output came from animals produced by the dairy sector, that is from dairy cows at the end of their working lives and from calves most of which were reared until 18/24 months of age. Beef also comes from specialist, ‘suckler’ herds.5 These animals are generally kept on less-productive land than dairy cattle though the resulting beef is of better quality. Farming is more than facts and statistics. Many producers are proud of inheriting their role from fathers, grandfathers and not infrequently more distant ancestors. Many are equally conscious that the impersonal forces of economics are likely to make them the last of their line in farming. ‘Family farms in peril’ is how the farming press tends to put it. Attitudes towards the amalgamation of holdings and increased farm size vary, but it would be fair to say many see these trends as regrettable. This factor has its political significance and is reflected in the pressures faced by policy-makers when disasters occur.

The animal feed sector Most feed consumed by most cattle is in the form of grass either eaten direct from the sward or preserved as hay or silage. To this day some cattle never consume anything other than grass and their mother’s milk. For about a century, however, many cattle have been fed in part on the output of the animal feed industry. In particular milk output can be increased by the feeding of ‘concentrates’.6 Dairy calves need special feed until they can consume grass, since their mothers’ milk is not available to them. Like other young mammals they need feed rich in protein. In recent decades the nutrition of cattle and other farm animals has become better understood. Clearly there is an equation which links the increase in output to be gained from feeding an animal with a particular feed and the cost of the feed. Nowadays computers are used to determine optimum economic choices. The largest component of cattle feed is usually cereals, but from the perspective of BSE the most significant was the frequent inclusion (until 1988) of meat and bonemeal (MBM), produced in part from cattle carcasses. MBM was included primarily as a source of protein. Probably one of the more widely known facts about BSE is that it was spread by cattle consuming feed containing MBM derived from cattle contaminated with BSE. Articles of the ‘how could they have allowed cannibalism’ sort have been common for years. The advent of BSE has indeed demonstrated the dangers of allowing cattle to consume bovine MBM. But before we assign blame we need to examine the circumstances which were helpfully researched in detail by the BSE Inquiry. They showed that: MBM was already used in ruminant feed in the UK in the 1920s; that the same practice was followed in the USA also in the 1920s and in Australia and New Zealand certainly by the 1930s: that in the UK during the Second World War MBM was specified as an obligatory component of animal feed: and that the use of MBM grew after the War, partly on the basis of official

The Cattle and Ancillary Industries 9

recommendation. In the UK by the late 1980s production may have amounted to 400,000 tonnes per annum of which 10 per cent may have been included in feed for ruminants. Thus for many decades before the arrival of BSE a large number of people in many countries7 – everyone concerned in fact – saw nothing untoward with feeding bovine MBM to cattle. There is no record of anyone protesting. The inescapable conclusion would seem to be that before BSE nobody saw anything wrong with feeding bovine MBM to cattle;8 and that later claims that it is obviously wrong in principle owe everything to hindsight. Those who claim otherwise are seeking scapegoats after the event. Any such scapegoats would have to include virtually all those working in the field of animal nutrition in every developed country stretching back over many decades.

Slaughterhouses All farmed animals, including those reared primarily for another purpose, such as the production of milk, eventually go for slaughter. With trivial exceptions all farmed animals such as cattle are required to be killed in licensed slaughterhouses.9 The deficiencies of the hygiene controls in UK slaughterhouses in the 1980s and early 1990s, the denial by some that those deficiencies existed, and the difficulty the government had in improving matters is an important part of the BSE story, sufficient to justify a chapter of its own (Chapter 3). Here I deal with other aspects of the sector. It is noteworthy that in some cultures10 those involved in animal slaughter are required to separate themselves from society at large. There are deep-seated human taboos about killing things. This has important consequences in that, one suspects, slaughterhouse workers are a more robust group than would be found by randomly sampling the population at large. In recent decades economic forces, notably the advantages of maximizing the utilization of equipment and of production lines – economies of scale in short – have brought about the concentration of the industry into fewer and larger enterprises. In 1971 there were 1,890 slaughterhouses in Great Britain; by 1986 the number was under 1,000, by 1995 it was under 500. It has continued to go down subsequently. Preparing cuts of meat from a slaughtered animal involves a large number of processes many of which are likely to make the average person feel somewhat uncomfortable. The Report of the BSE Inquiry contains an excellent list11 of 19 such processes including ‘stunning, pithing,12 shackling and hoisting, sticking,13 bleeding, removal of horns, feet and udders, removal of head, tonsils and tongue, pulling of tail and dropping of bung’14 and so on. For our purposes we only need to remember that slaughterhouse practices cover a wide range of activities, many of them messy. In the mid-1980s slaughterhouses processed about four million cattle annually which produced about one million tonnes of beef and the same amount of other material, that is bones, intestines and all the messy stuff produced by dead bodies.

10

The Politics of BSE

A million tonnes of such material cannot be dumped and in developed societies most of the material from slaughtered animals that does not go for human consumption is passed on to renderers.

The rendering industry Rendering is the process by which the material left over after the meat has been removed from carcasses,15 which would otherwise decay unpleasantly, is transformed into two relatively stable products – tallow, and meat and bonemeal (MBM). Until the advent of BSE both had value, so that slaughterhouses were paid by renderers for their waste material. Though processes vary slightly, essentially rendering involves crushing and heating. The heating drives off water and eventually the material separates into two fractions, one consisting mainly of protein from which MBM is produced, and the other consisting mainly of fat (tallow). Traditionally tallow was the more valuable product and was used for candles. It is still used for that purpose but now it can also be used in the manufacture of numerous other products including, notably, soap. The main uses of the protein fraction were in animal feed and fertilizer. Rendering has traditionally been a lightly regulated industry with commercial demand determining standards. In 1981, however, a government Order specified that ‘processed protein’ must be salmonella16 free, though how that was achieved was left open. Nevertheless, one of the explanations of the BSE crisis put forward after 1996 was that it resulted from ‘deregulation’ of the rendering industry. In fact there was not much regulation of rendering before BSE and its advent resulted in various extra requirements being imposed on the industry. At no stage was there any deregulation.

Head-boning plants There really is (or more accurately was) an industry going by this name. Its objective was to extract maximum value from bovine heads by removing as much as possible of the meat, which is found mainly in the cheeks and tongues. Removing meat from heads could not be fully mechanized and was done by operatives skilled in the process using circular electric knives. The specialist nature of the task led to its often being done apart from other slaughtering processes. In 1995 there were about 40 head-boning plants. BSE turned attention to head-boners since it was soon realized that brains were a main repository of infectivity. This led to successive tightenings of the controls on the industry until the coup de grace came in March 1996. Following scientific advice that cases of CJD in young people were linked to exposure to BSE, an Order was made requiring the whole head except the tongue to be treated as SBO. This prevented the recovery of meat from skulls. Thus the advent of BSE resulted in the disappearance of an industry while those concerned received no compensation. They were among the victims of the disease. It is also worth noting that what had previously been an economic resource – bovine heads

The Cattle and Ancillary Industries 11

(except tongues) – was after 1996 treated as a pollutant at considerable cost to producers and society at large.

Mechanically recovered meat (MRM) Maximizing the amount of meat recovered from a carcass has obvious economic advantages. In the 1960s automatic machines were developed which could accomplish this with greater efficiency than had been achieved previously. Typically the machines operate by subjecting bones to high pressure and forcing the resultant slurry (MRM) through a series of sieves. MRM resembles a puree and, unless treated, does not look like meat as normally understood by most people. In 1995 most MRM was made from chicken, but about 5 per cent was made from bovine material. The vertebral column and ribs were the main source of bovine MRM. It was relevant, therefore, that the spinal cord was known to be a source of infectivity. The unfortunate events which resulted in the production of bovine MRM from vertebral columns not being banned until 1995 is set out in Chapter 4. The whole concept of MRM has been attacked in recent years as being abhorrent in some way. Television programmes have shown close ups of puree emerging from the manufacturing process in the clear expectation that viewers will find it distasteful. Is there something inherently unacceptable about the product? Some manufacturers took a critical view of MRM well before 1995 and claim never to have used it. They were concerned at the virtual impossibility of tracing the origin of the animals processed which would be useful if there were an outbreak of disease. These individuals were prescient, though this does not mean that others following the rules are to be blamed. We are constantly exhorted to protect the environment and the earth’s resources by recycling and avoiding waste. The production of MRM (and indeed the inclusion of MBM in cattle feed) could be said to have achieved both. Perhaps the correct conclusion is not that MRM was an inherently unacceptable product, but that all practices should be constantly kept under review and that we should be prepared to alter the rules quickly in the light of new evidence.

Knackers and hunt kennels The production of meat is a messy business and the gory ramifications do not stop with MRM. In the UK there have long been enterprises that cope with those animals that cannot be slaughtered in licensed premises either because they have already died on farm or are ill or injured and need to be slaughtered directly and/or would not be accepted for human consumption. In the UK such animals are traditionally processed by knackers and hunt kennels. In the early 1990s there were just over 100 knackers and rather fewer than 300 hunt kennels. By definition, meat from knackers does not go for human consumption. The plants’ importance in the context of BSE lies in the possibility that they might have acted as sources of infection for animals. Theoretically they could have done so either by the direct sale of meat as petfood or via the waste eventually sent by

12

The Politics of BSE

knackers to renderers, which could have found its way into cattle feed if not correctly handled. Meat from carcasses sent to hunt kennels is fed to the hounds. After November 1990 any SBO ought not to have been fed to the hounds (or any other animal). MAFF investigations showed as late as 1995 that this provision was not always complied with, but fortunately BSE has not yet been found to cause illness in dogs. Historically knackers, the more important of the two types of enterprise, undoubtedly fulfilled a useful function, but by 1986 most were struggling.

Gelatine One wonders even now how many people realize gelatine is made from pig and cattle carcasses. Specifically it is made from the hides and bones of pigs and cattle which are treated with either acid or alkali and the resulting extract heated. The treatment is thought to be sufficiently rigorous to deactivate the BSE agent. The product is very widely used in foods, in the manufacture of pharmaceuticals, in photography and in numerous other industries.

Other industries The industries discussed above are not the only ones involved with cattle. To name only two it does not cover the leather industry nor retail butchers. The industries discussed are, however, those of most importance in the context of BSE.

Consumers Obviously production is only viable if there exist willing consumers for the relevant output. It is therefore important that starting in about 1970 (some would put the date a bit earlier) the interest of consumers in food production and diet and in the related official standards and rules increased enormously. Consumer bodies and pressure groups of many kinds have decided views on what ought and ought not to happen and constantly seek to publicize their views in order to influence the public, while also lobbying government to act in their preferred manner. Responding to such pressures is a major task for all in the food chain, notably farmers, manufacturers and retailers, and also for government. This book is only indirectly concerned with what has been reasonably called the consumer revolution, but it is important to realize that all the decisions discussed below had to be taken in the knowledge that they would be rigorously scrutinized not only by political opponents but also by consumer groups which, experience showed, were often both critical of government action and successful in gaining media attention. Notes 1 These days pigs and poultry are considered as being in effect processed cereals, hence the industries are concentrated in the east. This had its significance in the BSE saga (see p. 72). 2 Though the possibility that it originated in sheep has not yet been definitively disproved.

The Cattle and Ancillary Industries 13 3 And most products made by processing milk or beef. 4 Very recent (2003) agreements to make changes to the CAP may make this less true in future. However, most observers would accept that the above statement was true from the beginning of the CAP in the late 1950s until 2003 at least. 5 ‘Suckler’ because the calves suckle their mothers which is not usually the case for dairy calves. 6 Concentrates are animal feed with a high concentration of protein. 7 In effect all developed countries. 8 However, note Sir Richard Southwood’s reaction explained in Chapter 4, p. 44. 9 This is accomplished in a roundabout way – meat cannot be sold unless it comes from an animal killed in a licensed slaughterhouse. 10 For example Japan. 11 Figure 2.3 on p. 7 of Vol. 13. 12 The insertion of a rod or coiled wire through the hole in the skull of cattle made by the captive bolt to destroy the brain and spinal cord. 13 The act of severing some of the principal blood vessels. 14 Tying the rectum with the neck of the bladder to prevent faecal contamination of carcasses. 15 Renderers also made some use of other material, such as whole carcasses from animals that had died on farms (fallen stock) and waste from butchers’ shops. 16 The thinking presumably was that anything sufficiently rigorous to eliminate salmonella would also eliminate other bacteria and viruses. This is correct, but unfortunately the same is not true of BSE.

2 Science and Research

Introduction BSE is (mainly) an affliction of cattle. A human affliction now known to be closely related to it is called CJD. One objective of this chapter is to set out enough of the science of this group of afflictions to enable readers to appreciate the nature of the problem posed when BSE was identified. Another is to help them to appreciate why when faced with BSE those involved acted in the ways set out in the following chapters – and to judge whether these actions were satisfactory. Of course over time science moves on and more becomes known enabling better decisions to be made. However, decisions often cannot be delayed and have to be made in the light of the information available at the time and of the theories which best account for the known facts. The passage of time may reveal that the facts have been wrongly assessed or the theories accounting for them were deficient. In that case previous decisions may not have been optimal. This is inevitable and history abounds in examples of catastrophes caused in effect by ignorance. I describe below one such where young people treated with human growth hormone extracted from corpses were infected with CJD. In these cases the direct consequence of a medical treatment prescribed for the best of reasons was an appalling, early death. The class of disorders to which BSE belongs is a highly unusual one. For the purposes of this book I believe it will be most helpful if I first describe the relevant facts as they became established over the years up to the discovery of BSE in 1986. This was the state of knowledge when the initial policy decisions on dealing with BSE had to be taken. I will then turn to how these facts are now explained.

Advances up to 1986 Scrapie This approach requires us to start with scrapie which has been recognized as an affliction of sheep (and goats) for centuries. There was a particularly widespread and virulent outbreak in Germany in the eighteenth century, and contemporary accounts show that the disease existed in the UK at the same time. 14

Science and Research 15

Signs of scrapie do not normally occur until sheep are ‘middle-aged’, that is around three years old. They include scratching, for example against a tree or post, often until the wool and even the skin is rubbed away. The resulting half-naked look is what is often most noticeable. Affected animals are easily startled and difficult to control with dogs. They are unsteady on their feet and have a peculiar and distinctive gait. Affected animals do not recover; eventually they collapse and die (if not disposed of beforehand). Over time it was noticed that some breeds and families of sheep were much more susceptible to the disease than others. This suggests that the genetic constitution of an animal is relevant to whether or not it becomes infected. Later in the twentieth century it was established that some sheep appear to be totally resistant under natural conditions. Against that, large outbreaks sometimes occurred in other flocks for no apparent reason. In natural conditions, however, it is more usual for one or two animals in a flock to succumb. In 1936 French scientists first reported that they had transmitted scrapie to a healthy sheep by injecting tissue from the spinal cord of an infected animal into the eye of a healthy animal. The time from injection to apparent sickness was eighteen months.1 In due course other methods of transmission, such as injection into the brain, were also shown to work, again after a period of many months. Even more puzzling was the scrapie outbreak that occurred in Scotland also in the 1930s in many hundreds of sheep some eighteen months after they had been vaccinated against another sheep disease. The vaccine had been prepared from the brains and other tissues of sheep infected with this other disease (now confirmed as being caused by a virus). It had been treated with formalin, a standard method of inactivating viruses. By then it had been established that scrapie did not involve a bacterium since none could be cultured in the laboratory. At the time, however, most viruses were too small to be detected by the microscopes available. The general assumption was that scrapie was caused by a virus. When electron microscopes became available in the 1950s, however, no scrapie virus could be detected in cultures made from relevant tissues. Equally puzzling, no antibodies to the infection could be detected in the blood of infected animals. Given the strange behaviour of infected animals it was natural to examine their brains under the microscope, and they were found to be profoundly affected. In particular, the parts responsible for balance, arousal and metabolism showed substantial tissue damage. Overall the brain appeared abnormal, and microscopically somewhat like a sponge. Often brains contained plaques, later shown to be composed of polymerized (joined together) protein. Transmission experiments, normally involving the inoculation of tissue from scrapie-infected sheep into the brains of mice,2 were carried out to discover which organs other than the brain can contain infectivity. If the mice succumbed to scrapie as shown by an examination of their brains3 then the tissue injected into them had contained infectivity. The results showed that after the brain the spinal cord is the most affected organ though some other tissues also contain some infectivity. Later when protecting the public from BSE was under consideration these

16

The Politics of BSE

experiments were used as the basis for important decisions on which bovine tissues should be kept out of the human food chain (based on the analogy of BSE with scrapie which seemed reasonable in the absence of data for BSE-infected cattle, since both are ruminants). Finally the detailed results of various experiments led to claims that scrapie could be transmitted from ewe to lamb (though few claimed this was the only naturally occurring method of transmission). The existence of maternal transmission for scrapie (before or after birth) is widely accepted though some respected workers in the field dispute it. The latter claim the outcome of the experiments in question can be better accounted for by variations in inherited genetic susceptibility to infection. Until recently these facts could not be satisfactorily explained according to established theories. Most people assumed a virus must be involved, but this seems to have been more because theory required it than because of the evidence. Those working in the field sensed that there were major discoveries to be made but the subject seemed puzzling – too difficult in fact. The economic impact of scrapie was not major and no link had been established with human health. In line with the overall reduction in government expenditure on agricultural research the effort devoted to scrapie diminished in the period up to 1986. CJD in humans The full name for CJD is Creutzfeldt–Jakob disease. It is named after two German doctors who first categorized CJD in the 1920s. Over the following decades a picture of the disease was gradually pieced together. One reason why the facts took a long time to establish was that CJD was found to be extremely rare. Nevertheless, the closer people looked the more cases they found since some had originally been diagnosed as suffering from some other more common disorder such as stroke. Indeed it was not until the late 1970s that the relevant international authorities included CJD in the official list of diseases. However, even with very careful searching the rate of infection did not go above one case per million per year in a population. Statistics showed that the disease is in the main an affliction of late middle age. Its central features were loss of physical control of the body such as the ability to move limbs voluntarily, often accompanied by involuntary movements, and loss of mental faculties. Typically the brains of those infected, when examined after death, were found to be profoundly affected with loss of neurones and the appearance of ‘holes’ giving a spongy appearance under the microscope. In recent decades what appear to be sub-types of CJD have been identified. They share the main features of CJD in terms of loss of physical control and of mental faculties, but differ in the detail in which these features present themselves and sometimes demonstrate others in addition. In one, patients go blind though their eyes appear unaffected (in such cases the part of the brain dealing with sight is grossly affected). In another, patients lose the ability to sleep. In a minority of cases sufferers were found to have affected relatives, sometimes dozens of them over many generations, though for most CJD patients this was not

Science and Research 17

the case. Examination failed to identify any common thread of diet or lifestyle or exposure to danger or medical history that might account for who became infected (other than membership of the few families who seemed to be particularly affected). Kuru Kuru is the name given by an ethnic group in New Guinea4 to a mysterious disease that struck them in the twentieth century reaching its height in the 1950s. The main symptoms were a progressive loss of motor control (that is the ability to move one’s body as one wishes and not to move it as one does not wish) followed by dementia and death. The brains of those affected when examined after death were found to be severely affected with loss of neurones and a general spongy appearance. Often the brains contained plaques. When it came to the attention of the (Australian) authorities in the 1950s the disease was found mainly in women, young men and children of both sexes. Initially it was very rare in older men. Relatives and those who had been brought up together often succumbed even when they had moved away from their original homes many years before. Only the one ethnic group was affected. The numbers affected increased steadily as the 1950s advanced. Kuru became the major cause of death in women to the extent that the sex ratio among the ethnic group became severely distorted. One of the most important advances in understanding in this area occurred in 1959 when an American vet called Hadlow, a researcher into scrapie, wrote a letter to the Lancet pointing out the similarities between kuru and scrapie. Given the way I have presented the facts above this probably seems a less brilliant insight than it was. This is because I have made no mention of the many other brain diseases of humans and animals which demonstrate some of the features of scrapie and/or kuru and made the picture much more confusing than the one I have painted. It must also be borne in mind that human and animal diseases are generally investigated by different sets of professionals who do not often communicate. Nor was there any particular reason to link kuru and scrapie. There are few sheep in New Guinea and they are not known to suffer from scrapie. Hadlow recognized that his suggestion could be tested experimentally. If kuru was closely related to scrapie then probably it, too, would prove transmissible. Obviously experiments could not be conducted on humans, likely to be the most susceptible to transmission. Mankind’s closest relative is the chimpanzee so the best test possible would be to inject brain tissue from kuru sufferers into the brains of chimpanzees. The scrapie analogy suggested, however, that it might be months or years before the animals succumbed (if they did).5 Organizing such an experiment is a large task and it was 1962 before chimpanzees were injected with kuru-infected brain. They became ill twenty months later and deteriorated for a further six months. Their brains were found to be severely affected in the same ‘spongy’ way as kuru sufferers, though the detail, for example which part of the brain was most affected, was different. However, it was clear that kuru had been transmitted to the chimpanzees. Hadlow’s insight had

18

The Politics of BSE

been correct. The experiment was reported in Nature in 1966 and one of the scientists concerned shared the Nobel Prize for Medicine in 1972. Some of the workers who examined the brains of the chimpanzees infected with kuru commented that they looked similar to brains they had previously examined of humans suffering from CJD. This suggested an obvious further experiment and by 1968 it had been reported that CJD, too, could be transmitted to chimpanzees though again with an incubation period measured in years. CJD, kuru and scrapie had been shown to be closely related diseases. These discoveries showed that infection might involve a lengthy incubation period so that any precipitating events had probably occurred long before – possibly many years before. Together with other evidence this consideration allowed the kuru mystery to be solved. The other evidence was that by the 1960s the age of the youngest child succumbing to kuru seemed to increase annually. This was especially true in those regions in closest contact with ‘Western’ influences. However, at the same time the number of adult men succumbing increased. The answer lay in cannibalism which was practised by the ethnic group concerned as a way of marking respect for the dead. Bodies were dismembered and cooked by women and the internal organs eaten by them and by children. Men ate only the flesh. Cannibalism was banned by the Australian authorities who gradually penetrated even the remotest regions, and by the end of the 1950s the practice appears to have ceased. Piecing together all the evidence the best account appears to be as follows. Kuru appeared in the 1920s as the result of the consumption of one individual who had died of CJD. (Remember most cases of CJD occur sporadically, that is they have no apparent cause.) By the Second World War it had spread to a number of villages, and it continued to spread after the war. A single incident was sufficient to cause disease, possibly decades later. The incubation period varied between four years (based on the youngest who succumbed at that age) to several decades (based on the experience of those who had moved from villages where kuru was common to villages where it was unknown and succumbed there decades after moving). Differing infection rates among men and women were accounted for by the different roles at the cannibalistic feasts and the different organs consumed, so that males only normally became infected while children. The epidemic was halted and kuru has died out because of the suppression of cannibalism by the authorities in the 1950s. In effect kuru represented CJD transmitted orally.6 A link between CJD and scrapie? CJD and scrapie having been shown to be similar types of disease the question was posed as to whether the link was very close indeed. Could CJD be caused by scrapie? However, on careful examination of medical and veterinary records no causal link could be found. CJD occurred worldwide at comparable frequencies (if allowance were made for different intensities of searching) and appeared to be unrelated to the presence of scrapie. Indeed CJD was found in countries where scrapie was unknown.

Science and Research 19

Acquired CJD Kuru was unfortunately not the only example of CJD being spread by human activity. Various medical practices have also contributed to the dissemination of the disease in the last fifty years. These include treatment with growth hormone or gonadotrophin derived from human pituitaries to induce growth and to combat female infertility respectively; transplantation of the cornea; the use in brain surgery of instruments or electrodes used previously on other people; and the use of dura mater (a natural covering of human brains) in operations. Fortunately none of these examples has led to major epidemics, but worldwide over a hundred people have died from human growth hormone related CJD. These facts demonstrate how persistent the agent causing the disease can be. For example the instruments and electrodes implicated in causing CJD had been sterilized to normal surgical standards – that is, what would normally be regarded as a very high standard. This was not sufficient to prevent the transmission of CJD when they had previously been used on someone later shown to be suffering from the disease, though it was certainly sufficient to kill any known bacterium or virus. Experience also showed that the incubation period was dependent on the method of transmission. In the case of contamination via brain surgery or corneal transplant – that is injection directly into the brain – the period was two years or less. In the case of injections of growth hormone outside the brain the period is at least eight years and often longer. Related diseases Finally we need to mention two other animal diseases which are recognized as falling within the same family of diseases as CJD, kuru and scrapie, that is within the group of transmissible spongiform encephalopathies (TSEs). One is a disease of mink known as TME, severe outbreaks of which occur occasionally in mink farms. TME has similar features to other TSEs. It might or might not be relevant that farmed mink are typically fed animal waste such as the carcasses of animals that have died. Apparently7 in one experiment healthy mink fed on scrapie-infected sheep did not succumb to the disease but did so if the scrapie infected material were rubbed into abrasions in their skin. Another TSE was first found in mule deer and elk in wildlife parks in the US states of Colorado and Wyoming. This has now spread outside the parks and is found in deer and elk in several states and in a more limited way in Canada (and in South Korea which imported animals from Canada). The prion theory Let us recall the principal facts that need to be accounted for by any theory purporting to explain TSEs. Using CJD as the main illustration they include: (a) most cases do not appear to have an environmental or genetic cause, they occur ‘sporadically’; (b) CJD occurs at a low incidence in all human populations;

20

The Politics of BSE

(c) nevertheless some cases of CJD ‘run in the family’ and are likely to be genetically based; (d) it can be transmitted most effectively by injection of infected material into the brain, but sometimes by other means, for example, orally; (e) transmission can occur whether the material comes from a sporadic case, from a familial case, or from one that was itself the result of transmission; (f) infection with a TSE does not generate antibodies in the host; and (g) the infectious agent is impervious to treatment that would kill all known bacteria and viruses. Before the prion theory was put forward these facts could not be accounted for. That a disease could arise spontaneously and yet be transmissible was only one seeming incongruity. The essence of the prion8 theory put forward by Prusiner in 19829 is that the transmissible agent in TSEs is radically different from other infectious particles and probably consists wholly of protein. This was a highly radical suggestion in terms of existing biological theories, and it was by no means generally accepted at the time. Since 1982 the theory has been developed further and we do not have time to follow every twist. It is important to remember, however, that until the 1990s most scientists regarded the prion theory with deep suspicion. Though it was ingenious the evidence to support it was flimsy. The state of knowledge when BSE emerged in 1986 was as set out above. As will become apparent from the account which follows of the prion theory as it has been developed over the last twenty years, it now explains quite well many of the features of TSEs, which is why most workers regard it as the best theory yet advanced. This is not to say that further discoveries may not require it to be modified or even rejected. That is the ultimate fate of all scientific theories.

The current theory A simplified version of the current theory goes like this, again using humans and CJD for purposes of illustration. One of the tens of thousands of human genes is found on chromosome 2010 and is called the PrP gene. Its function is unknown though it is presumably significant since very similar genes are found in a large number of animals. Like other genes it brings about the production11 of a protein in this case called PrP. This is found in normal healthy humans. Like most proteins it can be destroyed fairly easily by chemical action.12 As is the case for other proteins it is believed PrP is constantly being made and destroyed in healthy people. Normal PrP is also found in those suffering from CJD. However, in the latter cases a different version of the same protein13 is also found especially in the brains of sufferers, which is much more sinister. This sinister version is virtually impossible to destroy by methods which normally destroy proteins. The reason is that the sinister version (known as PrPSc14) has a different geometrical shape15 which serves to protect it from agents which destroy most proteins including normal PrP (known as PrPC).

Science and Research 21

The theory is that very occasionally for some unknown reason PrPC converts itself into PrPSc. Unlike PrPC the body cannot destroy PrPSc once it is made. Moreover, by some unknown mechanism PrPSc can catalyse (help) the transformation of PrPC into PrPSc. Thus once PrPSc is present in a person the amount of it steadily increases. CJD sufferers have large amounts of PrPSc in their brains. The accumulation of PrPSc in a brain is eventually incompatible with its normal functioning; the person concerned has contracted CJD. In recent years it has become possible to unravel the detailed composition of the genes of any given individual. Where CJD runs in families those affected are found to have an abnormality (mutation) in one of their PrP genes. Presumably the mutation makes the production of PrPSc more likely. Several such mutations have now been detected and each has a characteristic incubation period before those possessing it succumb to CJD. No known environmental action can prevent the person concerned from developing CJD. The detailed conformation of the PrP gene has other important effects. I will give one of many possible examples. At one place16 on the human PrP gene there are two alternative versions17 that can be present. Since everyone has two copies of the PrP gene inherited from their father and mother respectively, there are three different possible presentations for any person. They can have the same copy of either of the versions or one of each version – as it were two heads, two tails or a head and a tail. Yet of more than a hundred persons who have so far succumbed to vCJD believed to result from exposure to BSE all have the same presentation. Since this presentation is shared by only 38 per cent of the UK population this is not chance. Whether the other 62 per cent of the population are not susceptible to vCJD or might contract it later after a longer incubation period is one of the important unknowns. The future Significant discoveries about TSEs continue to be made at a rapid pace. Scientifically the area is a ‘sexy’ one; it has already resulted in two Nobel Prizes and, having met some of the main workers in the field, I am confident that there exists in some quarters a strong determination to increase the number. Areas where major discoveries may be made include the development of reliable early tests for the disease in animals and man and of a treatment for CJD in man. Another might involve the relationship between TSEs and other brain diseases. Notes 1 Initially this time lag led to the connection between the two events being doubted. As we shall see, lengthy incubation periods are typical of the diseases we are considering. 2 In the early 1960s mice were shown to be susceptible to scrapie if so injected, but only after an incubation period of several months, that is a significant time in relation to the life-cycle of mice. 3 As would be expected the mice would be killed and examined if they appeared to show signs of infection, but left if they appeared healthy. Eventually if none of the mice injected with some particular tissue appeared unhealthy and if after a long time (for such experiments) their brains appeared normal then it was concluded that the organ from which the tissue had been prepared did not contain infectivity in sheep. Such experiments are very laborious and tedious and need the best care and method if error is to be avoided.

22

The Politics of BSE

4 The ‘Fore’ people. 5 In fact workers on kuru had already tried some transmission experiments but these had been discontinued when the animals did not succumb after a few weeks, apparently demonstrating that a virus was not responsible. 6 The possibility of non-oral transmission at the feasts cannot be discounted. For example, infective material might have entered the bodies of those participating via sores or cuts on the skin. 7 I take this from Ridley and Baker, p. 36. Their book, Fatal Protein, Oxford University Press, 1998, is the best source for those who wish to know more of the science of TSEs than there is space to include here. 8 Derived from proteinaceous infectious particle. Why ‘prion’ rather than ‘proin’ is just one of life’s mysteries. 9 For which he, too, received the Nobel Prize. 10 Setting aside the sex chromosomes every individual has two copies of each chromosome, one from their mother and one from their father. Hence they have two versions of each gene which may or may not be identical. 11 I say ‘brings about’ because the precise process of protein production is a complicated one. It is true, however, that each gene causes a specific protein to be produced. 12 In the case of living entities such chemicals are called ‘enzymes’. 13 By the ‘same’ I mean that both versions of the protein have the same chemical formula. 14 The ‘Sc’ stands for ‘scrapie’. 15 It is common for there to be compounds which share a chemical formula but have different geometrical shapes and different properties. Different versions of sugars with the same formula have vastly different sweetnesses. 16 Known as ‘codon 129’. 17 Producing methionine or valine in the PrP molecule.

3 Slaughterhouses

Public attitudes Most people think about slaughterhouses as little as possible. Though only a very small percentage of us are vegetarians there is something about the organized killing of large animals which causes us to recoil.1 A consequence of this state of mind is that few, if any, deliberately seek to visit a slaughterhouse to see what goes on. In some ways this is a pity since standards would undoubtedly be helped by a measure of public scrutiny. Another is that more sensitive souls do not, by and large, work in slaughterhouses. There is plenty of evidence suggesting that the attitude towards authority among slaughterhouse workers is often what might be called robust. In one UK pig slaughterhouse until recently visits by senior management used to be greeted by a synchronized banging of (very sharp) knives on tables. Management there did not interfere with the line unnecessarily. This does not suggest an atmosphere where it is easy to enforce 100 per cent compliance with detailed rules. Unfortunately some discussion of slaughterhouse activities and standards is necessary for a proper understanding of the BSE saga. This is partly because the low standards in many undertakings and unsatisfactory enforcement of the rules by local authorities were two of the most significant difficulties the government faced in controlling the BSE epidemic. When the enforcement problem was solved in 1995 by the establishment of a new national body, the Meat Hygiene Service, it was possible greatly to improve the protection of the public.

The state of the UK slaughterhouse sector in the 1980s/early 1990s Towards the end of the 1980s the UK slaughterhouse sector faced a wide range of practical and political problems. They included: (a) low profitability hence a lack of funds for investment; (b) low standards of hygiene; 23

24

The Politics of BSE

(c) a confused system of control, MAFF had responsibility for licensing some (and by the early 1990s all) slaughterhouses and setting the rules while local authorities were responsible for enforcing them; (d) poor enforcement by many local authorities; (e) differing standards, those applying in plants licensed to export outside the UK were required to be higher than in others; (f) a requirement that all slaughterhouses should over time be upgraded to the standards of those licensed for export for which upgrade the operators concerned often had neither the necessary funds nor will; (g) resentment by Environmental Health Officers (EHOs) and Meat Inspectors and their unions that following the requirements of EU law some of the functions they had traditionally exercised in slaughterhouses in the UK had been taken over by qualified vets and this process was planned to go further; and (h) political and media opposition to attempts to improve standards which were characterized as either unnecessary in technical terms being really based on the wish of ‘bureaucrats’ to enhance their powers, and/or unreasonable impositions by EU fiat. The ‘excessive’ requirements of EU law on meat hygiene constituted a stick constantly wielded by eurosceptics in their battles with government. Thus the eurosceptic case depended on EU law in this area being ‘excessive’ and, unsurprisingly, they found little difficulty in persuading themselves this was in fact the case despite the expert view being solidly to the contrary. Let us consider these points more fully. The slaughterhouse sector in the UK, especially in England, was surprisingly undeveloped. Most plants were small with a poor structural layout which both made it difficult to sustain high standards of hygiene and to achieve economies of scale. Though there were exceptions in economic terms the sector was something like grocery before the advent of supermarkets. There was also excess capacity. For all these reasons profitability was low. On hygiene there are two related but different considerations. There is first the physical structure of a plant. This relates to such matters as the amount of space available and the materials used. To give one example, slaughtered cattle have to be hung up by a hind leg for organs to be removed. If the height of the hooks from which the carcass is suspended is insufficient it will touch the floor and inevitably become contaminated. Plants showing such deficiencies were required to invest in new overhead lines. Licensing of plants by MAFF was based on their having satisfactory structures. Plants licensed for export had to meet EU requirements in full, while lower standards, sometimes much lower, were initially accepted for other plants. It was known, however, that all plants would have to meet the higher standards eventually. Low profitability meant that many plants were unlikely to be able to find the necessary funds for the necessary investment. Second, ‘hygiene standards’ can also refer to the way in which cattle are processed from live animal to meat – for example whether the utensils used are cleaned properly. Obviously it is easier to act hygienically if the plant structure is a good one but this is not guaranteed. As to low standards of hygiene (in both

Slaughterhouses 25

senses) being widespread there is abundant evidence. In 1985 an official report, the Preston Report, referred to: problems include slack methods of dressing carcasses, careless spraying of carcasses with water, infrequent sterilisation of knives and washing of hands, and inadequate cleaning of the slaughter hall and equipment. In 1990 another MAFF report referred to: stomachs frequently dropped on floor during evisceration… external doors left open (entry of flies, etc.)… trays of meat in contact with floor… no cleaning or sterilising of knives, no washing of hands or aprons, faecal contamination of carcasses. Nevertheless, all the political pressure was to the effect that slaughterhouse operators were being subjected to unreasonable demands. Thus Nicholas Soames, then Parliamentary Secretary at MAFF, received a very hostile reception from his own backbenchers in a Parliamentary adjournment debate in October 1992. This was no doubt why later in the month the Minister, John Gummer, quoted to the House of Commons Agriculture Committee some of the official reports he had recently seen: Slaughter hall floor heavily soiled with blood, gut contents… cleaning brush heavily contaminated with blood and fat being used to wash carcasses… missing window pane in roof – birds, flies entering… effluent discharging across floor under dressed carcasses. And so on. All qualified observers seem to have agreed that standards in many plants were well below acceptable levels. These qualified observers included the European Commission. However, it was not an EU plot; all qualified UK observers held the same view. The only exception lay in the UK body politic most members of which believed, against all the evidence, that UK standards were sufficiently high and that other member states did not apply the rules. MAFF Ministers were constantly pressed by their Parliamentary colleagues to adopt a lenient approach to the rules. Often the belief behind this request, stated or unstated, was that the rules were unnecessarily onerous and bureaucratic. The existence of low hygiene standards was partly a function of poor plant structure but also of unacceptable attitudes among plant management and poor enforcement by local authorities. That local authorities varied widely in their approach to enforcement had been realized since at least the Preston Report. Some were good. Others gave little attention to the matter. In some cases inspectors appear to have become far too close to those they were meant to be inspecting. In others there appears to have been outright intimidation. All this was bad enough, but matters were made worse by the resentment among EHOs and meat inspectors at what they perceived as the reduction in their status implied by EU rules. Outside the UK responsibility for the enforcement of

26

The Politics of BSE

slaughterhouse rules had always been allocated to those who had undergone a veterinary training. EU regulations had been drawn up on that basis. Where EU single market rules were applied in full EHOs/meat inspectors could only work under the supervision of a vet. That was already the position in export plants by the early 1990s and would have to be the case in all plants eventually. It was argued by some that the vets who enforced the rules in slaughterhouses elsewhere in the EU were not of the same calibre as UK vets and that EHOs/meat inspectors were their real equivalents. There appeared to be something in this in that a sizeable proportion of foreign vets did not seem to be the types who would have gained the equivalent of three or four ‘A’ grades at ‘A’-level as virtually all UK vets qualifying in recent decades had done. However, years earlier the UK had sought to argue in Brussels that EHOs/meat inspectors should be accepted as meeting the requirements of inspectors for the purposes of meat hygiene legislation. By the late 1980s this argument had effectively been lost. Many slaughterhouses, especially small ones, needed to invest to be able to meet EU structural standards. Those trading on very low margins – a substantial proportion – found this difficult. Though a period of grace was usually granted to make the necessary changes it was known that eventually those not meeting the requirements would not be licensed and hence would be forced to close. Operators placed in this position tended to criticize the EU rules, the immediate, obvious cause of their difficulties. The need to comply with EU rules may sometimes have been the final straw forcing the closure of some slaughterhouses but the problems of the sector went far deeper. They were overcapacity, chronic low profitability and lack of investment. But it was the ‘unreasonable’ requirements of EU law that got publicity, even though in my experience the private opinion of most UK experts was that something very like the EU rules should have been adopted by the UK long since. Within government the drive to improve standards of meat hygiene appeared to run directly counter to the political current which from 1992 was given focus in the deregulation initiative. Almost all representations MAFF received on the subject argued either for less onerous rules and/or more ‘sympathetic’ enforcement. The general premise was clear. The move towards higher standards was unnecessary and reflected undesirable interference by the EU and the influence of over-regulatory civil servants in MAFF. This attitude went right to the top. The Prime Minister, John Major wrote to the Minister (Gummer) on 30 November 1992: The regulatory burden we are imposing on business frustrates enterprise, innovation and growth. Regulations result in lost jobs, reduced international competitiveness and higher public expenditure. We must change all this. In case Gummer had not got the message he went on: We… need to look at the new rules on meat hygiene which have caused alarm to local business, including butchers and village shops selling meat. Do we go too far in bowing to EC pressure on such things?

Slaughterhouses 27

In other words, those at the top of government believed the propaganda against their own administration’s policies. That was the background against which MAFF were trying to drive up standards so that the public could be better protected and the UK could meet its EU obligations.

The decision to establish a national meat hygiene service A precipitating factor in the decision by MAFF to try once and for all to break out of the ghastly state of affairs described above was the imminent advent of the European Single Market. This required the abolition of veterinary checks on exports from one member state to another. Accordingly all members had to have confidence in the standards operated elsewhere. In a single market any product can end up anywhere so in practice all plants had to be brought up to an acceptable level. Also, member states were required to exercise control over slaughterhouse standards and the system operated in the UK did not really provide for this. The EU Commission considered that both the standards in many UK slaughterhouses and the UK enforcement system itself were not compatible with EU rules. MAFF was therefore faced with an industry with low standards, poor and inconsistent enforcement by local authorities and the imminent coming into force of rules (those of the Single Market) which the current system would not be able to deliver properly. Infraction proceedings in the European Court were inevitable eventually unless there were a change of direction. One likely consequence would be a finding that the UK was in breach of its obligations which could well have serious implications for UK meat exports worth many hundreds of millions of pounds annually. After considering a report on the possibilities for the future commissioned by MAFF and DoH, John Gummer decided to take the plunge. On 18 July 1991 he wrote to the DoH Secretary of State (William Waldegrave) advocating a new national, dedicated, enforcement service for meat hygiene to replace the local authority system. This was, he suggested, the only way to improve standards, ensure consistent enforcement and meet the UK’s obligations under the Single Market. Waldegrave replied two months later that he was ‘content’. In other words, DoH would not oppose the concept but would not help much if it ran into opposition. That was exactly what happened. Gummer put his proposal to the Prime Minister on 4 November 1991. John Major asked for the views of the Treasury which were negative as, one suspects, Major, who had recently been Chief Secretary and Chancellor, had known would be the case. It is also pertinent that while financial considerations are relevant to all policies, the Treasury would have had no expertise in the factors Gummer had cited as justifications for his proposal – low slaughterhouse standards, inconsistent enforcement and the failure of the existing system to meet the UK’s obligations under the EU Single Market and meat-hygiene legislation. On the last criterion the Cabinet Office’s European Secretariat, the obvious persons from whom to seek a second opinion, would no doubt have confirmed MAFF’s assessment. But they were not asked.

28

The Politics of BSE

After the inevitable inter-departmental wrangling, Major asked the Machinery of Government Division in the Cabinet Office to take matters forward. One does not need to be a conspiracy theorist to detect another attempt to stifle the idea. However, Gummer’s persistence in matters he regards as important is often underestimated. In this case his support for the proposal will have been reinforced by the fact that it would help the UK to meet EU obligations. Eventually Major agreed and Gummer announced the intention to create the new body on 9 March 1992. Only the veterinary profession expressed itself in favour. Opposition from EHOs and local authorities was only to be expected, but opposition was widespread including among the government’s own supporters in the House of Commons. The creation of a new centralized enforcement body simply did not fit the political mood of the day especially in the Conservative Party. The hostile debates in Parliament referred to above took place just after the announcement on the MHS. Given the hostility towards the embryo MHS among MPs it was not surprising that when Gillian Shephard replaced Gummer in May 1993 she immediately decided to review the decision to create it. Fortunately she approached this, despite the political pressures, by putting an assessment of the public interest at the forefront of her considerations. She read accounts of the appalling standards achieved in some plants, came to the view that local authorities were unwilling or unable to do anything about it, and took on board the UK’s obligations under the Single Market. As a consequence she accepted the official advice to maintain Gummer’s policy. I was relieved. While a national service was proving very difficult to get off the ground I knew that if we did nothing matters would eventually get even worse.

The putting in place of the MHS Nevertheless political opposition to the new body continued right up to its creation. At Cabinet level John Redwood, who had been appointed Secretary of State for Wales in 1993, expressed complete opposition despite the Prime Minister’s decision made only a few months before. This was serious since certain of the provisions needed to establish the MHS needed to be included in a Parliamentary Bill coming forward (ironically enough called the Deregulation Bill) and Redwood’s agreement or at least acquiescence was needed for this. I advised Mrs Shephard not to give an inch, judging that Redwood would not be satisfied with anything which would leave in place a service capable of achieving the improvements we needed. When Redwood proved obdurate I suggested we should in effect ignore him and agree the necessary modalities with the Treasury. After all it was we, MAFF, who were trying to take forward agreed government policy. However, the Chief Secretary, Michael Portillo, also raised objections similar to Redwood’s. We were obviously facing a eurosceptic phalanx in the cabinet itself. I reluctantly concluded that I would have to recommend to Mrs Shephard that she should appeal to the Prime Minister to clear the logjam which I had held back from doing earlier judging him (Major) to be of doubtful reliability on this

Slaughterhouses 29

subject. Before I did so, however, Ian Lang, the Secretary of State for Scotland intervened in our support, one of the few occasions a helpful intervention came from that quarter. Redwood and Portillo backed down. These exchanges had wasted months during which it had not been possible to take the MHS project forward. Clearly it would not have been prudent to commit substantial sums of public money to a project which was opposed in the Cabinet itself. At much the same time we had to cope with a ‘deregulation scrutiny’ of meat hygiene suggested by the Cabinet Office. These scrutinies were conducted by individual officials for a special section of the Cabinet Office (for which they formally worked for the period in question) to see whether red tape could be reduced in the area in question. At the time they had a high political profile. It was clear that many expected major changes to be recommended in a meat-hygiene scrutiny, which would probably include not going ahead with a National Service. Most probably that was the main reason for having one. However, I was able to put forward a MAFF candidate for the task of ‘scrutineer’ who could be relied upon both to impress at interview and to take an objective view. Even so I was a little surprised when she was given the job. Probably she was so much better than the other candidates no way could be found to avoid appointing her. In due course the Scrutiny Report made a number of recommendations but, crucially, agreed a National Service was needed. At last we could get ahead. The vital need in setting up a new organization is to find a good Chief Executive. Unfortunately the Treasury, typically for the period, insisted on a salary for the MHS Chief Executive which seemed low. The Selection Panel, which included me, could only find an adequate candidate and recommended a serving civil servant as the best available. Mrs Shephard, sensibly, refused to accept anyone other than a candidate who appeared truly outstanding. So we advertised again at a higher salary and this time found someone we could enthusiastically recommend. Shortly after I put forward the recommendation to Ministers I bumped into Nicholas Soames, the MAFF junior Minister with responsibility for meat hygiene. The conversation went like this: NS: RP: NS: RP:

‘Hear you’ve put forward a new man for Chief Executive of the MHS’. ‘Yes, name of Johnston McNeil’. ‘Excellent name. Sounds just the sort of tough type we need. A Scot?’ ‘Comes from Northern Ireland in fact; but you’re right about the impression he gives’. NS: ‘Capital’. Neither Mrs Shephard nor Soames asked me any further questions about the recommendation and McNeil was duly appointed. Soames’s intuition was pithily put but proved sound. Shrinking violets would not have succeeded in welding together the disparate groups which formed the MHS, some with inadequate approaches to their work, into the successful organization the MHS became.

30

The Politics of BSE

However, even though we had appointed a Chief Executive designate we were not there yet. Commercial and political opposition to the new body remained strong and a ‘payment strike’ was threatened by one group of small slaughterhouses who opposed in particular the imposition of veterinary supervision. The clamour was such that when William Waldegrave succeeded Mrs Shephard as Minister in July 1994 he, too, queried the decision to set up the new body. Ministers were uncomfortably aware that indignation at the ‘excessive’ requirements being placed on slaughterhouses was widespread among people they would usually count as their friends and not unnaturally wanted to investigate whether there was any way out of an awkward situation. However, Waldegrave, like Mrs Shephard, eventually concluded that the reasons for going ahead were stronger than those favouring delay. He, too, put the public interest before political expediency. The establishment of the MHS was beneficial in many ways. In particular, as the BSE Inquiry later concluded, it allowed the enforcement of the BSE controls to be greatly improved. The Inquiry’s Report states: The establishment of the MHS had a beneficial impact on the implementation of both the human and animal SBO ban. It is unfortunate that this was so long delayed. (Vol. 1 para 690) [The CVO] was correct to stress the structural problems prior to 1995 of enforcing Regulations in slaughterhouses. The MHS was not introduced as a response to the problems of BSE. Its introduction was, nevertheless, of the greatest significance in addressing the dangers that BSE posed to the human and animal food chains. (Vol. 1 para 484) On the last point I would only comment that driving up standards in slaughterhouses was always one of the principal reasons put forward for a national service. While the problems of BSE were admittedly not explicitly quoted as a justification for the MHS, an improvement in the enforcement of the rules in slaughterhouses was exactly the sort of result anticipated by those who supported the MHS.

Assessing the reasons for support for and opposition to the MHS I have mentioned the opposition of some well-known figures to the MHS, but this was merely the tip of a large iceberg. Negative representations were made by numerous Conservative members of Parliament. The Opposition, who claimed to be more sensitive to issues of food safety than the government, gave no support. Many others, especially those opposed to the EU, chipped in – all negatively. Local authorities and the representatives of EHOs and meat inspectors – vested interests which as events showed were incapable of administering an effective system – claimed a new body was unnecessary. ‘Deregulation’ and ‘excessive bureaucracy’ were cited as justifications for opposing the MHS by people who gave little sign of having thought about the iniquities of those phenomena in other fields. The DoH

Slaughterhouses 31

gave no support. Consumer associations were too busy launching campaigns that would gain them publicity to support a proposal that might be of immediate practical advantage to consumers. For their part the media were fully aboard the fashionable bandwagon. There were plenty of articles about the plight of small slaughterhouses put in difficulty by bureaucracy and the EU. I have not found one from the relevant period that examined the opposite proposition – that the fundamental problem lay in low UK standards and poor UK enforcement; and that a national enforcement service might be a way of dealing with this. Those who opposed the creation of the MHS might well have succeeded in causing the government to abandon the project at least for a period. As it was they delayed the establishment of the organization. As a result the severity of the BSE epidemic was heightened and its duration lengthened. Were those who opposed the MHS culpable? The answer, I suggest, is both ‘no’ and ‘yes’. To take the ‘no’ elements first, there is every reason to question departmental proposals especially if they involve the establishment of a new bureaucracy. Likewise EU legislation ought to be examined and, if appropriate, challenged. Valid questions include does the legislation actually require the action government claims it does and are the requirements justified? In some cases it would be reasonable to suggest government ought to propose in Brussels that the legislation should be changed, though one must be realistic as to whether such an objective has some chance of success. But those operating in the political world also have a responsibility to examine a case made especially if the matter is one of public safety. MAFF presented plenty of evidence that over a prolonged period the local authority system had not delivered satisfactory hygiene standards in slaughterhouses. They had pointed out that if matters were left to drift substantial and valuable UK meat exports would eventually be compromised. Most of those who opposed the creation of the MHS did not seriously address these questions because they did not wish to do so. In some cases this was because it was inconvenient for their political position if the facts were as MAFF claimed so they simply assumed that the MAFF claims were unjustified without seeking any evidence to support that conclusion. They simply asserted their position comforted by the fact that others were asserting the same thing. Those who opposed the creation of the MHS without properly addressing the evidence that MAFF had put forward that such a body was necessary to protect the public and without having an alternative proposal to meet this objective were in my view culpable. What about those who supported the establishment of the new body? John Gummer originally put the proposal forward though he must have known that it would be unpopular with his colleagues and more widely. He sustained that line even though the Prime Minister made it clear he was unenthusiastic and despite Treasury and much other political opposition. Gillian Shephard could have quietly reversed the policy when she became Minister knowing that this would have obtained her immediate plaudits from a wide range of commentators. William Waldegrave could have done the same. MAFF officials could have proposed a reversal of tack, let it be quietly known to the Treasury and Cabinet Office that

32

The Politics of BSE

they had done so and reap career benefits since they would be deemed to have shown ‘judgement’. All the above continued to support the establishment of the MHS because they believed it was the correct course of action given the established facts. They were right. A little praise seems in order. Note 1 Interestingly we do not have the same aversion to the killing of rats and mice even though they are by most biological measures at least as advanced creatures as, say, cattle or horses, and therefore presumably as deserving of our sympathy. The truth is our response is instinctive and not wholly rational.

4 A Chronicle of Events until 20 March 1996

A summary of the chronology of events precedes the Introduction to the book.

The period up to early 1988 The beginning The grim saga began, later analysis suggests, possibly in south-west England in the 1970s or, conceivably, even earlier. We know this because we now know that the incubation period for BSE in cattle averages just under five years and the first case later identified as BSE was seen (or more accurately its brain was examined) by veterinary pathologists at MAFF’s Central Veterinary Laboratory (CVL) in 1985. This cow had shown the symptoms, notably excitability and loss of control of limb movement, now recognized as indicative of BSE. Examination of the brain of this animal showed a condition which was compatible not only with an SE but also with other possible diagnoses and its significance was not immediately appreciated. The diagnosis of BSE was made later when tissues were reexamined after the existence of the new disease had become accepted. Similarly when the written records were examined cases were found of animals – dairy cows – which had gone down before 1985 often on the same farms as animals which were later diagnosed as having BSE with symptoms which, with the benefit of hindsight, looked suspiciously similar. A very few further cases were sent to CVL towards the end of 1986. On examination by the pathologists the brains showed characteristics similar to but not identical to scrapie in sheep. On 19 December 1986 the Head of the Pathology Section sent the Laboratory Director a note commenting on the brains of the animals examined: … the lesions observed have similarities to spongiform encephalopathies of other species and in particular scrapie of sheep. In the same note the author mentioned two major concerns if indeed this turned out to be ‘bovine scrapie’, namely the implications for the export trade and possibly human health. 33

34

The Politics of BSE

Though its relevance was not appreciated until later, it is significant that in the summer of 1986 CVL had diagnosed a spongiform encephalopathy in the brain of a nyala (a bovine species) which had become sick at a small English zoo. This was the first known example of an SE in a bovine species. Over the next few months it became clear that the 1986 cases were not isolated. Gradually more cases came to light in herds in southern England. Initially the records were not kept as systematically as they were later but the BSE Inquiry went into the evidence comprehensively and concluded that by the end of January 1987 four cases had been confirmed by brain examination in two herds. By the end of May there were six confirmed cases and 13 suspects (that is cases awaiting brain examination) in four herds. By the end of June there were nine confirmed cases in seven herds. By early 1987 the Chief Veterinary Officer (CVO) and the equivalent administrator had been informed of the position. It is necessary now, over fifteen years later when over a hundred people have died and nearly two hundred thousand animals have been slaughtered at a cost of billions of pounds as a consequence of BSE to remind ourselves that there was absolutely no reason why any of this could have been appreciated in the early days. New animal diseases emerge quite regularly without their having such dramatic effects. Nevertheless as the existence of the disease became firmly established in the first half of 1987 two questions naturally arose; first, who should be informed and when, and second what measures to take in response (if any). Examining events fifteen years later the BSE Inquiry concluded some things ought to have moved faster. This may be right but it is worth remembering that the expectation that the public will be informed rapidly of just about everything has developed enormously over recent decades. I invite anyone who doubts that proposition to study the history of nuclear power in the early postwar period. Even fifteen or twenty years ago the ‘principle of freedom of information’ which the Inquiry rightly regards as a present standard was less fully accepted than it is now. It is also necessary to have in mind the position of the scientists involved in what appears to be a new discovery when it is made. They have two main preoccupations which might be summarized as, first, the desire not to look foolish which, experience shows, can happen if announcements are made before all angles are thoroughly checked, and, second, the desire to take a proper share of the credit. These are very important matters for someone who makes a career as a scientist. A mistake on a serious matter will significantly lower their reputation while the opportunity to make a name in the (scientific) history books may only come once. These considerations lead to the wish to keep matters private until results are published or at least until a paper has been submitted to a relevant journal (though many journals take a dim view if the results they expect to publish are publicly revealed beforehand). There are two further considerations, which will always be present in the mind of anyone with policy responsibilities when a significant new development occurs. The first is that it is desirable to be able to answer at the time of the announcement the questions to which it is likely to give rise. While the reply ‘don’t know yet’ may

A Chronicle of Events until 20 March 1996 35

be perfectly reasonable objectively it is unlikely to attract favourable comment. The second is that if some new ‘fact’ turns out subsequently to be wrong any adverse consequences of premature announcement (for example a decision by a foreign government to ban imports of something as a response) will be blamed on those responsible for the announcement. Those who are eager to criticize any delay in announcing something will not be standing up if things go wrong to explain that the odd error is a price worth paying for complete transparency. A specific factor which the written record suggests influenced the senior vets (the CVO and the Director of the CVL) when BSE emerged was the possibility that an announcement that ‘bovine scrapie’ had been discovered in the UK would lead to restrictions on UK exports of cattle and (less probably) beef. This was a perfectly reasonable concern that could justify hesitating over making an announcement for as long as there was any real likelihood that comparing the new disease to scrapie might prove misleading. The BSE Inquiry went into this in great detail and find that the CVO and Director of the CVL unjustifiably operated a policy of restricting information flows within the SVS, to others in the veterinary profession, to other research groups and more widely for a period of some six months at the beginning of 1987. When information was released it was to limited groups only and subject to a requirement that direct comparison with scrapie be not made. While the Inquiry accord less weight to the reasons for limiting information flows set out above than some might regard as reasonable the delay in giving the full facts, including the pathologists’ views on the resemblance to scrapie, went on for far too long. I found the decisions to restrict information flow in the first half of 1987 surprising in one respect. This is that the CVO did not inform Ministers or the Permanent Secretary about the new disease. Even at the time the keeping of information within a very small circle was controversial within the SVS and the natural course for a civil servant in such circumstances is to seek cover. If Ministers or the Permanent Secretary had been informed about BSE in early 1987 the responsibility for disseminating information would have been passed upwards. The criticism eventually made of the CVO by the Inquiry would not have been possible. All this shows that vets, perhaps like other professionals, do not think like civil servants and are reluctant to involve others in decisions they regard as falling within their remit even when formally those others stand higher in the hierarchy. The principal British journal for veterinary matters which can be expected to reach the great bulk of the profession in the UK and a significant proportion abroad is the Veterinary Record. The first communication was published there by SVS staff on 11 July 1987. This referred to a ‘previously unreported slowly progressive neurological disorder of adult cattle… in England’. However the original draft which had referred to an encephalopathy was amended; the published version stated that the nature of the disorder was ‘undetermined’. Ministers and the Permanent Secretary were informed of the disease on 5 June 1987 when a submission was sent to the Parliamentary Secretary (Mr Donald Thompson) though it did not reach him until 15 June after the General Election. Other Ministers were informed by a paper sent forward on 7 July. Eventually an

36

The Politics of BSE

article giving a full description of the disease noting its similarity to scrapie was submitted to the Record on 17 August and published on 31 October 1987. After August lapses in communication about BSE were in the main unintentional though as we shall see there was a problem with informing DoH. Hence by summer 1987 the existence of a new disease in cattle apparently very similar to scrapie in sheep had been established. The disease was probably a TSE though it was not formally (and still provisionally) classified as such until January 1988 when fibrils characteristic of some TSEs were identified in the brains of infected animals. This diagnosis was strengthened in September 1988 when transmission (as in the ‘T’ of ‘TSE’) of BSE to mice was achieved at the NPU by injecting infected tissue from cattle brains into mice brains. The Director of CVL asked the Head of Epidemiology, John Wilesmith, to investigate the origin of this scrapie-like disease. The need was to identify some common factor which could explain the outbreak. Possible explanations included contaminated vaccines, the newish and widespread use of organophosphates, and genetic factors. However, by the end of 1987 attention was focusing on contaminated feed since commercial concentrates had been fed to all the known cases. Meat and bone meal (MBM) appeared the most likely culprit even though it was known this had been incorporated in animal feed for a long time before BSE had appeared. Wilesmith identified a number of changes that had occurred in the material being sent for rendering and in the rendering process itself in the late 1970s and early 1980s. The size of the UK sheep flock had increased and the incidence of scrapie might also have increased; changes in rendering processes, for example the reduction in the use of solvents, might also be significant. While no one factor seemed the key cumulatively they could perhaps have been sufficient to cause some animals to become infected. In any event the theory that infection was caused by MBM was strengthened when at the same zoo that a nyala had succumbed to a TSE in 1986 a gemsbok also succumbed in June 1987 and it was found that MBM from south-west England was included in the antelope feed used there. On 26 February 1988 Wilesmith concluded that the evidence strongly suggested that the epidemic was caused by ‘the introduction of an infectious agent via commercial cattle feedstuffs’.1 By then there had been articles in a number of papers about the new disease. For example on 29 December 1987 an article in The Times referred to a new ‘mystery disease’ and speculated whether it might be ‘transferable to humans’.

1988: first policy responses Consideration of a slaughter/compensation scheme and of a ruminant feed ban Now that it was beginning to seem that MBM that had somehow become infectious had been the immediate cause of the epidemic it was possible to consider possible policy responses.

A Chronicle of Events until 20 March 1996 37

At this point it is necessary to stress one factor common to all TSEs, namely their lengthy incubation periods. In 1988 this period was not known for BSE but by analogy with other TSEs was expected to be a matter of years. This is important because, in the absence of a reliable test for infected live individuals (still the case for BSE), the success or otherwise of policies adopted to eliminate the disease will not become apparent for a period at least as long as the incubation period. Only after this time will the absence of newly infected individuals constitute evidence for the success of the policy. Of course the partial failure of a policy may become apparent earlier as animals succumb after a period less than the average incubation period. But the extent of success or failure can only be judged when the proportion of animals succumbing has been established – that is after more than the average incubation period has passed. In diseases with long incubation periods, like BSE, this puts a premium on getting the policy detail right first time round. By early January 1988 officials had concluded two policy responses were needed. These were first that the disease should be made ‘notifiable’, that is that it be made a legal requirement to report suspected cases to the authorities (MAFF) and second that a slaughter and compensation scheme be established. The slaughter of infected animals was a common method of coping with animal health problems (such as foot and mouth disease) while it would also provide a degree of protection in case the disease had implications for human health. A research project had been set up designed to test whether BSE was transmissible to marmosets, which would give evidence (though not proof) on whether BSE posed a danger to humans, but because of the likely incubation period results were not expected quickly. In line with expectations at this period thought was given to whether the costs of a slaughter scheme should be recovered from the industry for which there were contemporary precedents. However, officials decided that this would not be appropriate since a major justification for the proposed scheme was the protection of the public. In putting forward a submission on 24 February 1988 recommending that a publicly funded slaughter and compensation scheme be established, the Permanent Secretary, Sir Michael Franklin, advised the Minister that he did not see how this could be avoided unless the CMO agreed that such a scheme was not necessary to protect public health. On 29 February the Minister, John MacGregor, gave his initial views. MacGregor was unenthusiastic about the recommendation for publicly funded compensation worrying about possible implications for the campaign to eradicate rhizomania, a disease of sugar beet and hence of interest to farmers in his Norfolk constituency, for which no compensation was provided. At this stage he appears not to have focused on the potential risk to public health from BSE mentioned in the submission. Humans were known to be susceptible to TSEs, while in contrast it could be stated with confidence that rhizomania posed no threat to humans. MacGregor did agree that Franklin should consult the CMO as proposed. However, before learning of MacGregor’s views he (Franklin) had anticipated writing on the basis that MAFF intended to introduce a slaughter and compensation scheme unless the CMO advised this was not necessary to protect the public. In the light of MacGregor’s attitude he could not do so. Instead he wrote on 3 March

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The Politics of BSE

in more general terms asking the CMO’s view on ‘the possible human health implications’. The CMO had apparently not previously taken on board the existence of BSE, though there had been by this date a fair amount of comment in the newspapers. At that time DoH had no veterinary expertise so the articles in the Veterinary Record would probably have passed them by. Some relatively informal and low-level contacts with MAFF on BSE had taken place, the significance of which had been exaggerated in the papers that had gone forward within MAFF. As a consequence MAFF administrators appear to have assumed DoH were in the picture to a greater extent than was the case. Years later the BSE Inquiry got rather onto their high horse about MAFF’s ‘failure’ for some nine months from mid-1987 formally to alert DoH to the potential risk to human health from BSE. This is unjustified. It would not have been apparent to those concerned how DoH as a Department would be affected – what could they do? – nor how they could help given the limited information available. Subsequent developments show such an attitude was a reasonable one save in one respect. Informing DoH somewhat earlier would have helped in giving the CMO rather more time to think about the matter. Even so given the existence of human TSEs the CMO should probably when he received MAFF’s letter of 3 March have replied that sick animals ought be kept out of the human food chain. That is clearly the view of the Inquiry though they stop short of criticizing the CMO for not doing so. The Southwood Committee, established in response to the CMO’s recommendation, is discussed in more detail below. It quickly recommended that to protect the public the carcasses of infected animals should be destroyed as MAFF had proposed and Southwood wrote to Franklin on 21 June 1988 to this effect. In the meantime MacGregor continued to express doubts about publicly funded compensation. This had one useful result in that the possibility of industry funding of a compensation scheme was examined. The beef industry was resolutely opposed. Had this not been done the Treasury would probably have insisted it be examined later when their authority to proceed with a scheme was sought. In the light of the Southwood Committee’s recommendation MAFF officials advised, correctly, that the negotiating position had changed. Government had to implement a slaughter/compensation scheme and it was now not possible realistically to argue that such a scheme should be industry funded. MacGregor continued to worry about the cost and eventually after Treasury agreement was obtained a scheme paying compensation at a rate of 50 per cent of average market values was established. It came into force on 8 August 1988; notification had come into force earlier on 21 June. The above account shows that compulsory slaughter/compensation came into effect nearly six months later than it might have done due to a series of events which were in retrospect unfortunate. In early 1988 MAFF officials decided such a policy was necessary both to protect the public from any risk (though this was considered unlikely) and to get on top of an animal-health disease in a traditional way. This was a view which all, arguably, ought to have shared on the evidence

A Chronicle of Events until 20 March 1996 39

by then available. However, the Minister (MacGregor) expressed doubts when the recommendation was put to him, although he accepted the CMO should be consulted. MacGregor’s doubts caused the issue to be put to the CMO in less definite terms than MAFF officials had anticipated. In particular the CMO was not told that MAFF officials had advised slaughter/compensation was necessary to protect human health. Also MAFF had not previously formally informed DoH about BSE so the CMO was unprepared. Even so he ought probably to have recommended infected animals should be kept out of the food chain. After all if MAFF officials could work out that this was necessary to protect public health why could the CMO not do so? However, he took the less exposed option of suggesting the advice of an expert committee be sought. Only when that committee had been established and recommended that clinically infected animals be kept out of the human food chain was action put in hand. This six-months delay is of some significance since (though it was not appreciated at the time) the number of cases was increasing very rapidly. In the absence of a compensation scheme more infected animals may have gone for human consumption than would otherwise have been the case. The other obvious need was, if possible, to cut the disease off at source. We saw above that the head MAFF epidemiologist (Wilesmith) had concluded by February 1988 that the infectious agent was found in commercial feedstuffs and that changes had been made in rendering processes in the late 1970s and early 1980s which could plausibly account for MBM becoming infectious from this time. Discussion on a confidential basis with the renderers, and the absence of any viable alternative explanation, led to the firming up of the MBM hypothesis over the following weeks. On 3 May Wilesmith confirmed his earlier view and advised that a ban be instituted on the inclusion of MBM in cattle and sheep feedstuffs. One conclusion he reached was to have important consequences though it was not relevant to the ban on MBM. This was that: The… picture is typical of an extended common source epidemic in which the incidence increases sharply over a short period of time and then maintains at a constant incidence. In line with the conclusions on feed on 6 May the CVO advised Ministers that attempts should be made to persuade the feed industry voluntarily to withdraw MBM from ruminant feedstuffs. Officials may have suggested a voluntary scheme in the light of MacGregor’s reservations about compensation. Certainly a compulsory and legally enforceable scheme was much to be preferred. In any event MacGregor quickly decided, at a meeting on 18 May 1988, that a compulsory ban was necessary. MAFF vets also decided quickly and correctly thereafter that, although suspicion at that stage was directed at sheep remains because of BSE’s resemblance to scrapie and the absence of any previous history of a bovine TSE, the most logical form for the ban would be for it to cover the inclusion of all ruminant derived material in feed for ruminants. This would address the possible problem of BSE being recycled via bovine remains.

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The Politics of BSE

This was a wise decision since experience subsequently showed that it was essential that cattle remains be included within the ban since they were probably the main source of infection. Otherwise the measure decided upon might be described as minimalist. Though it was recognized that some feed already prepared and about to be prepared would contain infectivity, no special steps were taken to deal with it for example via a feed-recall scheme (which would of course have led to further demands for compensation). At the time it was assumed that any infectivity would be washed through the system without any major effect. Similarly it was not considered necessary to introduce any new, special precautions for the manufacture of ruminant feed for the future. Manufacturers already had to ensure antibiotics, included in some feeds but banned from others, could only be detected where they were permitted. Presumably it was considered that precautions equivalent to those needed for antibiotics would suffice. It was, of course very much in the interests of manufacturers that their products were not suspected of containing infectivity so it was reasonable to assume they would work to keep it to a minimum. This approach made an implicit assumption which appears not to have been fully articulated at the time though as we shall see some indications supported it. The assumption was that very small quantities of infectivity would not suffice to bring about infection. If this were not true then the measures adopted would not suffice. In the event subsequent developments showed that the amounts of infectivity which had to be consumed to cause infection was less than most had assumed. The Order instituting the ban was signed on 14 June 1988 and came into force on 14 July. It proved very successful up to a point. Professor Roger Morris, a distinguished veterinary epidemiologist from New Zealand, told the BSE Inquiry that the ban had been ‘spectacularly successful’. He calculated that the risk of a cow contracting BSE had increased by a factor of 25 times between 1985 and 1987 and would, but for the feed ban, have increased by a factor of 40 times between 1985 and 1988. Instead the ban produced an immediate reduction in risk of 80 per cent and this figure increased in the following years. Yet the ban was far from being completely successful. As we shall see many thousands of animals born after the ban eventually succumbed to BSE. We will consider the reasons for this later. Taking stock: late 1988 By the second half of 1988 two major measures had been put in place to contain the spread of the disease; the slaughter and compensation scheme requiring the destruction of the carcasses of animals showing clinical signs of disease, and the ban on the inclusion of ruminant protein in ruminant feed. The former also provided a significant degree of protection for the human population should BSE prove to be a risk to humans. At the scientific level the disease had been identified as a TSE closely related or identical to scrapie; the cause of the epidemic, contaminated feed, had been identified though the original trigger remained speculative. Unfortunately the current best estimates of the number of infected animals not yet showing symptoms greatly underestimated the scale of the epidemic but this could not have been known at the time.

A Chronicle of Events until 20 March 1996 41

1988 onwards; independent scientific advice to government; the Southwood Committee, the Tyrrell Committee and SEAC The establishment of the Southwood Committee As we have seen, the CMO suggested that the views of an expert committee should be sought when he was asked by MAFF for his opinion on the merits of a slaughter and compensation scheme for clinically infected animals. He proposed that Sir Richard Southwood FRS, Professor of Zoology at Oxford University, should be the Chairman. Southwood, the CMO and the MAFF Permanent Secretary agreed on three additional members, Professor Anthony Epstein FRS, recently retired head of the Department of Pathology at Bristol University, Sir John Walton, a clinical neurologist soon to be Warden of Green College, Oxford, and Dr William Martin, a vet and recently retired Director of the Moredun research institute. All four members were, therefore, distinguished though none was expert in TSEs. It was suggested by MAFF that Dr Richard Kimberlin, who was such an expert, should be included but Southwood objected apparently because this might involve the committee in the fierce controversy over the nature of TSE agents. The establishment of the working party was announced by MAFF on 21 April 1988 though the detailed membership was not finally settled for another month. MAFF and DoH finally agreed a very wide remit for the committee: To advise on the implications of Bovine Spongiform Encephalopathy and matters relating thereto. The committee, which it had been agreed should have joint secretaries from MAFF and DoH, held its first meeting on 20 June 1988. After the meeting Southwood wrote at once to the MAFF Permanent Secretary with four immediate recommendations of which the most important was that the carcasses of infective animals should be destroyed – in effect endorsing the slaughter and compensation scheme MAFF officials had recommended in February but which had been held up by MacGregor’s reservations and the CMO’s caution. Another important recommendation was that an expert working party should be established to advise on research needs. The committee also asked the secretariat to investigate the use of bovine products in biological products such as vaccines, about which they expressed unease. On the interim recommendations the MAFF Permanent Secretary wrote to Southwood on 20 July confirming that the recommendation to slaughter and destroy infective animals had been accepted and a slaughter and compensation scheme would be introduced. He added that the CMO and he also agreed on the need to set up an advisory body on research. The second meeting was held on 10 November 1988 and Dr Kimberlin was invited to attend part of it though in the event he was present throughout. Kimberlin’s attendance followed a letter from the MAFF Permanent Secretary to Southwood strongly advocating he be consulted by the committee. The evidence

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The Politics of BSE

given to the BSE Inquiry by members of the committee on the one hand and by Kimberlin on the other appear to show that there was some tension between the committee and Kimberlin at the meeting over ten years earlier. The cause is not immediately apparent from the record but it may be that Kimberlin (who had had to travel from Edinburgh for an unpaid meeting of a committee of which he was not a member) thought that insufficient scope was given for him to contribute, while the committee perhaps thought that he had been rather foisted on them by MAFF and resented the fact. Following this meeting the committee made two recommendations, first that the ruminant feed ban (due to expire at the end of the year though nobody expected this to happen) should be extended indefinitely and, second, that milk from BSE suspects should be destroyed. Both were accepted. After the first and second meetings Southwood himself and the secretariat had sought to encourage those with responsibilities for human and veterinary medicines and occupational health and safety actively to consider the possible risks of BSE. Their efforts were not best judged and did not lead to much useful action. The committee was also considering whether some protection should be introduced in relation to human consumption of ‘ox brain’ which might be sold as or incorporated in food. This discussion represents the committee wrestling with the problem of whether there was some protection that could be provided for the human population from the threat, which they clearly regarded as very small, of infection from apparently healthy animals which were incubating the disease. The committee appears to have been hampered by an understandable lack of expertise about what could be done to eliminate potentially infective tissues in slaughterhouses. However, they did not attempt to investigate this in detail. Eventually the only recommendation they made that would protect the public from subclinically infected animals was the baby-food recommendation described below. The committee held two further meetings on 16 December and on 3 February 1989, at the latter agreeing the final text of the Report and signing the letter to Ministers. The principal extra advice in the Report not covered by the earlier interim recommendations was that: … manufacturers of baby food should avoid the use of ruminant offal and thymus. The committee subsequently clarified that they had not intended ‘offal’ to include liver and kidney but only brain, spinal cord and lymphoid tissue. The Report said that the committee had considered the potential for transmission of BSE to occur through the use of bovine products in medicines, including human medicines. It noted that in this connection Southwood had been in contact with the Chairmen of the relevant advisory committees. In similar vein they recommended that the Health and Safety Executive should consider issuing guidance to occupational groups likely to be exposed to the BSE agent. Hence the principal recommendations made by the Southwood Committee were (i) that clinically infected animals should be destroyed; (ii) that an advisory

A Chronicle of Events until 20 March 1996 43

body on BSE research needed should be established; (iii) that the ruminant feed ban should be extended indefinitely; (iv) that milk from animals showing clinical symptoms should be destroyed; (v) that ruminant offal should be excluded from baby food; and (vi) that further action against possible risks to workers and from the inclusion of bovine products in medicines should be considered by the Health and Safety Executive and the relevant advisory committees. All these recommendations were taken up. Even with hindsight all seem sensible, though there is a question over whether given the knowledge at the time more recommendations were needed. However, the Report also had other important consequences going beyond its recommendations. These include the effects of its comments on risk and its conclusions on the origins and likely course of the disease. It is worth examining these points here because for reasons that will be explained they had an impact for many years. The Report was drafted by several hands including the joint secretaries, which is quite usual for Reports of this kind. Significant sections were also drafted by Wilesmith, and again there is nothing inherently odd about that. Drafting reports is a time-consuming business, and it is natural that a committee of this kind will want help in drafting. They were four busy people and it must be borne in mind that they were unpaid. The important point is that the committee should revise the draft and accept full responsibility for the final version. This they did. After thanking the secretariat and others for their assistance Southwood stated in his letter sending the Report to Ministers: The Report remains our own. The Report was clear that in the committee’s judgement the risk to human health was probably very small. It was also apparent that this was based on analogies with scrapie about which data had been assembled for centuries. No link between scrapie and the incidence of CJD had ever been shown. Thus the Report states (para 5.3.5): … the risk of transmission of BSE to humans appears remote. Again it states (para 9.2): … it is… most unlikely that BSE will have any implications for human health. However, clear warnings were sounded. Paragraph 9.2 continued: Nevertheless if our assessments of these likelihoods are incorrect the implications would be extremely serious. Though it was known humans could contract TSEs, which was obviously relevant, the main evidence on which to base an assessment of the threat to human health

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posed by BSE was the analogy with scrapie. This was the case whether BSE was considered to be a manifestation of scrapie in cattle or a new disease of cattle. Given their assessment of the level of risk outlined above, it was not easy for the committee to decide whether to recommend the introduction of controls to protect human health. In the event the baby-food recommendation was the only one they put forward. Making the baby-food recommendation, the only one which could protect humans from infected cattle not yet showing clinical symptoms, looked odd. If babies should be protected what about everyone else? There was some faint evidence that calves (hence babies?) might be more susceptible than adult cattle but it was not a strong prop on which to base the baby-food recommendation. In any event many parents do not feed babies on commercial baby food (they use mixers to prepare a mash from their own food instead) so the recommendation would not even have protected them completely. Whether the middle-aged gentlemen on the committee were aware of this fact is not clear. However, the committee had to reach a decision on what to recommend knowing that the evidence needed for them to come to an authoritative view did not exist and would not be available for years. As it was the committee did a reasonable job on this aspect. Any other committee of comparable standing that might have been appointed would probably have shared their view that BSE was ‘most unlikely’ to pose a risk to humans. Nevertheless they gave a clear warning that this conclusion was not certain and that protective measures were worth considering. However, they might have done better if, instead of making a detailed recommendation (the one on baby food), they had stated simply that because it could not be proved for years that BSE had no implications for human health, meanwhile it would be desirable if potentially infective tissues were kept out of the human (especially baby) food chain so far as possible. The point was that what could be done depended not only on the specification of potentially infective tissues, a biological question on which the committee were competent to assess the evidence, but also on detailed slaughterhouse practices on which the committee could not be expected to be expert. This would have left others to assess what could be done at different levels of cost. As it was the committee appear not to have appreciated that something like the specified offal ban (discussed below) was a possibility. There was one curious episode just before the Report was finalized. Southwood had concluded that feeding animal waste to herbivores was inherently undesirable. His reasoning was that herbivores would not have evolved defences against infections which might be acquired in this way (because natural selection had not had an opportunity to act to provide such defences) and hence new pathways could be opened to the infection of animals and, via them, humans. Southwood apparently hoped to include a recommendation against the recycling of animal waste in the Report, though whether he originally considered animal waste should be banned from pig and poultry feed is not entirely clear since they are not herbivores. His method of achieving this was to hold the idea back until the last minute and hope to finalize the drafting with the DoH secretary only, thereby excluding any MAFF protests.

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Southwood’s basic concerns were valid ones, which deserved to be carefully considered. The development of BSE appeared to have shown that feeding ruminant protein to ruminants was a ‘recipe for disaster’ in the later words of the BSE Inquiry even though it had been going on for decades without apparent ill-effect. Southwood identified a basic scientific explanation for the occurrence of BSE before anybody else and saw that it raised important questions about agricultural practice. However, Southwood’s method of going about matters was naïve and unwise. MAFF were unlikely to allow themselves to be excluded from the debate by such crude tactics; they were understandably concerned about the consequences of prohibiting a use of animal waste which provided an economic route for disposing of hundreds of thousands of tonnes of unpleasant and potentially dangerous material each year. MAFF pressure resulted in the recommendations on this point in the Report being watered down so that they were compatible with the ruminant feed ban. No doubt MAFF were irritated by what appeared to them to be the sneaky way Southwood had gone about things. Southwood would have done better to raise his fundamental concerns openly and to include in the Report a suggestion that they warranted examination in detail. As it was he appeared to want to slip proposals into the Report without being prepared to see them openly discussed, and then to back off when challenged. One of the principal legacies of the Southwood Report was its conclusion that BSE posed only a remote risk to humans. This continued to be quoted for many years by Ministers and officials as the best guide available. The BSE Inquiry were unhappy at this. For example they state: Unhappily, the Southwood Report was treated by many…in MAFF and… DoH… as if it contained definitive conclusions based on an evaluation of adequate data by expert scientists in relation to the extent both of the risk and of the precautionary measures necessary to counter that risk. (Vol. 4, para 1.1) This is to miss the point in spectacular style. The issue is an important one which we will follow as matters develop so it is worth setting out my position here. The Inquiry’s description, quoted above, is a travesty. There is, admittedly, no view so foolish that nobody has held it, so I cannot claim with certainty that nobody treated Southwood’s views in the way described. I can say that I never met anybody who did so. It was well-appreciated by all that Southwood had had to work with very little data and that his views were as a result necessarily tentative at the time of his Report. The real point is that as more and more data became available over the years, Southwood’s conclusions on risk were not discarded or amended to any significant extent by the government’s scientific advisers. Instead they were implicitly and sometimes explicitly endorsed. They were implicitly endorsed by the decision of the advisory committee not to issue an amended assessment. They did not, for example, state following any of the developments of the years after 1989 that the likelihood of transmissibility to humans could no longer be described as ‘remote’. Note it would not have been necessary for them to say transmissibility was likely. They could have said it

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The Politics of BSE

was still improbable but not as unlikely as it had appeared earlier. If they had been concerned at public reaction they could first have sent private letters to Ministers. Indeed on such a fundamental point one must go further. If the government’s scientific advisers considered that the well-known Southwood conclusions on risk had been overtaken it was their manifest duty explicitly to draw this to Ministers’ attention. They did not do so before their well-documented reconsideration starting at the very end of 1995 which in itself constitutes strong evidence that they never clearly reached any such conclusion. In the absence of new advice it is obvious that existing advice remains valid. Southwood’s advice was not replaced for the good reason its successor committee believed it to be the best assessment of the risk posed. This is proved by the fact that in 1994 (by then known as SEAC) the advisory committee explicitly endorsed Southwood’s view that the risk to man from BSE was remote: Our conclusion therefore is that, as the Southwood Working Party determined, taking all the available evidence together, the risk to man from BSE is remote. The gratuitous reference to Southwood scarcely suggests reservations about his advice. Similar statements were made well into 1995 by leading members of SEAC including the Chairman and Deputy Chairman and the CMO. Those in MAFF and DoH were not, therefore, living in cloud cuckoo land, disregarding a changed scientific view. In quoting Southwood’s assessment up to the end of 1995 they were following the advice of their own expert committee, which had both implicitly and explicitly reinforced it. The BSE Inquiry’s strictures are unjustified. Instead it is they, as we will see below in chapter seven, who have misread the evidence and in effect substituted their view of what ought to have been the position for what took place. Whether the views expressed in the Southwood Report on the unlikelihood of BSE proving to be a danger to man should have been amended by SEAC later in the light of new evidence as it arose is an important point. Whatever our answer the Southwood Committee cannot, of course, be held responsible. They can only be held responsible for the advice they gave when they gave it. Finally, the Report contained predictions about the future course of the disease, which in the event proved optimistic. The BSE Inquiry discovered that this section had been drafted by Wilesmith and it is apparent they took a disapproving view of this. However, presumably the committee were convinced by his account of how the disease had arisen. Most people were at the time (and many of his deductions, notably that transmission had occurred via infected feed, are still regarded as essentially correct). In the event his predictions on the future course of the disease, accepted in full in the Report but not ascribed to him, proved highly optimistic because he had not allowed for the extent to which cases coming forward represented a recycling of earlier cases of BSE in cattle which had gone undetected. The Tyrrell Committee At its first meeting the Southwood Committee had recommended that an expert committee should be established to advise on research into TSEs, notably BSE.

A Chronicle of Events until 20 March 1996 47

After some typical sparring between MAFF and DoH it was agreed that the committee should consist of two medics suggested by the CMO, two vets suggested by MAFF and one other. The Chairman decided upon was Dr David Tyrrell FRS, a virologist and Director of the Medical Research Council’s (MRC’s) Common Cold Unit. Other members were Dr William Watson, director of the CVL, Professor John Bourne, another vet and Director of the Institute of Animal Health, Dr Robert Will, a neurologist and Dr Kimberlin. The establishment of the committee was announced on 17 February 1989. Its remit was the one described above with the addition that any new work recommended should be prioritized. On 10 June after three meetings the Committee presented an ‘interim’ report to the government; each piece of new work recommended was allocated one, two or three stars in ascending order of importance. The Committee had deliberately worked with speed so there would be minimal delay in getting projects underway. The recommendations covered a wide range of experiments into BSE and CJD with particular emphasis on the epidemiology of BSE and its transmission and related genetics. However, one aspect which the Tyrrell Committee’s Report did not cover and could not have covered was finance; and experiments cannot be done without the money to pay for them. The bulk of the work recommended fell to be financed by MAFF. There was also a political dimension. The Minister (John Gummer) took the view that it was essential for the government to be able to say that all the new work prioritized at two or three stars would be undertaken. Until he was in a position to announce this he did not want to publish the Report. Accordingly the source of the required sums had to be identified in each of the several years ahead. The rules of government accounting make this more difficult than might be expected though there is not space here to explain in detail why. For example while in theory some money might have been found from elsewhere in the MAFF budget such a course would be risky since underspends in particular areas are prone to be reclaimed by the Treasury at no notice. In practice the money needed to be found from the funds earmarked for research. Although only some £2 million per year was at stake, and this would be dwarfed by later expenditure, this was not easy to find. The need to find this sum was only the start of an ever-growing problem. Looking forward in time it is no coincidence that throughout the 1990s MAFF non-veterinary laboratories and some Research Council institutes outside the livestock area which traditionally did a lot of work for MAFF experienced financial difficulties including closure. The reason was the same in both cases; MAFF funds were being drained away in ever-increasing amounts by work on BSE. Eventually the necessary funds were found for all the work to which the Tyrrell Committee had allocated two or three stars and an announcement made accordingly but not before 9 January 1990. At the same time the Report was published – over six months after it had been delivered. This was awkward and the delay understandably irritated Tyrrell. On the narrow issue no great harm was done by the delay since work was put in hand as soon as possible. Nevertheless it would have been better to publish the Report earlier which would have allowed others

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outside the world of MAFF, DoH and the Research Councils to put forward any bright ideas they may have had about what was proposed or how the work might be done. The establishment of SEAC Following the Report of the Tyrrell Committee in June 1989 it was recognized in both MAFF and DoH that government would continue to have need of independent, expert advice on TSEs. This would need to cover research and, it came to be recognized, wider issues including matters of policy. The establishment of the new committee, the Spongiform Encephalopathy Advisory Committee (SEAC), was announced by John Gummer on 3 April 1990. Its remit was a wide one: To advise the Ministry of Agriculture, Fisheries and Food and the Department of Health on matters relating to spongiform encephalopathies. The membership was initially very similar to the preceding committee. Dr Tyrrell continued as Chairman and Drs Will, Watson and Kimberlin as members. Professor Bourne was replaced by Professor Fred Brown, a virologist formerly of the Animal Virus Research Institute at Pirbright. Later in 1990 the membership was enlarged to include Professor Ingrid Allen, a neuropathologist, Professor Richard Barlow, a veterinary pathologist and Mr David Pepper, a veterinarian in private practice. Thereafter the membership remained unchanged until 1995 except for the appointment of Dr William Hueston, a veterinary epidemiologist from the USA in 1994. SEAC thus consisted of distinguished individuals from the medical, veterinary and research fields. Together with its predecessors, the Southwood and Tyrrell committees, it has been the main source of advice to government on BSE to the present day. Because of the positions and reputations of its members and the fact that most were seen to be outside government, it had prestige and was viewed as independent. Because it had prestige and a reputation for independence Ministers found it valuable to cite its advice in defence of their policies – which were in any case often based on SEAC recommendations. Ministers quickly recognized that they could not act against SEAC advice. To be more precise, they recognized that they could not take fewer precautions than SEAC had recommended. Taking more precautions than SEAC recommended needed careful justification but was sometimes desirable and possible. Also relevant is the highly adversarial nature of UK party politics, especially where the Opposition senses it is on a good wicket such as was the case in the area of food safety in the 1980s and 1990s. Ministers and MAFF more generally were routinely denounced for complacency and/or putting the public at risk unnecessarily. Such denunciations were supported by many in the media. The merit of individuals or of specific proposals had little effect on this state of affairs. Given the uncertainties over BSE it was apparent that virtually anything Ministers might decide could be attacked in a way which a substantial proportion of the public would find alarming. The temptation to score in this way was irresistible to

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politicians and commentators alike. To minimize this standing problem there was every incentive for Ministers both to be guided by SEAC and to justify measures on the basis that they were based on SEAC advice. In this way they hoped to put SEAC between them and criticism. There was a disadvantage to this process in that it came very close to delegating government decisions to a specialist committee which, while it was eminent in some areas, did not know everything. We saw above how the Southwood Committee may have made suboptimal recommendations on protecting human health from BSE because they were insufficiently versed in slaughterhouse techniques. However, given the realities at the time it is difficult to see how this dependence on SEAC on matters of policy could have been avoided. Overall, whether or not it is accepted that the reliance on SEAC on policy matters to the extent it occurred was inevitable, that is what happened. This pre-eminent position of SEAC and its predecessors on policy issues within government was established at a very early stage. In April 1990 DoH objected to MAFF advising farmers not to breed from animals which were the offspring of cows that had succumbed to BSE mainly on the grounds that Southwood had not recommended such action. (The thinking behind the MAFF idea was to prevent inadvertent spreading of BSE should it be maternally transmissible and/or should certain animals be genetically susceptible to infection.) The matter was referred to SEAC at DoH insistence. The outcome was that MAFF felt unable to issue their intended advice which, as the BSE Inquiry recognized later, would have been sensible and fell more within MAFF’s area of competence than SEAC’s. The establishment of the CJD surveillance unit (CJDSU) As discussed above, though the Southwood Committee considered it highly unlikely that BSE would prove to be a human health hazard they did not rule out the possibility. They recognized that, since there was no test to identify those individuals who were developing TSEs, there was a case for carefully monitoring relevant illnesses in the human population. Their Report states: It is a reasonable assumption that were BSE to be transmitted to humans, the clinical disorder would closely resemble CJD… Identification of any such cases as unusual or atypical would not be easy… The CMO could consider whether… neurologists, neurophysiologists and neuropathologists…should be made aware… of BSE so that they can report any atypical cases or changing patterns in the incidence of the disease. Consideration of this recommendation and the concerns that lay behind it led to Will presenting a paper to the Tyrrell Committee. Will had much experience of working on CJD including the first systematic surveillance of the incidence of the disease in the UK in the late 1970s/early 1980s. His advice was accepted and as a consequence the Tyrrell Report recommended the monitoring of all cases of CJD in the UK for the following two decades. DoH accepted this recommendation and CJDSU started on 1 May 1990 based in Edinburgh where Will was working.

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The Unit considered all cases of suspected CJD (including the diagnosis) and developed a detailed procedure for investigating the genetics and environment for each case. In 1996 it was the Unit’s discovery that in the cases of CJD in young people the brains of those affected showed unusual features that was largely responsible for SEAC’s initial conclusion that the cases were probably the result of exposure to BSE.

1989: the decision to impose the human SBO ban The BSE saga has a number of unhappy aspects. As this account shows there were occasions when things went wrong essentially because of bad luck, and others when wrong decisions were taken or matters moved too slowly. There was, however, one occasion when matters went very much right perhaps with the help of a bit of good luck. This occurred in 1989 when the Southwood advice (which fell short of a recommendation) that bovine offal should be kept out of baby food was transformed by MAFF, against mild opposition from DoH, into a requirement which excluded almost all the tissues which we now know to be potentially infective from the human food chain. This measure added to the protection afforded to human health by the slaughter and compensation scheme. Obviously the biggest risk to human health is posed by animals that are clinically ill since there is much evidence that the concentration of infectivity increases rapidly in the disease’s final stages. In his evidence to the BSE Inquiry Southwood went so far as to suggest that it might be that all cases of vCJD were infected before this measure was adopted. This might be true though there is no proof of it as yet. A more cautious claim would be that it is unlikely that anyone has become infected since the imposition in 1989 of the human SBO ban. This imposed a requirement to exclude from the human food chain certain tissues from all bovines. The tissues concerned were those believed then (by analogy with scrapie but reasonably accurately as subsequent work has shown) to carry the highest doses of infectivity in infected animals. (The measure is known as the Specified Bovine Offal Ban or ‘SBO ban’ for short.) This is because the SBO ban offered a large measure of protection against infection via the consumption (for example of food or medicines using bovine material) of material from animals infected with the disease but not yet showing clinical symptoms, that is ‘subclinically infected’ animals. Though such animals would normally contain a smaller amount of the infectious agent than would animals showing clinical symptoms there were many more of them. The Southwood Report was well-received both nationally and internationally. The committee had been composed of eminent individuals and their Report was also the main prop on which government relied to explain to the public that they were being properly protected. It was, therefore, difficult for government to go beyond its recommendations since to do so could seem to imply lack of confidence in its conclusions. It might also cause trouble with the wider scientific community. The former reason lay behind the lack of enthusiasm DoH showed for the SBO ban

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in the wider form in which it was eventually introduced. MAFF were also affected by the same considerations. This makes it all the more remarkable that it was adopted as quickly as it was. Yet doubts were quickly raised as to whether the Southwood recommendations to protect human health went far enough. There was no straightforward decision that led from Southwood to the SBO ban, rather a number of factors which, cumulatively, led in that direction. First, at a very early stage two senior officials in MAFF (but none in DoH) questioned why if babies were to be protected as Southwood had recommended bigger children and adults were not. Second, concerns that the risk posed by BSE might be greater than Southwood had assumed began to be voiced both in the press and by the Opposition in Parliament. Third, through the good offices of Pedigree Petfoods, a leading manufacturer which had retained Kimberlin to advise them on BSE, the latter’s detailed views became known. He had been working on TSEs for decades, and it was therefore pertinent that his recommendations for petfood went beyond Southwood’s recommendations for human food, that is he was more cautious and recommended that more tissues be excluded. Kimberlin’s explanations, backed up by detailed knowledge of the scientific literature, appears to have brought about a change of view in the CVO, who was himself influential in MAFF. Fourth, the Parliamentary Secretary, Sir Donald Thompson (as he became) queried whether more ought not to be done than Southwood had recommended. Thompson was the sort of MP who rarely attains political office let alone senior office. However, on BSE Thompson sensed a need where others did not. Over a period of two or three months the climate of opinion changed. Among those who came down in favour of a more cautious regime than that advocated by Southwood were the Chairman of the British Veterinary Association (a body for veterinary practitioners akin to the British Medical Association for doctors), the Chairman of the Meat and Livestock Commission (MLC), a Director of the largest UK renderer and the Women’s Farming Union. By late May 1989 it appears that MacGregor had decided that a ban excluding certain offals from all human food should be introduced. His reasons appear to have been a mixture of the presentational, that is seeking to reassure and respond to political pressure, and the objective, that is seeking to deal with concerns that clinically infected animals might be going for human consumption despite the slaughter scheme and that subclinically infected animals might pose a danger; and that as suggested by Thompson and others in principle a more precautionary approach was preferable. He seems to have given the first (presentational) considerations the most weight. Ministers and officials were still worried, however, about how to justify publicly a departure from Southwood’s recommendations. That was why DoH were unenthusiastic about extra measures. This was a perfectly understandable concern. Government is always keen to operate coherent policies and if in this case it went further than Southwood then how could it explain why it had done so or, indeed, why it had not gone further? What was clear was that if government decided to do anything that appeared incompatible with Southwood’s recommendation he would have to be told and

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that it would be awkward if he did not support the action proposed. For his part Southwood could scarcely alter his recommendation in the absence of new scientific evidence. These awkwardnesses were solved by making use of something that had become apparent as officials had examined how effectively to implement the baby food recommendation. This was that such a measure would be very difficult to control if the banned material could be used in other human foods. The solution identified was to emphasize that a wider ban in respect of all human food was the most easily enforceable way to implement a ban in respect of baby food. This had credence since it would then become possible to specify that the banned material had to be removed at the slaughterhouse and made subject to special arrangements for its disposal. This would make for much easier controls than if the materials in question could be used in adult but not baby food. Stressing the control aspects of the decision to provide for a wider ban than Southwood had recommended got over the difficulty of going beyond his recommendation while keeping him onside. He made no claim to be an expert on enforcement and readily agreed with the ban when it was explained this was the easiest way to give effect to his recommendation. The official presentation made in a Parliamentary reply on 13 June 1989 by MacGregor did not mention concerns that clinically infected animals might be reaching the human food chain. This would have been a difficult thing to acknowledge openly though it was widely known that this was a concern. It did however point out that the SBO ban in the form adopted would deal with any risk posed by subclinically infected animals. Thus the measure, which with hindsight we can see was more or less in the form needed to protect the public, was adopted early on despite the fact that a committee of distinguished scientists had not recommended it and the Department whose only remit was to protect public health was mildly hostile to it. In most walks of life those who took the decision in MAFF would now be covered with praise for having brought about such a feat. Generals are normally praised for victories even if everything does not go smoothly on the way. However, this has not been the case here. The truth appears to be that all association with BSE impinges negatively on those concerned even where, as here, matters have gone surprisingly well. We should not diminish this achievement – the introduction of the human SBO ban – by thinking that the decision was inevitable because of public pressure. On matters of food safety there is a vociferous lobby which almost always argues for greater restrictions which always have an economic cost. Ministers and officials get used to the clamour; they also note such pressure often has little scientific backing. On BSE there was no ‘right’ answer. The natural course would have been to take the best scientific advice and implement it and to brush aside complaints. When the course ahead is hazy following professional advice is the least risky option. Nevertheless, it is clear that even if MAFF had not acted when they did an SBO ban in broadly the same form would have been adopted eventually as further information came to light over the coming months and years. However, if the baby-food proposal had been put in place in the form advised by Southwood there

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would have been a reluctance to change it subsequently. It might have been many months and perhaps years before a full SBO ban was adopted. This would have been a serious matter since it subsequently became apparent that the number of subclinically infected animals going for slaughter was increasing very rapidly by the end of 1989. Hence the action taken was important in bringing about a major reduction in the amount of infectious material reaching the human food chain. The drawing up of the SBO order After the announcement on 13 June 1989 that a human SBO ban would be put in place it was still necessary to decide on the precise contents of the necessary Order. Though the principle was clear – exclude tissues likely to contain high doses of infectivity from the human food chain – and Kimberlin’s summaries of earlier work were useful guides, a large number of detailed, micro decisions still needed to be made. Bovines have four stomachs with slightly different natures. What about tripe made from bovine stomachs? Similarly what about rennet also made from (different) bovine stomachs (and used in cheese manufacture)? Other important questions included how to deal with bovine heads (which contain the most potentially infective tissue, the brain, but also include substantial quantities of meat in the cheeks and the tongue); what to do about MRM produced from the spinal column, which contains the spinal cord, another potentially highly infective tissue; and what to do about calves which ought to pose much less of a risk since the ruminant feed ban had been in force for some time and in any case even if they had consumed contaminated feed the agent would not have had time to reach the brain and other nervous tissues. In the absence of new evidence, which even if experiments had been started immediately could not have been obtained for several years, the answers to most such questions were a matter of judgement. In fact decisions were informed by no less than ten reports from the head of the Pathology Department at the CVL on the detailed anatomy and physiology of the tissues under consideration and the consequent likelihood (based on the scrapie model) of their containing infectivity in an infected animal. It was regarded as highly probable from the start that brain, spinal cord, thymus, spleen, tonsils and intestines from adult animals would come within the ban. Following extensive discussions within MAFF, between MAFF and DoH, and public consultation the Order was made under the Food Act on 8 November and came into force on 13 November 1989. This defined the ban as applying to the bovine tissues listed in the previous paragraph. The four bovine stomachs, certain fat (mesenteric) and calves under six months of age were exempted from the ban. No extra controls were imposed on MRM. The production of sausage casings (made from intestines) fell within the ban. Even with the benefit of hindsight this list appears reasonably accurate. However, it appears that the position of MRM made from spinal column (which in turn contains the spinal cord) was not considered with the same care as the other issues. My suspicion is that the nature of the manufacturing process for MRM was not widely understood. However, it is unlikely the process could have been

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banned in 1989 on the evidence then available. Even in the very different circumstances of 1995 manufacturers were prepared to challenge a ban via judicial review when government imposed one having taken account of evidence which did not exist in 1989. The Regulations required the necessary action to separate the banned tissues (Specified Bovine Offals (SBOs)) to be taken at the slaughterhouse. They thus fell to be enforced by the District Council tier of local government, which was responsible for the enforcement of meat-hygiene legislation. In autumn 1989 MAFF attempted to call a meeting to discuss the implications of the proposals with the relevant representative organizations (Association of District Councils, Association of Metropolitan Authorities and Association of London Authorities) but this proved impossible since the organizations could not make themselves available. Eventually a meeting went ahead on 18 October without them though the Institute of Environmental Health Officers (IEHO) attended. MAFF wrote afterwards to the organizations unable to attend. Later, the BSE Inquiry pointed out that local authorities were never told (by MAFF) that it was essential that the entirety of the spinal cord should be removed from carcasses. This is correct though it is not apparent this should have been necessary or that it would have had a useful effect. The Regulations were clear complete removal was required. Enforcing authorities were invited to contact MAFF if they had queries. Writing to enforcement authorities emphasizing that legislation ought to be enforced properly is unlikely to be received enthusiastically by those authorities or to lead to useful action. Writing to emphasise that parts of new legislation should be enforced properly (for example that concerning removal of spinal cord) is only too likely to be interpreted as implying that other parts of the legislation are less important and hence are a lower priority in enforcement terms. That, too, is likely to lead to problems. Enforcing authorities have to be trusted to act efficiently – or they should be replaced as eventually happened in this case. Problems posed by the human SBO ban The detailed form of the human SBO ban produced one unanticipated problem. It introduced controls on the treatment and movement of bovine heads because brains were known to contain large amounts of the infective agent especially in animals that were showing, or were near showing, clinical symptoms of disease. However, heads that had had brains removed were not subject to these controls. Unsurprisingly heads which were not subject to controls came to have a higher value. This obviously provided an incentive to remove brains from skulls at an early stage of processing and in fact the proportion of cases where this happened, though it remained fairly low, increased somewhat. This appeared and was undesirable. If the brain was removed under normal butchery conditions there would inevitably be some risk of contamination of the surroundings and some of the methods used (in a few cases splitting the skull with an axe!) were highly undesirable. This risk could be avoided if brains remained within the skull until after all head meat had been harvested. Afterwards the skull could go for rendering which was a process which did not risk contamination.

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The IEHO was quick to appreciate that, given the stated objectives of the SBO ban, removing brains from skulls before processing was completed was inherently undesirable and that the incentive to act in this way provided by the Regulations should be eliminated. The instincts of MAFF Ministers were similar. MAFF officials were initially more concerned to defend the integrity of the protective system just put in place, no doubt fearing that tinkering with it could cause a loss of confidence in the rules. However, in this case confidence was more likely to be shaken by the retention of rules, which inadvertently provided an incentive to act in a way which increased risk. The Minister (Gummer) asked SEAC to advise. At their meeting on 13 June 1990 they took the sensible view that removing the brain before all head meat had been harvested ought not to be permitted. On 14 June MAFF issued guidance to this effect. A little later the House of Commons Agriculture Committee recommended that this guidance should be given statutory effect. On 21 November 1990 the government accepted this recommendation, though legislation was only put in place on 12 March 1992.

Late 1989 to early 1990: pressure for an animal SBO ban Initial pressure for a ban The human SBO ban thus went further than Southwood had recommended. Subsequent events were to show that it was not completely watertight but nevertheless together with the slaughter and compensation scheme adopted earlier it provided a high degree of protection to the human population. However, as so often in the BSE saga, attention then immediately turned to another aspect. This was the continued feeding of SBOs to animals other than humans and ruminants. (The human SBO ban excluded SBOs from human food while the ruminant feed ban excluded all ruminant protein including SBO from ruminant feed.) Very soon after the human SBO ban was adopted a number of organizations pressed for SBOs to be excluded also from other food including pet food and food for other farm animals, notably pig and poultry food. Even before the human SBO ban was adopted the major pet-food companies, Pedigree Petfoods and Spillers, had taken steps to eliminate bovine material of the type later characterized as SBO from their products. There is a lesson here. Major manufacturers especially of goods sold directly to consumers have a strong interest in protecting long-term public confidence in their brands, and this provides an incentive for cautious and responsible behaviour. Thus three days after the government had announced its decision to introduce the human SBO ban, that is on 16 June 1989, the Pet Food Manufacturers’ Association, the umbrella body representing companies producing some 95 per cent of manufactured pet food, announced a voluntary code of practice under which SBOs would be excluded from pet food. Their reasoning, as explained in an internal note, was the need to avoid adverse publicity. The Association explicitly noted that the code was not based on scientific evidence. Animal-feed manufacturers felt similarly. Soon their main representative body the United Kingdom Agricultural Supply Trade Association (UKASTA) had decided

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in favour of a voluntary measure whereby member companies were recommended to exclude SBO from animal feed. Some renderers also wondered if the complete exclusion of SBOs from all feed chains would not be wise. Others to express unease included the Consumers’ Association and the Chairman of the MLC. MAFF were initially opposed to this pressure. What lay behind the pressure for an animal SBO ban and why did MAFF oppose it? The pressure to take action had two strands. The one which appears to have featured less prominently in the thinking of those concerned was the risk of transmission of BSE to other animals, notably pigs and poultry. This would be alarming partly because it would represent BSE jumping a species barrier, but mainly because it would have represented an extra risk to the human population from the consumption of products containing pig and poultry meat. The main drive behind the pressure for an animal SBO ban was, however, not this concern but worries of a presentational kind. The public were seen to be uneasy about BSE. There was therefore from the perspective of the commercial interests involved advantage in distancing their products, such as pet food and animal feed, from such concerns. As we have seen those concerned were normally clear that their actions were not based on science. At this stage most thought along the lines of the Southwood Report – that the risk to humans was remote. MAFF consistently opposed this thinking to the extent of putting a degree of pressure of their own on UKASTA to amend their position and withdraw the recommendation not to use SBOs in animal feed. It is illuminating to consider why they took such a strong line. The relevant considerations are not fully set out in the Report of the BSE Inquiry. This reflects the Inquiry’s procedures which relied primarily on evidence from individuals. While this approach has a number of advantages each individual witness was obviously primarily concerned to explain and justify his or her own actions. In the cases of those rare individuals where this may not have been their own instinct they would have received firm advice to this effect from their lawyer who will also have recommended against commenting on issues with which they were not personally involved. As a consequence what might be called institutional concerns can be overlooked. One such institutional concern would have been the need to base policy on best scientific advice if there was to be any hope of deciding where to draw the line on protective measures and explaining and sustaining that line in discussion. It is always a disadvantage for governments to be pushed from pillar to post. That is one reason why from the government’s perspective it was desirable that the Southwood Committee and its successor, the Tyrell Committee, should include eminent individuals – to give their recommendations weight. It was true that the science on BSE and TSEs more generally was known to be highly uncertain as Southwood had made clear, but that made it all the more important to take and keep best advice on where the line should be drawn. Though I have not found an explicit statement to this effect in the evidence to the Inquiry, at this time (1989/early1990) MAFF officials probably regarded the pressure for an animal SBO ban as demonstrating the wisdom of keeping to the scientific advice. The human

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SBO ban had gone beyond that recommended by Southwood. This had not induced confidence but on the contrary appeared to have resulted in pressure to go yet further and adopt another measure not scientifically recommended. Where would this end? One moral which probably suggested itself to the officials responsible is likely to have been that going beyond Southwood in respect of the human SBO ban had made it more difficult to resist this further pressure. That indicated the wisdom of sticking to the authoritative advice. Another institutional concern would have been the possible repercussions of the economic effect of extra measures on the different sectors of the beef industry. This was not because MAFF officials had an exaggerated concern for the welfare of producers to the detriment of food safety as is sometimes claimed. The point was that an animal SBO ban would destroy the value of a product (SBO) so that total returns to the beef food chain (farmers, slaughterhouses, renderers, retailers) would be reduced. Both economic theory and experience suggested most of the effect would be felt by farmers and slaughterhouses. This was regrettable in itself and clearly such action should only be taken if necessary. But that would be unlikely to be the end of the story. A deterioration in the profitability of farms and slaughterhouses would be likely to lead to pressure for compensation, especially if that deterioration had been brought about by government action and action moreover which could not, on the evidence available, be claimed to be essential to protect the public. Farmers in particular had many champions especially on the government (Conservative) backbenches in the House of Commons. Experience showed that such pressure for compensation could not always be resisted successfully. If Ministers wanted to make concessions to such pressure that would inevitably put the Department in difficulty. The Treasury would certainly object and refuse to find new money on the grounds that it was for industry to meet such costs. If the pressure for compensation grew strong enough they might relent to the extent that they agreed to the subsidy if the Department found the money. Since MAFF was badly strapped for cash this would pose difficulties. Taking money from elsewhere in the budget would be bound to give rise sooner or later, probably sooner, to complaints from those affected. It is these two classes of concerns, both points of substance, which will have underlay much of MAFF’s resistance to the animal SBO ban over this period. The resistance to the concept in MAFF as revealed in the pages of the Report of the BSE Inquiry looks odd unless account is taken of these factors not really covered there. With the benefit of hindsight we can, however, see that there were better arguments in favour of stricter controls on SBOs than were advanced at the time. The arguments put forward for an animal SBO ban other than presentational ones related to the danger of transmission of BSE to pigs and poultry. On that MAFF pointed out that pigs had been fed much higher concentrations of MBM than cattle for many years without a single case of an SE ever having been discovered (or indeed induced) in a pig while the likelihood of transmission to poultry was even more remote. These arguments have stood the test of time. To this day no case of an SE has been caused in pigs by oral ingestion, and SEs are still unknown in poultry. MAFF’s

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opposition to the case for an SBO ban as it was presented was, therefore, sound. However, what their arguments did not deal with was the disadvantage of allowing widespread movement of SBOs including in feed mills where ruminant feed was produced. In these circumstances the possibility of accidental (or indeed deliberate) contamination of ruminant feed with SBO must always have been present especially since no test was available able to show the presence of ruminant protein in samples. An animal SBO ban would help with this problem.

Other developments in 1990 Thus pressure for an extension of the controls to include a ban on the feeding of SBO to animals other than ruminants grew during the first half of 1990. At the same time a number of other significant developments were of political importance and kept BSE in the news. These included: (a) The transmission of BSE to mice fed on infected cow brain. (b) The adoption of new EU rules stated to have as their basis the need to protect consumers in other member states from BSE which required exports of UK cattle and beef to satisfy certain conditions. (c) The removal of beef from school dinners by some UK local authorities. (d) The discovery of an SE in cats. (e) The incident in which John Gummer fed a beefburger to his daughter. (f) The enquiry into BSE conducted by the House of Commons Agriculture Committee. (g) Comments were made on the safety of beef both by those in official positions such as Ministers, the CMO and SEAC and critics of the ‘official line’. Each of these developments, discussed individually below, received extensive publicity. The seemingly inexorable drip of bad news, with previous incidents being recalled each time something new happened, served to sensitize the public to BSE in a very major way. The transmission of BSE to mice fed on cow brain On 1 February 1990 MAFF announced the results of some of the experiments set up following the Southwood Report. The less significant which attracted little interest was that BSE could be transmitted by injection of infected material into the brains of living cattle. The more significant, which did attract considerable attention, was that mice fed on infected cattle brain went down with the disease. The point picked up by the press was that this represented a jump across the species barrier and thus, they suggested, could have implications for human health. While to a layman this seems a reasonable view, it has to be said that the government’s scientific advisers did not demonstrate any great concern at the result of this experiment. Perhaps they viewed the conditions, feeding raw brain to a tiny animal, as so extreme that conclusions could not really be drawn. If so their caution received some support from the pig experiment discussed below.

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The establishment of EU rules on UK exports of beef and cattle At the end of 1989 Germany imposed a unilateral ban on the import of beef and cattle from the UK; other EU member states including France and Italy followed suit. The economic core of the EU project is of course free and unrestricted trade between member states. As is natural the EU Commission is fully seized of the importance of free intra-EU trade and deeply suspicious of any claims that special circumstances justify departing from the principle. In particular they are instinctively opposed to national measures which interfere with trade flows. In their view either the measures should be removed or they should be replaced by EU measures. It is worth stressing that for the Commission the principle that trade should be regulated by EU rules is more important than the precise details of what those rules should be. In 1990 qualified vets and the public took different views of BSE, not only in the UK but throughout the EU. Thus the EU Scientific Veterinary Committee (ScVC) concluded on 8 January 1990 that: Meat derived from animals in countries in which BSE is widespread is not considered to be a significant danger to public health. As a precautionary measure every attempt should be made to prevent the inclusion of large quantities of lymphatic and nervous tissue from products intended for human consumption. Nevertheless the national bans mentioned above were brought into force reflecting the fact that Ministers had felt obliged to respond to the concerns of consumers who were anxious whatever the views of the professionals. It is, therefore, significant that ScVC’s view at their meeting on 6 June 1990 was: … meat derived from bovine animals in countries in which BSE occurs is not considered to be a danger to public health. Nevertheless, as a precautionary measure, every attempt must be made… to remove obvious nervous and lymphatic tissues… These tissues, where removed, must not be put into products for human consumption. Given that some members of the committee will have felt constrained by the action taken by their national authorities this is a remarkably mild recommendation no doubt reflecting the professional views of members that the concerns of laypeople were probably unjustified. This meeting was held directly before a meeting of the Council of Ministers starting on 6 June. The latter was the first occasion we have considered in which I played a part. I was the senior official present as I was at virtually all meetings of the Agriculture Council at this period, that being one of the tasks of the post I then held which was mainly concerned with EU policies on agricultural production and trade. As was and is not unusual the meeting went on well into the small hours. I remember being very concerned because until the very end, despite the scientific view quoted above, it appeared quite likely that the outcome might not allow the export trade in UK beef to continue. Though at that stage the Commission were

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helpful to the UK reflecting the view of their veterinary advisory committee the Germans in particular were reluctant to lift their national ban. Given the alarmed state of UK public opinion I suspected that if the outcome of the meeting did not allow exports to resume to all other member states the resulting furore in the UK might force the Minister to resign. A civil servant’s first responsibility is to protect his or her Minister; from the personal perspective it was also the case that being the lead official at a meeting following which the Minister was forced to resign would be unlikely to be career-enhancing! When I discussed this occasion many years later with John Gummer I learnt that he had had similar thoughts about his position. At the time, however, we both kept stiff upper lips. In the event matters resolved themselves less dramatically. In the small hours the position of some delegations crumbled. This is not unusual for the Council of Ministers; by, say, 4 a.m. of the second day only those who really care hang on. On BSE at this time only the UK really cared for the reasons given above. Hence the outcome was more favourable for the UK than had seemed possible a few hours earlier. However, the reality of negotiation in the Council of Ministers is that the final ‘compromise’ is almost always put forward by the Commission and reflects bits of what every delegation has said. For legal reasons the outcome in this case was set out in a Commission ‘Decision’, a Decision being an EU legal instrument. The Decision required the UK to certify that boneless beef exported to other member states was ‘fresh meat from which… obvious nervous and lymphatic tissue has been removed’. This reflected the advice of the Scientific Advisory Committee. Bone-in beef had to be from holdings on which BSE had not been confirmed in the previous two years. In practice this Decision allowed trade to resume while the national bans were lifted. From the immediate practical point of view the outcome was therefore a success for the UK and was by and large reported as such. However, from some perspectives it was less satisfactory. It proved impossible to find a legally satisfactory definition of ‘obvious nervous and lymphatic tissue’. If such tissue had to be removed to protect the public ought it to be treated as SBO? Since the trimming concerned would typically take place in butchers’ shops this would have required an extension of the exacting controls on SBO to the thousands of premises involved with major implications for them and for the control authorities, that is for local authorities. Further, removing ‘obvious’ tissue still left much of it attached to the muscle: that part would eventually be consumed as beef. It would be absurd to treat the same tissue as both SBO and as prime beef. Yet treating the tissue removed as SBO would have precisely this effect. The truth was that the reason the decision on nervous and lymphatic tissue was difficult to apply was that it was a fudge without any scientific merit. Either lymphatic tissue was a danger or it was not; removing some of it imposed a cost without achieving anything. Eventually this part of the Decision was implemented in the UK via MAFF guidance which simply repeated the words of the Decision. The other part of the Decision on bone-in beef also lacked scientific rationale. It reflected the kind of measures adopted to control infectious diseases. But even at this stage it was known that BSE was not infectious – that is animals did not catch

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it from contact with infected animals. New cases frequently occurred in herds that had never had a case before and had never been in contact with infected animals. The measures reflected what vets in other member states were used to and not the known facts. It gave the appearance of action and imposed costs while not doing anything useful. There was a further difficulty on bone-in beef. The UK lacked a computerized cattle-tracking system although a manual record of movements between holdings was supposed to accompany each bovine. However, there were doubts whether the practical application of the system was sufficiently robust for the new rule to be applied effectively in all cases given the incentives to cheat. No doubt the vast majority of vets who certified that meat going for export came from animals which met the specified criteria did their best but with the best will in the world the scope for honest error was significant while not everyone could be relied on to be honest. Again, therefore, the UK was faced with applying a protective measure which was both of little scientific merit and difficult to enforce. Thus there was scope for rows and bad publicity when instances were discovered when the rules had not been adhered to even though any such breaches were likely to have no implications for human health. Such rows (and bad publicity) erupted now and again over the next few years. The banning of beef from school dinners by local authorities In April 1990 Humberside County Council became the first UK local authority to respond to the public’s worries about BSE by removing beef from their school lunches. Over the coming months and years with each upsurge in concern similar action was taken by other authorities. This was news at both local and national level. Sometimes such action was taken by authorities in rural areas to the anger of local farmers. The ensuing rows became in themselves good copy which helped to keep BSE in people’s minds. Discovery of an SE in a cat John Gummer was informed on 9 May 1990 that it was likely that a cat first examined in the Bristol University Veterinary School had succumbed to an SE. Questions that immediately arose included whether the discovery resulted from the cat’s exposure to BSE probably via food or merely reflected the greatly enhanced sensitivity of vets to SEs since BSE had emerged. Cats might previously have developed an SE occasionally without it being identified. After all the rate of CJD in man was about one in a million and at that level a disease in cats might well have been missed. It was known that previously it had been found possible to infect cats experimentally with CJD by intra-cerebral injection. Significantly it had not proved possible to infect cats with scrapie either by this method or orally. SEAC were hurriedly convened to consider the implications of the cat on 17 May. Faced with the uncertainties outlined above they concluded that it would be premature for them to form a definite view. In short they did not recommend any immediate action. Over the coming months dozens of further cases of feline

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SE were identified, and at one point it seemed possible that the number of cases would reach epidemic proportions. However, this did not happen and relatively quickly the number of cases dropped away sharply. Gradually it came to be generally accepted that the cause of the disease was almost certainly consumption of meat infected with BSE. John Gummer, Cordelia Gummer and a beefburger On 16 May 1990 an incident occurred – ‘Gummer’s daughter and the hamburger’ – which became one of the defining moments in the BSE saga. It seemed that whenever BSE hit the news it was recalled and John Gummer denounced though it was rarely made explicit for what, precisely, he was being denounced. When in September 2000 the newspapers were speculating with relish on who would be revealed to be the main ‘guilty parties’ in the forthcoming publication of the Report of the BSE Inquiry most assumed that Gummer would be one of them largely because of this incident. What happened was that while public concern on BSE was at one of its periodic highs following the discovery of an SE in a cat, Gummer was challenged by the media present at an agricultural show to show his confidence in his own pronouncements that beef was safe by feeding a beefburger to his small daughter who was present. Probably the situation was given added piquancy by Gummer’s (justified) reputation for being very much family-orientated. No doubt envisaging the likely critical headlines if he refused to comply and also genuinely believing beef was safe Gummer agreed, only for the young Miss Gummer to burn her mouth on the said burger. Her spitting it out made good television. How so many people persuaded themselves that this occurrence would justify a formal criticism of Gummer was never clear (the Inquiry rightly dismissed it in a couple of paragraphs). However, the incident is interesting from a psychological perspective. The public were understandably worried about BSE, and as a consequence anyone who was strongly identified with the subject, as Gummer already was before the incident which itself served to reinforce that perception, was likely to have directed at them intense bursts of hostility much more vehement than could be justified by any reasonable view of their actions. Douglas Hogg suffered similarly at a later date. These prominent individuals became proxies on whom the public felt justified in venting their fury, which in turn reflected their fear and frustration. The Enquiry conducted by the House of Commons Agriculture Committee The committee decided to undertake an investigation into BSE on 16 May 1990. It received evidence in June and July and published its Report on 10 July. The Report was well-written, ranging over the major scientific issues. In general it supported government actions though inevitably it suggested it had taken too long to put some measures in place – unnecessary delay is always an allegation that those without executive authority find it easy to make. Being couched in moderate terms and being broadly supportive of the government the Report did not make many waves. Nevertheless it contained some

A Chronicle of Events until 20 March 1996 63

important passages. For example it explicitly noted that SBO would have been eaten by consumers before the human SBO ban came into force. This was not, however, taken up by the media so that the point made in the following paragraph remains important. The Committee also recommended that an enquiry be set up into animal feeding stuffs. This was accepted by government. Comments on the safety of beef In response to the alarm generated by the coverage of all the developments set out above and the pessimistic statements made by some commentators of whom Professor Richard Lacey received the most publicity, MAFF and DoH sought to reassure the public. They emphasized two points; first that there was no evidence that BSE was transmissible to man, which was of course true at the time, and second that they were confident beef was safe, which, given the first point and the protective measures taken, was also reasonable. However, such claims only covered the contemporary position. If, unexpectedly, BSE was in due course shown to be transmissible to humans the position before the human SBO ban was adopted in November 1989 would have been different – and dangerous. Commentators did not seem to grasp this point, however, and given public sensitivity it was understandable that those who did appreciate it did not volunteer the fact. To do so might have been seized on by the media and if that led to a ‘scare’ the person concerned could well have been criticized – hounded is probably not too strong a word. Nevertheless the fact that the reassurances given might have been construed by the unsophisticated to amount to a claim that nobody had ever been exposed to danger, though unjustified, had the potential to cause trouble if in the event it were shown later that BSE did pose a threat to man. The statements made at this time set important precedents examined later (and often criticized) by the BSE Inquiry. It is worth examining some of them. In particular, while concern about SE in a cat was at its height the CMO issued a statement on 15 May 1990 which included the phrase: British beef can be safely eaten by everyone, both adults and children. In a TV interview on 16 May the CMO said: There is no risk associated with eating British beef. In neither case did the CMO make any reference to the fact that this assurance depended on the proper enforcement of the BSE controls, notably the slaughter and destruction of clinically infected animals and the human SBO ban. On one view (taken, for example, by the BSE Inquiry) it is particularly incumbent on the CMO, who is known to have a freedom of expression not open to other officials or indeed Ministers, to be particularly careful that his statements are not merely accurate but do not lend themselves to misinterpretation. On that view the CMO’s statement quoted above is unsatisfactory. The Inquiry point out that by omitting all caveats it would tend to mislead the public; they do not go on, as they might

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have done, to note that by its categorical tone the statement might have misled officials also. Understandably the CMO was keen that his statement should be endorsed by SEAC, and SEAC agreed to do so at an emergency meeting on 17 May 1990. Their attitude is set out in the minutes of that meeting: In describing the risk as no greater than those of everyday life, this was not to imply that they were in any way comparable, say, to smoking. BSE was of a much lower order of magnitude. But…it would not be justified to state categorically there was no risk to humans. SEAC set out their views in a letter to the CMO dated 24 July 1990. They said: … we believe there is no justification for not eating British beef. In the annex to the same document they stated: … our own opinion based on our assessment of the available scientific evidence is that the BSE risk… is so slight it can be ignored. It is also helpful to note one other statement in the letter: Oral transmission of some spongiform encephalopathies undoubtedly occurs – although very large doses are needed because the oral route is very much less efficient than, say, intracerebral inoculation. Those who claimed later that large doses were needed to infect orally were therefore only quoting the government’s own scientific advisers. We can ignore later obfuscations introduced by SEAC seeking to justify themselves to the BSE Inquiry by which time it was known that a ‘small’ dose was sufficient. They went on about the difference between the amount of infective material and the titre (concentration) of infectivity in that material and claimed they referred to the latter only. This may even be true. However, the normal meaning of a ‘dose’ of something be it a medicine or whatever, let us call it an ‘agent’, reflects both the amount (volume or weight) of the material containing the agent and the concentration of the agent in the material. ‘Dose’ is one multiplied by the other. If we are given a medicine and told it has double the normal concentration of the agent we would expect to take half the usual volume (or weight). SEAC’s 1990 view, quoted above, was that a lot of agent was required to achieve BSE infection by the oral route. The reference to a ‘large dose’ was presumably meant to suggest that more agent was required than qualified observers might otherwise have thought.

Late 1990: new evidence leads to an animal SBO ban The developments described above all served to heighten public concern over BSE. By the summer of 1990 the position was that there was widespread pressure for a

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statutory animal SBO ban, while some organizations were informally operating one. In part this reluctance of some to use SBOs reflected concern at the possible risks posed by feeding SBOs to non-ruminants, but even more it reflected attempts by those with commercial interests at stake to think of something which might soothe public opinion even if this entailed accepting additional costs without a good scientific justification. Meanwhile MAFF continued to oppose taking any further protective measures not clearly justified by the science or (what amounted to the same thing) recommended by SEAC. All this was altered by the discovery that BSE could be transmitted to pigs. This was achieved only under the fiercest conditions, that is by subjecting the pig to simultaneous intracerebral, intravenous and intraperitoneal inoculation – that is to injection of infected brain into the brain, the blood stream and the abdominal cavity. This result became available to government on about 20 August 1990. Given the extreme conditions of the experiment it was not self-evident that in itself the result justified taking further protective measures, and indeed officials in MAFF and DoH queried whether this would be justified. However, SEAC advised at their meeting on 19 September that: … pigs should no longer be fed with protein derived from bovine tissues which might contain the BSE agent, i.e… specified bovine offals … It would make sense to extend this prohibition to feed for all species. As far as human health is concerned…we do not believe that…any further action needs to be taken. That settled matters. In the jumpy state of public opinion there was no question of not introducing the protective measures that SEAC had recommended, and the animal SBO ban had become inevitable. The precise way in which it was introduced did not follow normal procedures which, as we shall see later, was unfortunate. The normal procedure is to announce an intention to legislate and to circulate details of what is proposed to all with an interest who then have an opportunity to comment not only on its desirability in principle but, crucially, also on the detail; often the draft legislation is circulated or at least shown to those with major concerns and, crucially, those with expertise are given the opportunity to draw attention to any weaknesses in what is envisaged. In this case it was thought that public opinion was too febrile for this to be possible. Instead it was decided to keep the SEAC recommendation confidential for a short period and rapidly to draw up the secondary legislation necessary to put it into effect. In this way it would be possible to adopt the response to the SEAC recommendation virtually at the same time as it was announced. It was hoped that this would serve to reassure the public. Accordingly the results of the experiment, SEAC’s recommendation and the government’s intention to legislate were announced on 24 September 1990, while the legislation was introduced immediately thereafter on 25 September.

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The difficulties of the animal SBO ban Experience over the next few years showed, unfortunately, that of all the measures adopted by government during the BSE saga the animal SBO ban in its original form was the least satisfactory. We will come back to the reasons for this later, but a contributing factor was the decision to draft in secret and to implement without consulting either those with an economic interest or those charged with enforcement. This approach would have been acceptable albeit not desirable if those concerned in MAFF had made a good job of drawing up the draft Order. Unfortunately they did not do so and the lack of consultation meant that their proposals were not subject to any informed scrutiny. There is a lesson here, namely that consultation on such matters is desirable and should only be forgone in wholly exceptional circumstances. Whether the state of public opinion in autumn 1990 justified forgoing consultation is a matter of judgement. If we judge by results it was not a success. For the present we need only note that the basic system adopted was to continue to treat SBO in the same way as ‘unfit meat’, that is meat that had been condemned by slaughterhouse inspectors as being unsuitable for human consumption or meat from knackeries or hunt kennels all of which was excluded from the human food chain. SBO had, for example, to be stained with the same distinctive dye as unfit meat. The system had been adopted to implement the human SBO ban since the rules for unfit meat were well known and specifically designed to keep material out of the human food chain.

Taking stock: the protective measures in place from Autumn 1990 Thus a full array of protective measures was in place from September 1990. The slaughter and compensation scheme protected the public from clinically ill animals, while the requirement to remove SBOs from all bovines served to do so in respect of subclinically infected animals. So far as animal health was concerned ruminants were protected by the ban on feeding them with ruminant protein. Other animals were protected by the ban on feeding them with ruminant SBO, that is by the animal SBO ban; the latter measure acted as an additional protection for ruminants since even if they were inadvertently fed ruminant protein it ought not, after September 1990, to have contained infective material. This was a comprehensive (and costly) set of measures which had a substantial degree of success. While with the benefit of hindsight we can see that none of them were 100% effective we can also see that the measures to protect human health were the more successful.

A relatively quiet period: late 1990 to 1994 After the adoption of the animal SBO ban in September 1990, the BSE story entered a relatively quiet period. A comprehensive system of controls had been put in place which it appeared ought in due course to eliminate the disease

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(though because of the incubation period it was appreciated that this would take several years) while protecting the public from any unexpected risk. The size of the epidemic becomes apparent However, it was clear from the latter half of 1990 that the epidemic would be much greater than had been initially expected. The number of cases rose sharply until the beginning of 1993 when it reached a peak. As Figure 4.1 shows (on a monthly basis), confirmed cases per week rose from about 150 at the beginning of January 1989 to 320 in January 1990 to 420 to 800 in January 1992 and to 860 in January 1993; thereafter numbers gradually fell. Of course this increase in cases proved nothing about the effectiveness of the measures taken. By the end of 1990 it was known that the average incubation period of the disease was nearly five years so the effects of any measure would not be noticed for several years (see also Figure 4.2). Over the four years or so following the adoption of the animal SBO ban policy was adapted as the results of various experiments set up years before and as evidence of the effects of the protective measures taken became available. These are described shortly. One unwitting experiment was not, however, referred to very often. This was the effect on people of hundreds, perhaps thousands, of clinically infected animals which probably went into the human food chain before the slaughter and compensation scheme was adopted in 1988 (and in many cases before the disease had even been properly recognized). Significant quantities of infectious material may also have reached consumers from subclinically infected animals before the human SBO ban was adopted in November 1989. The point was not overlooked. When I became Permanent Secretary in February 1993 the CVO told me he was uneasy on the former score in particular. Matters were, however, being monitored. The CJDSU had been set up to check for any evidence suggesting that BSE was having an effect on human health. There was simply nothing anyone could do to alter what might have happened as a result of this exposure before 1988/89. The dose of infected material required to infect cattle with BSE by the oral route All the evidence is that until well into 1994 it was more or less universally assumed that a relatively large dose of infectivity would be required to infect cattle via the oral route. (An earlier experiment at the Neuropathogenesis Unit (NPU)2 in 1990 which showed that half a gram of infected brain could transmit BSE to a sheep was not properly brought to the attention of those active in the area such as SEAC and MAFF and was not discovered by them until the end of 1994.) This was clearly the overwhelming view in MAFF as is shown by numerous internal notes written at the time supported by the recollections of most of those involved; the evidence is that DoH shared this view, as indeed did SEAC as we have already seen. Naturally the various sections of the beef industry took their cue from the relevant departments. This widespread assumption about the dose required to cause infection was probably more significant than it might appear at first sight. For example it may account for current attitudes towards enforcement

0

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Source: DEFRA: Monthly BSE statistics (Data valid to end of March 2005. Produced July 2005), © DEFRA (2004).

Figure 4.1 BSE cases in Great Britain confirmed by passive surveillance, by month and year of clinical onset

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Source: DEFRA: Monthly BSE statistics (Data valid to 1 June 2005 The inset shows 1996 to 2000 on larger scale as the cases for later years do not show on the scale used in the larger) © DEFRA (2005).

Figure 4.2 Confirmed cases of BSE in Great Britain with known dates of birth, by month of birth

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particularly of the feed ban. Clearly if a large dose of infectivity is required to cause infection minor cross-contamination in mills probably does not matter much; accordingly there would be no justification in insisting the industry should adopt expensive extra precautionary measures. Why was this view on dose, later shown to be misguided, held? The Report of the BSE Inquiry is not helpful in this respect. Perhaps those concerned did not want to discuss the reasons that had led them to support a wrong view. However, in discussion with those involved over the years I have identified two reasons which are, at least superficially, plausible. One was the belief that BSE was either the same as or very closely related to scrapie and hence would behave similarly. Since scrapie had existed for centuries, perhaps longer, it seemed to follow, given that the scrapie agent would almost certainly have been present in feed at some concentration since MBM had first been incorporated in ruminant feed decades before, that the sudden occurrence of an epidemic in cattle must be caused by an increase in the amount of infective agent present. As we have seen, changes in rendering procedures which occurred when the epidemic started gave a plausible explanation as to how this might have arisen. Note that in this view significantly reducing the amount of infectivity in feed would suffice to stop animals becoming infected. The second reason reflected the need to account for a puzzling phenomenon, namely the number of instances where only one animal in a herd succumbed to the disease. This is quite unlike the pattern for other diseases. A plausible explanation seemed to be that a critical dose was needed to cause infection and that feedstuffs normally contained concentrations of infectivity at a level below the critical one so that only the odd animal which by chance ate unusually large amounts became infected. These explanations do not feature in the Report of the BSE Inquiry by when they were known to have been disproven. By then the consensus view was different and there were attempts by some to claim that they had never accepted that a large dose was needed to cause infection. It is, therefore, instructive to consider the details of the ‘attack rate’ experiment started at the CVL by MAFF in January 1992 essentially to determine the dose required to transmit BSE to cattle orally. Calves were fed homogenized brain from BSE cases in doses of 1 gram (g), 10g, 100g or 300g. It was appreciated that as in the case of all other experiments on BSE the results would not be known for years. The structure of this experiment gives a clear indication of the expectations of those who set it up. This is because any scientific experiment set up to assess sensitivity will seek to include within it concentrations which give both positive and negative results. In this way the experiment will yield the most information because the dose necessary to give a positive result will be narrowed down to a range. If all the concentrations tested give the same result all we can conclude afterwards is that the critical level is above or below a given figure which is much less informative. Accordingly we can deduce that the expectation, or at least the best guess, of those who set up the experiment was that a critical dose would be well above 1g and well below 300g. This was highly significant because later when

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it became apparent that 1g was sufficient to cause infection in all normal cases it came to be appreciated that the assumptions that had underlain attitudes towards enforcement were unjustified. The details of the experiment were also significant for another reason. The existence and details of the attack rate experiment were widely shared within the scientific community. There is no record that it was criticized on the grounds that the doses tested would yield less information than was possible for the same effort – or in other words that the doses tested should be smaller. This does not prove that there might not have been those who had suspicions that this might prove to be the case. It does, however, show that if anyone did have such doubts they were insufficiently confident to voice doubts publicly (or indeed privately) and hence run the risk of being proved wrong. Claims by some after the real position had been established that they had never accepted the ‘high-dose’ theory should be judged with this fact in mind. Why those at the NPU who knew of the earlier work with sheep did not comment is not clear. The emergence of infected animals born after the feed ban (BABs) The major development between late 1990 and the end of 1994 was the advent of BABs and the attempt to account for them. Eventually serious conclusions had to be drawn to the effect that there had been a degree of failure to comply with the rules in some slaughterhouses, rendering plants and feedmills, both accidental and deliberate; that the local authority enforcement system was even less effective than had been thought; and that the rules themselves were inadequate in some respects especially taking account of the results of the attack-rate experiment described in the previous section which became known towards the end of 1994. However, this is to jump ahead and it was some time before these conclusions were drawn. The first BAB was reported on 22 March 1991, though this case was complicated by the fact that its dam had died of BSE raising the possibility that it represented a case of maternal transmission. However, by 15 November five cases had been confirmed and by 14 February 1992 16 cases. By 11 June the figure had risen to 69. This unwelcome development led those concerned to reflect more closely on the constituents of feed following the feed ban. They noted that at the time of the feed ban there had been no attempt to withdraw feed that might be contaminated from the feed chain. They also began to appreciate that contaminated feed or feed ingredients (some farmers make up their own feed) might linger on farms for quite a time especially if purchases were not used up in the order of purchase, which might well occur if new purchases were placed on top of existing stock. Those of us with experience of regular purchases of yoghurt stored in the family refrigerator will appreciate the possibility that a particular item might linger for a long time if stock is not properly reorganized after each purchase. The conclusion was accordingly drawn, quite reasonably, that there could have been a considerable carry-over of infected feed after the ban came into force that would be expected to cause many cases of BSE. Even more importantly, it came to be appreciated as the number of cases rose sharply in the period 1990/92 that the

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rate at which animals were being infected in 1988 when the ban was imposed had been rising sharply. Thus the delay of a month between the making of the Order and bringing it into force had been more significant than had been thought at the time. By June 1992 MAFF vets were advising Ministers that carry-over of infected feed could be expected to lead to a three-month lag in the effect of the ban. By September, given the relentless increase in the number of BABs being confirmed they were speculating that the period might be six months. By 10 November 1992 the number of BABs had risen to 353, 16 of them born in 1989 and that day the CVO met UKASTA, the main representative body for the animal feed industry. The latter gave him in confidence the results of a survey of their members. This showed that some feed containing ruminant protein had probably been manufactured right up to the date of the ban and some sold as late as October 1988. The ban on sale was meant to have come into force on 18 July. It had also been expected that manufacturers would cease using ruminant feed in ruminant protein directly the Order were made; the responsible ones did so but, apparently some did not. This information, regrettable as it was, lent credence to the carry-over theory. SEAC considered the question of BABs at their meeting on 22 April 1993. By then there were 1,791 BABs of which 108 had been born in 1989. The carry-over of infected feed was still considered to be the most likely explanation of the phenomenon though other explanations, such as maternal and horizontal transmission could not be ruled out. By 7 October 1993 when SEAC again considered the matter the number of BABs had risen to 4,010 of which 614 had been born in 1989 and 4 in 1990 (Figure 4.2, p.69). Despite the problem of BABs it was established that the number of cases was very much less than would have been the case had the course of the epidemic up to the imposition of the feed ban in July 1988 continued unchanged. A MAFF epidemiologist published a paper in the Veterinary Record on 12 March 1994 showing the extent to which the epidemic had declined despite the advent of BABs. By then cross-contamination in feedmills was suspected to have contributed to the BABs phenomenon. She wrote: The accidental inclusion of meat-and-bone meal in cattle feedstuffs or contamination with ingredients used in pig and poultry rations is also possible. This last point reflected consideration by MAFF epidemiologists of the geographical spread of cases with a disproportionate number being found in the Eastern counties of England where pig and poultry production is concentrated for economic reasons (because these are the counties with the greatest cereal production which comprises much of the feed of both pigs and poultry). In other words, cross-contamination in feed mills had contributed to the BABs phenomenon. By August 1994 four BABs had been identified, born in 1991. This was worrying and significant because it meant that infection had not been cut off by the adoption of the animal SBO ban. Thus, despite that ban and the feed ban some SBOs were finding their way not only into feed, which ought not to have been

A Chronicle of Events until 20 March 1996 73

possible (provided the definition of SBOs included all the infective parts of the bovine carcass), but into ruminant feed. The protective system put in place over the period 1988/90 had succeeded in reducing the number of cases to a major extent but it had not been fully effective. Major improvements in it were needed. We deal with the action taken below. Enforcement and monitoring in slaughterhouses, rendering plants and feed mills in the period up to early 1995 Before looking at the changes made to the protective system essentially in response to the continued confirmation of BABs, it is useful to look at the enforcement of the original controls. Essentially these required SBO to be kept separate from other bovine material and destroyed, ruminant protein to be kept separate from other protein and feed for ruminants to be kept separate from feed for other animals. An important practical consideration was that SBOs, which contained the intestines, were bulky and messy. They could not be dumped or burnt; they had to be processed first into a more manageable form and in practice this meant treated in rendering plants. Thus care was needed in slaughterhouses, in rendering plants and in feedmills (and on farms) and in the transport of material between all such premises of all material from slaughtered bovines. The first responsibility for ensuring the rules were adhered to lay with the operators concerned. It was obviously in the interests of operators throughout the beef sector to be scrupulous in following the rules, especially those concerned with a highly sensitive matter like BSE, since all of them (the operators) could be affected by the public reputation of the sector. Moreover, given the number of operators, the small size of many of them and how scattered they were geographically there were limits to what outside enforcement could achieve with the resources available. Given the self-interest of operators in sustaining the reputation of the sector relying to some extent on self-regulation did not appear unreasonable. This was the general view. The Report of the Lamming Committee (set up to investigate animal feedingstuffs following a recommendation of the House of Commons Agriculture Committee in their report on BSE) stated on 16 July 1992: … the ruminant protein ban and the specified offals ban are to a considerable extent dependent of self-regulation by the industry. The Lamming Report stated that in their view ‘the controls are working’. Unfortunately it gradually became clear that this judgement was an exaggeration in two respects. First it emerged that some animals could become infected much more easily than had been assumed. Secondly and sadly, it became apparent over time that whatever the long-term interests of operators in sustaining the reputation of the beef sector, the rules had been ignored by some slaughterhouses and probably some rendering plants and feedmills also. Thus probably some BABs reflected the unwitting results of actions that those concerned would reasonably have regarded as responsible in the light of the information they had been given; others certainly arose as a result of deliberate and/or careless infringement of the

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rules. Unwitting contamination was at bottom a consequence of the widespread view that a large dose of infective material would be needed to cause infection. Deliberate flouting of the rules owed more to the unscrupulous nature of some operators and the financial strains to which they were subject. MAFF were uneasily aware that the success of their BSE policy was dependent on satisfactory enforcement and from the beginning operated checks of their own on what was happening on the ground. However, they operated under a number of handicaps in attempting to do so. Such activity was not part of their normal work; accordingly they were not financed or staffed to undertake it. While some such work can always be absorbed they could not spend too much time on the task without neglecting other work. Further, responsibility for enforcing the BSE controls fell to local authorities and MAFF had no formal enforcement powers in slaughterhouses, rendering plants or feedmills. The legislation did not even give MAFF powers to monitor local authorities as some authorities were quick to point out. In slaughterhouses MAFF did not have powers of entry but instead had to rely on the good offices of local authorities to secure entry. Since it was apparent to all that such inspections were directed at finding out whether the same local authorities were performing their duties properly it ought to cause no surprise that MAFF vets found only a small proportion of the widespread abuse that became apparent only after 1 April 1995. On that date the Meat Hygiene Service was established as a part of MAFF and from then on SVS checking only had to rely on another part of MAFF for cooperation. Both levels of local authorities were involved in enforcing the rules on BSE. So far as slaughterhouses were concerned dissatisfaction with enforcement by (District) Councils was one of the factors that had led government to conclude that a national system was required. Nevertheless, speaking broadly, policing of the controls to protect human health in slaughterhouses was the only area where some real attempt was (mostly) made to enforce the rules. In that part of slaughterhouses where activities did not impact on human health, notably the gut room where SBO was stored, enforcement appears to have been close to non-existent; enforcement elsewhere in the chain was patchy at best. MAFF’s attempts to monitor enforcement outside slaughterhouses was handicapped both by their absence of formal powers and by the absence of a test that could detect ruminant protein and differentiate it from other protein. Work to develop such a test started in a MAFF laboratory in 1988. By 1994 though still not perfect it was sufficiently reliable to be used in feedmills and MAFF, by then sufficiently alarmed largely to sweep aside doubts about the legal position which had inhibited them earlier, started testing samples. There is evidence that the mere fact that such tests were taking place led some feedmills to tighten up their procedures. It was also important that practices in rendering plants did not risk contaminating material which would ultimately go for animal feed with ruminant SBO, though of course renderers could do little if the material delivered to them was already contaminated or was simply incorrectly labelled. There is evidence that both occurred. However, following concerns expressed in 1991 at procedures in

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some plants MAFF issued a code of practice on 7 August 1992 stressing the need to keep SBO separate from other material and suggesting how this could be achieved. Transmission of BSE to marmosets On 14 February 1992, MAFF and DoH were advised that BSE had been transmitted to marmosets by inoculation of infective brain material into the brain. The significance of this was that marmosets are primates and hence more closely related to man than cattle, mice or any other non-primate species. However, in the same experiment scrapie had also been transmitted in the same way to marmosets so it was not clear whether the results represented something to worry about or not. SEAC concluded that in the light of previous experiments the result was ‘not surprising’. SEAC’s 1994 Report on the present state of knowledge and research In September 1994, SEAC produced a Report on the present state of knowledge. This was a useful document but attracted no media coverage. Later the BSE Inquiry claimed that it demonstrated a significant change in SEAC’s perception of the risk posed by BSE. I refute this claim in more detail in Chapter 7. For the present it is sufficient to note that there is no evidence that the Report had any effect on the attitude of any of those working on BSE in DoH or in MAFF, though I for one studied it carefully at the time. If SEAC had intended to indicate they had revised their perception of risk then they were signally unsuccessful. CJD in farmers In August 1992, Will, the Director of the CJDSU, reported that he had identified a probable case of CJD in a farmer who had had a case of BSE on his farm. SEAC considered the matter on 15 October. Will reported the case in the Lancet on 6 March 1993. He wrote there that the case: … is most likely to have been a chance finding and a causal link with BSE is at most conjectural. Despite this, inevitably the case excited much media interest. ‘Mad cow link to death of farmer’ was a typical headline in one tabloid. As a consequence of the media fuss the new CMO made a statement on the safety of beef on the same lines as his predecessor had done (p. 63). Again the BSE Inquiry later criticized him for not including sufficient caveats in it. Matters became more serious in July 1993 when it became known that Will had confirmed a second case in a farmer who had had a case of BSE in his herd. SEAC concluded on 20 July 1993 that ‘no conclusions could be drawn from the available statistical information’. The DoH issued a statement intended to be reassuring, and in October SEAC decided that if a third case of CJD in a farmer appeared it would need to hold a meeting immediately. As we shall see, a third and a fourth case of BSE in a farmer appeared in due course but before then attention focused on a different case.

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The case of Vicky Rimmer Public concern reached new levels of intensity when it became known in January 1994 that a 16-year-old girl was suspected of having contracted CJD. It is highly unusual for anyone so young to contract CJD and the implications seemed very worrying. Some were quite clear on the lessons to be drawn. Stephen Dealler was quoted in Today as stating ‘It is an inescapable conclusion that BSE has got into our food chain’. In The Times Richard Lacey was quoted as saying ‘… this is the first case of BSE infecting a member of the human race by this method’. (The method was eating processed beef.) The case struck a cord with the public, understandably given the appalling state to which a teenager had been reduced. However, to this day it has not been shown that it had any relation to BSE. This may come as a surprise to many given that it was cases of CJD in young people that eventually led to the conclusion that BSE had probably infected humans. Nevertheless, though Vicky Rimmer is another example of CJD in a young person her case may well have no connection to BSE. The point is that in the cases of CJD in young people which led to the conclusion that they had been infected with BSE the brains of those concerned demonstrated certain specific and otherwise unusual patterns when they were examined after death; such cases came to be described as new-variant CJD or vCJD for short. Vicky Rimmer is not included within this class. If, therefore, she was infected by BSE, which is possible, she is a member of a different class of which other cases have not yet been found. Alternatively, her case may have had nothing to do with BSE and she may simply have been dreadfully unlucky. BSE agent found in the distal ileum of calves On 17 June 1994 it was reported that a MAFF experiment had shown that BSE could be detected (via injection of material into mice) in the distal ileum (small intestine) of calves fed a large (100g) dose of homogenized infected cattle brain at four months of age. This was potentially significant since calves under six months of age were exempted from the BSE controls. On the other hand, 100g of infected brain is an awful lot of infectivity and enquiries revealed that that part of a calf’s carcass is not used for human consumption. On 25 June SEAC considered the matter and clearly thought the risks, if any, to be minute, though they did note one option was to include calves’ intestines within the definition of SBO. They concluded that: … the theoretical risk of infection of man via food derived from infected calves is miniscule if it exists at all. There is a theoretical risk and Government could respond by a limited SBO ban for calves to exclude the intestines. The CMO, however, was by now becoming alarmed about BSE and quickly concluded that extending the SBO ban to include calves’ intestines and thymus (another potential risk by analogy with the scrapie model) was the correct response. Judging by the evidence given later to the BSE Inquiry there appears to

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have been some disagreement about this at working level between DoH and MAFF; this would not be surprising given SEAC’s views. If this was the case it never surfaced at top level. The Minister (Gillian Shephard) quickly made it clear that she would be guided by the CMO and there was no dissent. The relevant Order was made and came into force on 2 November 1994. Result of attack-rate experiment The official results of this experiment were not put forward until February 1995. However, the Attack Rate Study was being conducted at a MAFF site and by the second half of 1994 it was becoming known to Ministers and officials that the animals succumbing to the disease included some which had received the minimum dose of one gram. One gram was a much lower dose than most had considered would be required. The information coming forward from the vets that one gram was sufficient became stronger as the months passed, presumably as more animals challenged with only one gram succumbed to the disease. This information on dose was of considerable significance since it suggested greater care was needed throughout the animal feedchain than had been hitherto assumed by all if contamination were to be avoided. Report of CJD surveillance unit An appropriate end to this section is provided by quoting from the third Report of the CJDSU published on 7 October 1994: We see no evidence… of an emerging CJD epidemic. We…. remain satisfied with the adequacy of current controls to protect public health in regard to CJD.

1994: a reassessment of the success of the animal health controls By the summer of 1994 it had become clear that a substantial proportion of BABs could not be attributed to the carry-over of feed after July 1988 when the feed ban came into force, or even after October 1988 when the sale of ruminant feed which incorporated ruminant protein and hence possibly BSE infectivity had apparently actually stopped. Action needed to be taken to strengthen the animal health controls. The position with which policy-makers were faced was that there was no evidence that infection had been caused other than by infected feed. New cases had therefore probably consumed infected feed. On current theories feed could only be infectious because it contained ruminant protein which after July (or October) 1988 ought not to have been possible. Further, after November 1990 when the animal SBO ban came into force ruminant protein ought not to have contained SBO. Nevertheless, feed could only contain infectivity if despite the rules it contained not only ruminant protein but SBO. Alternatively the current definition of SBO might not include all the organs which could contain infectivity. There was at this stage no evidence for the latter so feed which caused infection had probably included ruminant protein which itself included SBO.

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Each one of the steps in the above argument was at the time rather less certain than I have presented it. It must be remembered that BSE was a new disease and little was certain. For example horizontal (bovine to bovine) or vertical (dam to calf) transmission had always been recognized as possibilities although by this stage it was known that if either occurred it was at a low level. Later, in 1998, it was found that one organ, the dorsal root ganglia, not included within the definition of SBO, could contain infectivity. This shows how in a new field nothing is ever entirely secure. However, even with the benefit of hindsight it is apparent that not treating dorsal root ganglia as SBO did not fully account for the BAB problem. By mid-1994 it was clear that action was needed. The disquieting analysis set out above seemed to imply the rules were not being followed either in slaughterhouses or in rendering plants or in feedmills or in transport between sites or, conceivably, all these possibilities were true. Yet another possibility was that the rules were wrong. Possibly stricter controls were required. This could involve a number of minor changes but two major ones were considered. The first was to concentrate on SBO by requiring it to be processed in specially dedicated rendering plants and keeping it separate from other material until disposal. This approach would have as its aim and method keeping infectious material away from cattle feed. The second was to require ruminant feed to be manufactured in specially dedicated mills, thereby eliminating the possibility of ruminant feed being cross-contaminated with feed for non-ruminants and, hence, perhaps with infectious material despite the animal SBO ban. The two possibilities were not mutually exclusive; it would have been possible to require both. It was apparent that both would prove difficult for the industry, especially small operators (renderers or feed manufacturers) which might well be forced out of business. Consideration of what modifications to the rules would provide the most effective system at least cost proceeded in parallel with the search for what had gone wrong. Three conclusions seemed inescapable. The first was that the animal SBO controls adopted in 1990 were misconceived and unsatisfactory. The system for treating SBO was essentially the same as had been put in place when the human SBO ban had been adopted in 1990. It was based on the long-standing regime for ‘unfit meat’. The latter consisted of material condemned in slaughterhouses or derived from ‘fallen stock’, that is animals which died on farm and were sent to knackers or hunt kennels. Before the adoption of the animal SBO ban this system had been a reasonable one since the only objective then was to keep SBO material out of the human food chain. The unfit meat regime was designed to do just this. However, much meat deemed unfit for human consumption after processing went for animal feed; that was economically and environmentally the best way to dispose of it. The whole system – which involved bins of material travelling round the country labelled ‘unfit for human consumption’ – was inadequate for material which had to be kept out of animal feed. Unless bins were carefully labelled SBO could be confused with other material unfit for human consumption. The same dye was used to stain unfit meat and SBO and this requirement was left unchanged when the animal SBO ban was adopted. Hence even a diligent enforcement officer – of whom there were far too

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few – would have had difficulty in ascertaining whether a particular batch of animal residue in various stages of decay contained unfit meat or SBO. The legislation contained no requirement not to mix SBO with other material. Given the economic incentives it is small wonder that a proportion of SBO (a source high in protein) found its way into animal feed. In short the need fundamentally to amend the SBO regime when the animal SBO ban was adopted had been missed. Secondly, and even allowing for the unsatisfactory nature of the animal SBO ban, it appeared that local-authority enforcement had also been inadequate. The full extent of this failure did not become apparent until after 1 April 1995 when the MHS assumed responsibility for enforcement in slaughterhouses. I describe this below. At this stage it was more a matter of suspecting that failures in enforcement had occurred more frequently than had been detected. Accordingly, the intensity of monitoring by the SVS in slaughterhouses and in feedmills was stepped up at this time despite the legal difficulties and the difficulty in finding veterinary resources. Thirdly the suspicion began to emerge, fed in part by information and/or rumour, that a proportion of operators in slaughterhouses and to a lesser extent in rendering plants and feedmills was prepared to act irresponsibly. MAFF officials decided it would be best to concentrate on controlling the treatment and movement of SBO. With the approval of the Minister (William Waldegrave) the following proposals were circulated to interested parties for comment in August 1994: (a) a suggestion that SBO should be rendered in dedicated lines or in dedicated rendering plants; (b) a requirement to stain SBO with a distinctive dye, that is a different dye than that used for unfit meat; (c) a requirement to handle, store, transport and process SBO separately from non-SBO material; and (d) a requirement that operators keep extra detailed records of the treatment of SBO which had to be kept available for inspection. At this stage (a) was put forward more tentatively than the other proposals, because it was known that several renderers could only operate such a system if they installed expensive new equipment. They might not be able to afford to do so and if not one renderer, Prosper de Mulder, which already operated dedicated lines, might gain a virtual monopoly in treating SBO. Since the Monopolies and Mergers Commission had expressed concern more than once about the dominant position in rendering exercised by this firm, this would be unfortunate. At about this time the first results of the attack-rate experiment began to become known, which provided extra justification for the proposals put out to consultation as did emergence at much the same time of BABs born in 1991, well after the animal SBO ban had been imposed. As expected, the principal difficulty that emerged from the consultation was over the possibility of requiring the use of dedicated rendering facilities for SBO.

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Eventually early in 1995 the CVO decided in the light of all the emerging evidence that it was necessary to make this a requirement even though it might take some time to put into effect. A paper to this effect was put to Ministers on 9 January 1995. This was discussed with the Parliamentary Secretary on 19 January when I am recorded as saying that ‘it was clear we needed to implement the proposals… The difficulty would be in explaining why we had not done so at the outset.’ This last remark proved all too accurate. The proposals were approved and it was decided to go ahead with the introduction of the new staining requirements ahead of the other proposals. An Order was made accordingly with the requirement to use the new dye coming into force on 1 April 1995, the same day as the Meat Hygiene Service (MHS) took over responsibility for meat inspection from local authorities. As we shall see, these two changes were the key to the major improvements in standards it was possible to achieve over the next few months. Standards in feedmills are improved From the second half of 1994, MAFF was engaged in tense discussions with UKASTA. The discussions would have appeared to outsiders as a mysterious dance but what lay behind them was UKASTA’s fear that their members might be pursued in court by farmers for selling them feed contaminated with BSE. UKASTA hoped to get an indemnity or, more realistically, some assurance from MAFF which would help in this respect. To obtain it they suggested that they might be forced to cease using MBM which they knew would be unwelcome to MAFF because of the unpleasant economic and environmental effects. In short, UKASTA’s game plan was to threaten to cease using MBM which they expected to alarm MAFF who would urge them not to take such a damaging step. They would be able to reply that they might not make the change if they were assured that reasonable endeavours on their part to keep MBM out of ruminant feed would meet their legal obligations. If we had been prepared to make such a statement no doubt they reasoned that thereafter any legal liability would lie with government rather than their members. UKASTA’s representations on these lines were made to me. I was sympathetic in general but naturally could not give any assurances implying that the regulations excluding ruminant protein from ruminant feed need not be fully met. The trap was an obvious one. From about this time matters seem to have improved. The information on dose from the attack rate experiment had an effect as did the threat posed by MAFF’s growing use of the ELISA test as it became more reliable. Among actions taken by feedmills were the exclusion of MBM from ruminant mills and the installation of dedicated blow lines for MBM in others.

From 1 April 1995: the establishment of the meat hygiene service transforms the situation The MHS took over responsibility for enforcement in slaughterhouses on 1 April 1995. As a direct result it was discovered that some operators were more or less

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ignoring the rules on the treatment of SBO and that the attitude towards enforcement of a proportion of those charged with providing it was unacceptably lax. As a consequence of what was learned for the first time about the real position on the ground, significant changes were made to the protective system and because of the existence of a single body under departmental control it proved possible, though only at significant cost, to achieve major improvements in enforcement standards. The advent of the MHS represented a major step forward not least in government’s ability to control BSE, and it is a pity it did not come into being earlier. Improved enforcement standards did not come about overnight on 1 April. Except at the top level MHS staff had been taken on from local authorities and they carried on as before. The breakthrough occurred as a result of monitoring by the SVS on the use of the new die for SBO. Now that monitoring was a matter of checking on enforcement by a MAFF body it was a much easier process because the legal constraints disappeared; obviously the department was entitled to monitor itself. It was perhaps also significant that the top management of the MHS were new and hence could not be held personally responsible for existing practices. They were therefore less defensive when deficiencies were found than might otherwise have been the case. In late April 1995, Prosper de Mulder notified the SVS that most SBO arriving at their relevant plant, which processed some two-thirds of the SBO produced in the whole country, was arriving without being stained with the new die. SVS enquiries seemed to confirm this surprising finding though it was not clear whether this was a transitional problem reflecting the introduction of the new die. As one consequence the SVS decided to make an unannounced visit to every slaughterhouse to check on the treatment of SBO during May/June. Follow up action would follow any contraventions found. The summary of this round of visits put together at the beginning of July noted that 14 per cent of slaughterhouses had not fully complied with the rules on separating SBO, and 65 per cent had not complied fully with the rules on staining. Though some of this failure reflected the recent change in the required die there was, the official noted, ‘widespread and flagrant’ infringement of the staining regulations. In some cases no attempt had been made to stain SBO and it was stored in unmarked containers suggesting it would have found its way into animal feed eventually. In some cases management had not even sought to obtain the die without which they could not operate legally. This finding came as a shock since it showed a much worse situation than had been found before when such inspections had had to rely on the goodwill of local authorities. It led to vigorous action by the SVS on this and other matters and to a series of instructions to the MHS which over the next few months was able to transform the situation. Inspectors who had been transferred from local authorities to the MHS came to appreciate that different and higher standards were required across the board not least regarding the BSE controls. Further series of unannounced visits were held and the situation gradually improved; even recalcitrant slaughterhouse operators – a tough lot – came to realize that they would be prosecuted if they did not comply, a sanction almost never invoked under the

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previous regime. All this was reinforced by the Minister (Douglas Hogg). On 9 November 1995 he told slaughterhouse operators that 100 per cent compliance was required, that there would be no more warnings and that deficiencies would result in prosecutions. By 4 January 1996 the failure rate – that is slaughterhouses where lapses had been found – had dropped to 6 per cent and these were of a minor nature. Further improvements in the animal health regime We saw above that the requirement to stain SBO with a specific die was introduced on 1 April 1995 ahead of the other proposed improvements in the animal SBO ban. This had proved a good move since it had revealed the extent of noncompliance in slaughterhouses and the weaknesses in enforcement and allowed steps to be taken to deal with both. These discoveries reinforced the need for the other measures. An Order introducing all the new requirements was signed on 18 July 1995, though the obligation to use dedicated lines for rendering SBO was delayed for six months to give those concerned time to comply. The drive from MAFF and the MHS with consistent, energetic support from the Minister (Douglas Hogg) drove standards upwards throughout 1995 at all stages of the beef chain as is shown by the rate at which animals became infected (see Figure 4.2). Why was enforcement unsatisfactory and why was this not discovered earlier? It was well-known to MAFF that standards in slaughterhouses were dubious and that the local authority enforcement system could not or would not bring about improvement. This was the main justification for the decision to create the MHS. Of course it did not help that there was a vociferous lobby denying that standards in slaughterhouses were low, denying the need to involve vets in enforcement and opposed to the creation of the MHS. Nor did it help that these views were well represented on the Tory backbenches and in the Tory press and, one might add, among some non-MAFF Ministers. This negative chorus was not countered by support for the concept of the MHS from consumer organizations, which one might have thought would interest themselves in proposals to improve meat hygiene and the enforcement of rules on BSE. The extent of the transgressions in the treatment of SBO revealed by SVS monitoring in 1995 came as a surprise. It is instructive to consider why these had not come to light earlier. Enforcement work was underfunded by local authorities and many of those involved in it appear to have been demoralized. The system was due to be replaced which will not have helped. There was among some meat inspectors a resentment at veterinary ‘interference’ along the lines of a standard trade-union demarcation dispute. Rivalries between those charged with enforcing the rules will not have helped the overall enforcement effort. In some cases it seems meat inspectors did not operate as independent entities charged with protecting the public interest, but more as members of plant staff; ‘regulatory capture’ is the technical phrase and

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this was a particular problem for slaughterhouses where the regulators are few and isolated among many of the regulated. A culture of avoiding prosecutions had grown up. In short the system was inadequate for modern purposes and was probably getting worse as the time approached when it would be replaced. Though the shortcomings listed above confirmed the wisdom of the decision to replace local authority enforcement with a national system enforcement may well have deteriorated as the change loomed. One question that arises is whether the SVS ought to have discovered these inadequacies of enforcement earlier. Later the BSE Inquiry made rather a meal of this looking into all aspects in great detail. On this we need to remind ourselves of the limited powers the SVS possessed. They were not the enforcement authority in slaughterhouses or elsewhere; that role fell to District and County Councils respectively. The SVS had not been given any statutory role to monitor the position, and after the Food Safety Act came into force in 1990 they did not even have powers of entry. This meant that the SVS could only monitor matters from a position of weakness. They could only act with the agreement of slaughterhouses – that is those whose activities were being inspected – or, failing that, with the agreement of local-authority inspectors who did have powers of entry but whose efforts at enforcement were also under inspection. Some of the latter would have harboured resentments that their role was due to be taken over by a new part of MAFF (the MHS), and this will not have made cooperation easier. It must also be recalled that at this period the deregulation initiative was at its height. Under this banner a proportion of the press were apt to criticize ‘petty bureaucrats’ who exceeded their powers. Since SVS staff did not have any powers in relation to the animal SBO ban, any attempt on their part to push matters with, say, a recalcitrant slaughterhouse owner would lay them open to just that charge. Given the legal position and government support for ‘deregulation’, a veterinary officer out in the field who suspected that all was not well in a given slaughterhouse and was contemplating how hard to push matters with the management and/or local authority could be forgiven for wondering how much support he would receive from his superiors if a complaint were made that he had exceeded his powers – a complaint likely to be justified by a strict interpretation of the legal position. This thought will not have encouraged courageous action. All these considerations put obstacles in the way of effective monitoring of the situation by the SVS. In particular because of the absence of legal powers it would have been likely that inspection visits by SVS staff would have been agreed with slaughterhouse management beforehand giving plenty of scope for things to be tidied up. Really vigorous and unannounced inspections were unlikely to be made unless staff knew the need for them was fully recognized right at the top and that this task had priority over others. This did not happen until the 1995 developments described above. Given the circumstances it is perhaps not surprising the real situation was not revealed until then. There are some lessons here. One is that it makes a big difference whether those charged with enforcement and/or monitoring of enforcement are possessed of the

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formal powers to fulfil the role assigned to them. It is not satisfactory to expect people to achieve something if they have not been granted the powers to accomplish it. During the period after 1990 SVS management – with periodic encouragement from Ministers – had required the field service to report on whether the BSE controls were being enforced properly and it is now clear that the reports they received were misleadingly optimistic. When in 1994/95 the true position became clear there was some breast beating about all this. Anecdotal evidence, some of it from seemingly reliable sources, had certainly been received from time to time that SBO was being improperly mixed with other material. Reading about how these reports were treated one is left, overall, with the impression that with different personalities in some key positions in the SVS something like the truth might have been established earlier. This is not, however, the main point. The SVS had no formal locus in the control system for slaughterhouse operations (other than in the licensing scheme) as is made clear by the fact that they did not even have powers of entry to check on operations. Relying on exceptional individuals in another service (SVS) to identify deficiencies in the activities of those whose responsibility it was to provide enforcement (District Councils) would have been absurd. Further, with the system of local authority enforcement it is doubtful whether even if the truth about the widespread breaking of the rules had been known it would have been possible to put matters right. More limited deficiencies are found in the human health controls: action is taken on mechanically recovered meat SVS monitoring discovered widespread non-compliance with the rules protecting animal health. In October 1995 it also revealed for the first time a few cases where the human health controls had not been met in that pieces of spinal cord, a part of the carcass which can contain substantial amounts of infectivity in animals harbouring BSE, had not been removed properly yet the health stamp had been applied by the inspector. Subsequent checks showed these were not isolated cases though the level of failure was always low. The first such incident came as a shock to everyone since it was the first time evidence of any failure in the human-health controls had been discovered. (It must be appreciated that the existence of BABs showed only that all was not well with the animal health regime.) The CMO came to see me on 25 October and registered his concern at this development and at the position on BSE more generally; at his request I arranged for him to see the Minister (Douglas Hogg). (After my meeting with the CMO I recommended to Hogg that MAFF should call in the slaughterhouse owners and ‘read the riot act’. Hogg did so personally and this helped to impress on them the necessity of doing better.) Later in his evidence to the BSE Inquiry, the CMO stated that he had always relied on a system of inspections having been put in place by MAFF to ensure the ban was in place and (implicitly) 100 per cent effective. It is not clear whether he was aware that enforcement in slaughterhouses was not a MAFF responsibility until 1 April 1995 and the lapses had only been discovered because of this change in responsibility.

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In any case the finding ought not to have occasioned such surprise. It subsequently emerged that as long ago as 1990 MAFF had submitted a paper to SEAC which stated that it was inevitable that occasionally pieces of spinal cord would not be fully removed from carcasses. A minute’s reflection on the nature of the process involved – sawing down a backbone with a hand held saw sufficiently accurately to allow the spinal cord to be wholly removed afterwards leaving no traces behind – confirms that this must be the case. However, it is true that examples of such failure had not been found before, so it had come to be assumed that they did not happen. Also the results of the attack-rate experiment and the cases of CJD in farmers and young people cast BSE in a more sombre light and reactions to the discoveries on spinal cord probably reflected the fact. The 1990 MAFF paper had been put forward to aid SEAC’s consideration of whether special rules were needed to govern the production of MRM especially from the spinal column. At that 1990 meeting SEAC had concluded that the MRM process could be allowed ‘provided all the rules were properly followed’ – that is provided things happened in the very way MAFF had advised could not be relied upon. It appears that MAFF had assumed their technical advice on the practical position in slaughterhouses had been set aside by SEAC as inconsequential, while the truth was that SEAC had simply overlooked it in the press of a large agenda and limited time. Instead they had substituted their own views on what was possible in slaughterhouses, a subject in which they were not expert. SEAC had subsequently reconsidered MRM but confirmed their previous advice. The findings of spinal cord in 1995 gave reason to reconsider matters. The discovery of sections of spinal cord in carcasses after they ought to have been removed was made public by arranged Parliamentary reply on 22 November together with the steps taken to deal with the problem. In the light of these developments SEAC considered matters on 23 November 1995. By then small amounts of spinal cord had been found in carcasses on 17 occasions. This was the first meeting held under the new Chairman, John Pattison, who must have quickly come to realize what he had let himself in for. Eventually SEAC decided that: … until it was clear that the removal of SBO, particularly spinal cord, was… being undertaken properly in all cases it would be prudent, as a precaution, to suspend the use of vertebrae from cattle aged over six months, in the production of MRM. A measure to this effect was pushed through quickly, though for practical reasons the restriction had to be applied to all cattle. Only a few days were allowed for consultation contrary to standard practice and the measure prohibiting the use of the spinal column in the manufacture of MRM came into force in early December. By now BSE was very much centre-stage and legal and constitutional niceties took second place. Even so the legislation concerned was attacked by way of judicial review. Thus, ironically, the production of MRM from the spinal column was banned just as enforcement of the rules was being tightened up to a major degree. However, the change also had the unintended effect of keeping dorsal root ganglia

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out of MRM which was probably of greater significance since it was not defined as SBO and years later was found to harbour infectivity. Further cases of CJD in farmers: cases of CJD in young people In late 1994 a third dairy farmer died from CJD, which was sufficiently disturbing for SEAC to hold a special meeting to discuss the matter on 13 January 1995. This was recognized as being statistically significant in the technical sense, that is the likelihood of three cases in farmers emerging by chance given the total number of cases was very small indeed, but in the absence of evidence that these cases differed from the normal sporadic type there was little SEAC could do other than to seek further information. The press learned of the third case in September when a suspected fourth case in a beef farmer who had had a case of BSE also came to light. Also, even more ominously, further cases of CJD in young people were discovered. Suspected cases were referred to the CJDSU in May, August and October 1995. By the end of the year there were seven suspect cases in persons aged under fifty years (the normal lower age limit for cases of the disease) in addition to three confirmed cases. I am not clear whether DoH was aware of the number of suspected cases; certainly MAFF was not informed until later when SEAC was discussing the possible link with BSE. On 23 October SEAC issued cautious comments on both phenomena noting that there was no evidence of a link to BSE. One of the leading academic workers on CJD and BSE is Professor John Collinge of St Mary’s Hospital in London. His work interests are reflected in one of his job titles in 1995, ‘Honorary Consultant in Neurology and Molecular Genetics’. He was, in short, just the person to take a keen, expert interest in unexpected or unexplained cases of CJD. By 31 October 1995 he was sufficiently concerned that the cases in young people might have BSE as a cause to put his concerns direct to the CMO at a meeting which it appears he sought. The CMO suggested at about this time that Collinge and others should become members of SEAC. Collinge was obviously well-qualified and following Ministerial approval he became a member in December. The CMO did not, however, pass on to me or anyone else in MAFF Collinge’s fears. There is an interesting point here. At the beginning of the BSE saga in 1986/88 MAFF had taken some time to inform DoH of the discovery of BSE, which was, of course at that stage not expected to have any implications for human health. Later the BSE Inquiry made a lot of this and founded a specific criticism on this ‘failure’. However, they did not even ask Collinge or the CMO why they had not informed MAFF of their fears in 1995. This difference in approach is surprising. In 1986/88 there was nothing DoH could have done to protect the human population; indeed as we have seen all they achieved when they were informed was to delay action necessary to achieve that end. In 1995, by contrast, MAFF was theoretically in a position to take action to protect the public better, for example by pushing up slaughterhouse standards even faster. As it happens the CMO could possibly have justified his position by saying that the doubts raised by Collinge were insufficiently well based in October 1995 and

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in any case SEAC was the government’s formal adviser. However, this is not so obviously a satisfactory reply as to make it unnecessary to ask him the question. The fact that the Inquiry did not put it to him throws an interesting light on their mind set. Reactions, media reporting and official comments Thus developments in 1995 included the finding of CJD in farmers and young people, the discovery of unsatisfactory removal of and handling of SBOs in slaughterhouses and government decisions to tighten the protective rules and enhance enforcement effort. All these attracted intense public interest all too well reflected in the media. Alarming articles appeared in every title. The media sought comments from anyone who might be credible as a commentator or whose remarks might be worth quoting. The stress level for those involved in government was high and, unsurprisingly, some made comments they would later regret. In one widely publicized comment, Sir Bernard Tomlinson, a retired Professor of Pathology, said on 1 December that ‘all offal should be kept from public consumption’ and that he personally would not eat beefburgers. Sir Bernard was justified in being concerned at the trend of events but had no basis for questioning ‘all’ offal which would include some, for example liver, in which infectivity had never been found and where it was implausible to think it might be. The BBC chipped in giving advice to listeners on the dangers of BSE over a ‘helpline’. Inevitably, given their lack of credentials, they got matters wrong. One listener was advised that meat stock cubes such as Oxo were unsafe. Oxo was in fact made from supplies from South America where BSE was unknown; thus a brand was damaged for no good reason. In response to this appalling publicity the MLC embarked on an advertising campaign which contained several exaggerations for which their Director-General was later criticized by the BSE Inquiry.3 On a TV show Stephen Dorrell, then Secretary of State for Health, was trapped into agreeing that there was ‘no conceivable risk from what is now in the food chain’. This, too, was later criticized by the Inquiry. The Inquiry also criticized the CMO for making statements (like his predecessor) that beef was ‘safe to eat’ without making it clear this advice depended on the proper implementation of the SBO controls. The Scottish CMO was also criticized for unwise remarks he made at this time. However, the most interesting point