Volume 1: Findings and Conclusions
3. The early years, 1986-88
The ruminant feed ban
Exports

198 While Mr Wilesmith was exploring why cattle were succumbing to BSE, consideration was also being given to the implications that the disease might have for humans. Before turning to that part of the story, let us follow the reaction to Mr Wilesmith's advice that the practice of including animal protein in cattle feed should be subjected to a temporary ban.

199 If Mr Wilesmith's conclusions were tentative, Mr Rees, the CVO, thought that the picture was clear. In a submission to Mr John MacGregor, the Minister of Agriculture, Fisheries and Food, he advised that he was:

. . . satisfied from the information produced by the investigating teams that the source of the transmissible agent which has caused BSE is through meat and bone meal derived from sheep material in which the rendering process has failed to inactivate the scrapie agent. Affected sheep material is continuing to be processed and it must be assumed therefore that cattle continue to be exposed to infection. ¹

200 He advised that the feed industry should be asked to agree a voluntary withdrawal of MBM from ruminant feed, but that if they refused, a mandatory ban should be imposed.

201 Mr MacGregor was even more decisive. On 19 May 1988 he determined that there should be a 'speedy and compulsory ban on sheep meat material in feed for ruminants'. It fell to Mr Alan Lawrence, a Grade 7 official in MAFF's Animal Health Division, to implement this decision in consultation with departmental lawyers and with the benefit of advice from his administrative and veterinary colleagues. It was decided that the ban should extend to the feeding of ruminant protein to ruminants. In effect the ban was subsequently operated as if it encompassed all animal protein, for no renderers attempted to segregate their raw materials in order to produce non-ruminant MBM. The ban was achieved by an Order ² signed by Mr MacGregor and Welsh and Scottish Office Ministers on 10-14 June. This made it an offence to sell, supply or use for feeding to ruminating animals any feedstuff in which the offender 'knew or had reason to suspect' that any animal protein had been incorporated. The ban was initially only up to the end of 1988, but it was subsequently to be extended, and finally made permanent.

202 This simple Order has been described by one distinguished epidemiologist as:

A spectacularly successful control measure . . . one of the notable success stories of global disease control.

203 It has, today, come close to eradicating an epidemic that, at its height, was of gigantic proportions. Primary credit for this goes to Mr Wilesmith and his Department for their diagnosis of the source of infection, but credit also is due to Mr Rees and Mr MacGregor for their prompt and decisive response. Unhappily, though, the measure was not a total success. There were shortcomings in its implementation. We turn to consider why this was.

204 The question arose in the course of consultation as to when the ban should come into effect. After consulting its members, the UK Agricultural Supply Trade Association (UKASTA) asked for a three-month period of grace to enable the industry to clear from the distribution channels all stocks of ruminant feed that had already been compounded. After taking advice from the veterinarians in MAFF, Mr Lawrence proposed a two-month period of grace. MAFF's press office advised that a delay as long as this would lead to accusations of risking the further spread of the disease simply to make life easy for the industry. Mr MacGregor, on the advice of Mr Alistair Cruickshank, ³ compromised and decided that the ban should come into effect on 18 July - five weeks from the date of the Order.

205 We initially questioned the grant of this period of grace, but concluded that our reservations were the result of being wise after the event. Mr Kevin Taylor, one of the MAFF veterinarians involved in the preparation of the ruminant feed ban, explained to us his reasons for viewing a period of grace of as long as two months as perfectly acceptable from a veterinary point of view. On the basis of the information then available it did not seem to him that such a delay was going to make very much difference. The industry had been exposed to infected feed for 380 weeks. A few weeks more would not make a great deal of difference.

206 In June 1988 MAFF officials reasonably expected, on the basis of Mr Wilesmith's advice, that the rate of infection was likely to have stabilised at about 60 cases a month. Mr Taylor considered that if no period of grace had been granted, farmers and the industry would initially have disregarded the ban. We found force in these points and reached the conclusion that the compromise period of grace decided upon by Mr MacGregor could not be criticised. Had it been appreciated that cattle were being infected at the rate of thousands of cases a week, we have no doubt that a very different approach would have been adopted.

207 Much later it became apparent that infected feed had continued to be fed to cattle on a substantial scale after 18 July. Nearly 12,000 cattle born after the ban (BABs) in 1988 and over 12,000 born in 1989 subsequently developed clinical signs of BSE. A far larger number must have been infected, but slaughtered before signs became apparent. Some of these cases will have resulted from accidental contamination of feed. Some will have resulted from farmers, who had little or no means of knowing whether their feed contained ruminant protein, continuing to use the feed they had in stock. But we are satisfied that some feedmills and feed merchants deliberately continued to sell cattle feed containing animal protein after the ban come into effect.

208 Had the only source of contaminated feed been existing stocks of cattle feed made up before the ban came into effect, the BABs would have come to an end once this had been consumed. In the event, over 5,600 cattle born in 1990, 4,500 born in 1991, 3,000 born in 1992, 2,200 born in 1993 and 1,000 born in 1994 were to go down with the disease. With hindsight, it is clear that most of these infections resulted from cross-contamination of cattle feed with pig and poultry feed, containing infective MBM, in the feedmills. The risk, indeed the certainty, of a degree of cross-contamination when the same production lines are used to produce different batches of feed is, and was in 1988, well established. One reason that has enabled us to conclude that cross-contamination did indeed result in infection of cattle is knowledge that we now have as to the quantity of infectious material that suffices to transmit BSE orally in cattle.

209 An experiment carried out by the NPU has demonstrated that ½ gram of homogenised brain from BSE-infected cattle is sufficient to transmit the disease orally across the species barrier to sheep and goats. Another experiment carried out by the CVL has demonstrated that 1 gram of such material can transmit the disease orally to cattle. ⁴

210 The results of these experiments were not available when the ruminant feed ban was introduced. What consideration was given at that stage to the amount of material that might infect? What consideration was given to the question of whether cross-contamination might pose a risk of infection? UKASTA witnesses spoke of receiving repeated reassurances from MAFF right up to 1994 that a large amount of contaminated feed would be necessary to infect a cow.

211 We found no specific evidence of when or by whom such assurances were given. A number of MAFF administrators spoke of their understanding that a large amount of infective material was needed to infect. Some of the professionals - Dr Watson, Mr Kevin Taylor, Mr Bradley - told us that they had no idea what the minimum quantity would be. There was general surprise, when the result of the attack rate experiment was made known, that as little as 1 gram had sufficed to infect. Although there is no record of Mr Keith Meldrum ⁵ reassuring UKASTA that there was no need to worry about cross-contamination, he is recorded as telling representatives of the cattle industry in June 1988 that feedmills presented at worst a low contamination risk and would not be investigated. He advised at the same meeting that MBM could safely be used as fertiliser because the dose that might be received by grazing cattle would almost certainly be too low to cause disease.

212 Was there any valid basis upon which Mr Meldrum could have concluded in 1988 that cross-contamination in the feedmill would not involve sufficient quantities of infective material to give rise to transmission? We have concluded that there was not. Mr Wilesmith told us that he had concluded that a very small amount of infective material would suffice to infect. This he deduced from the small inclusion rate of MBM in calf rations. He believed that his view should have been widely shared by administrators at MAFF. Those who designed the experiments at the NPU and CVL, to which we have referred above, envisaged the possibility that ½ or 1 gram would suffice to infect. Had the question of the amount of material needed to infect been explored at the time of the imposition of the ruminant feed ban with those best placed to advise, the conclusion should have been reached that this amount might be very small.

213 Mr Meldrum told us that if he or any other MAFF or industry representative had known at the time that the infective dose was so low as to lead to cross-contamination problems, the issue would have been pursued. As it was, the existence of a danger from cross-contamination was not considered to exist at the time.

214 We have concluded that at the time that the ruminant feed ban was imposed, there was a lack of rigorous thought about its implementation. One person who should have given more thought to this was Mr Meldrum. He had knowledge of how feedmills operated, and of the problem of cross-contamination between batches. He assumed this would not matter but did not have adequate grounds for that assumption. A failure to attach significance to the possibility of infection through cross-contamination in feed was understandable when the apparent rate of infection was only about 60 cases a month. However, in the course of September 1988, 435 cases of BSE were reported in Great Britain. Once this was apparent, Mr Meldrum should have ensured that proper consideration was given to this matter. This should have led to guidance being given to both the feedmills and to those farmers who mixed their own feed, on the need to take precautions to minimise cross-contamination. ⁶

215 Mr Meldrum is a man of great energy and industry. He had only just taken up the reins of the CVO. His national and international duties were onerous. These are considerations which should temper any criticism of his oversight on this occasion.

216 Failure to appreciate that cross-contamination mattered carried with it a failure to appreciate the importance of a test that would detect cross-contamination. When the ruminant feed ban was introduced, there was no test which would detect animal protein in compound feed, let alone ruminant protein. Without such a test the Order was unenforceable. Steps were put in hand to develop, in-house, the ELISA technique so as to produce a test that would identify ruminant protein in feed. This was not treated as a matter of priority. Deliberate breach of the ban was not considered likely and accidental cross-contamination was not considered to be cause for concern. Development of the ELISA test followed a leisurely course and did not approach achievement until the end of the period with which our Inquiry is concerned. ⁷

Exports

217 The United Kingdom exported very little compound feed, but did export significant quantities of MBM. This was exported initially to Europe to manufacturers of concentrates who re-exported their products to the Middle East or North Africa. Some have suggested that the United Kingdom should have imposed a ban on the export of MBM when the ruminant feed ban was introduced to try to make sure that foreign countries did not infect their cattle with BSE. This would have been difficult. Renderers were still permitted to sell MBM to British purchasers for incorporation in pig and poultry feed. Most MBM that was exported was used for the same purpose. An attempt to prohibit exports would have been likely to be challenged in the Courts. It could be argued convincingly that foreign importers could be adequately protected by warnings that MBM should not be fed to cattle.

218 Were adequate warnings given? Mr John Gummer urged before the ruminant feed ban was introduced, when he was the junior Agriculture Minister, that we had a moral duty to warn our neighbours of the danger of feeding MBM to cattle. Under European law this country was obliged to give notice of the ruminant feed ban to all EU members and did so. What of the countries that were not members of the EU? Mr Meldrum told us that he relied on the customary means of communicating with them on the subject of animal diseases. He notified the Office International des Epizooties, which passed the information on to all members in a report of its annual General Session in May 1989. In February 1990 Mr Gummer, by now the Minister of Agriculture, Fisheries and Food, insisted that Mr Meldrum take the further step of writing a letter of warning to Chief Veterinary Officers of all countries which imported MBM from the UK. There is scope for arguing that Mr Meldrum should have done this earlier. We think the argument is academic. The only country outside the EU where it is suspected that cattle were infected with BSE as a result of importing MBM is Switzerland, and it seems that the MBM in question reached Switzerland via Belgium. If this occurred after the ruminant feed ban, both Belgium and Switzerland were aware that ruminant protein was suspected to be the cause of BSE. Accordingly we have seen no need to pursue this issue further.