Volume 1: Findings and Conclusions
3. The early years, 1986-88
Human health implications
Mr MacGregor's reaction
Sir Donald Acheson's advice

219 BSE had implications for human health in many different ways. The one of which the public was most aware was the possibility that BSE posed a risk through food. Responsibility for addressing this risk was shared by MAFF and the Department of Health (DH). Mr Meldrum emphasised to us that DH was responsible for assessing risk to human health. He told us that he did his best to avoid making public comments on this matter. He saw MAFF's role as being risk management, together with the provision of advice to DH on matters that fell within the expertise of the veterinarians.

220 We have not found it easy to draw a distinction between risk evaluation and risk management. Throughout the BSE story, MAFF officials and Ministers appear to us to have proceeded on the footing that it was their responsibility to see that whatever left the slaughterhouse to go into the human food chain was safe to eat. MAFF made the running in considering both what was and what was not safe to go into the food chain, and how what was not safe should be kept out of it. Problems arising over the safety of animal feed, which were unquestionably MAFF's responsibility, tended to mirror problems of the safety of human food. In relation to the latter, DH was consulted, but not often actively involved in the initial formulation of policy. Whether DH should have been more involved is a matter that we shall consider.

221 BSE also posed a potential risk to human health as a result of the use of bovine products or by-products in the making of pharmaceuticals and cosmetics. So far as the former were concerned, DH had responsibility for human medicines and MAFF for veterinary medicines. Responsibility for the safety of cosmetics fell to the Department of Trade and Industry (DTI). These areas, and the occupational risks posed by BSE to those who handled cattle, or their products, we consider in separate chapters of this volume.

222 MAFF Ministers were first informed about BSE after the General Election in June 1987. Mr MacGregor was appointed Minister of Agriculture, Fisheries and Food, and Mr Gummer his Minister of State. Mr Donald Thompson retained his post as MAFF Parliamentary Secretary. In a note to him about the disease, Mr Rees commented, 'There is no evidence that the bovine disease is transmissible to humans,' a statement that was to be frequently repeated. Mr Thompson met officials on 22 July. The Permanent Secretary, Sir Michael Franklin, observed that the establishment of any risk to human health was the highest priority, and Mr Thompson said that he was particularly concerned about this. In a paper for him, which was subsequently seen by the Minister, Dr Watson advised that there was no reason at all to believe that any risk to human health existed.

223 By the end of July, 46 probable cases of BSE had been identified involving 18 herds. Both Mr Thompson and Sir Michael Franklin had raised concerns about human health. Mr Rees did not share those concerns. He viewed BSE as an animal health not a human health problem. Dr Watson thought it very unlikely that BSE posed a risk to human health.

224 In mid-September Mr Rees prepared a progress report for Ministers. This included a statement that DHSS was aware of the problem. ¹ Dr Watson had told Mr Rees that Dr Thomas Little, the Deputy Director of the CVL with responsibility for veterinary medicines, had discussed BSE with DH colleagues at a meeting of a subcommittee of the Committee on Safety of Medicines. Regrettably Mr Rees did not explain to Ministers the limited nature of the communication that had occurred. There had been an informal discussion in the margins of that meeting, but news of BSE had gone no further within DH.

225 By this time there were 73 suspected cases in 36 herds across 11 counties. In a Q&A briefing for the media in October, Mr John Suich, who headed the Animal Health Division, included the following:

Q : Can it be transmitted to humans?

A : There is no evidence that it is transmissible to humans.

226 On 11 November 1987 he repeated this comment in a briefing for Mr Thompson, adding the suggestion that reassurance could be drawn from an analogy with scrapie.

227 On 4 December Lord Montagu of Beaulieu wrote to Mr MacGregor expressing concern at the fact that cattle with BSE were being slaughtered for human consumption. He suggested that:

Perhaps this is an area where the Ministry should make the disease notifiable and pay compensation at the full value for animals infected.

228 It seems that this letter served as a catalyst for formal consideration by MAFF officials of whether action should be taken to address the possibility that BSE might be transmissible to humans, though other letters from the public were received to similar effect. Mr Rees chaired a meeting of MAFF officials on 15 December. It was agreed that a paper should be prepared for Ministers setting out the options. On 29 December an article in The Times, headed 'Mystery Disease Strikes at Cattle', observed that there was no indication of whether the disease was transmissible to humans. By the end of the year, 370 suspect cases had been reported and 132 had been confirmed.

229 The options to be submitted to Ministers were discussed by, among others, Mr Rees, Mr Cruickshank, Dr Watson, Mr Meldrum, Mr Wilesmith and Mr Lawrence. The submission was perfected by 16 February 1988 and forwarded by Mr Cruickshank to Mr Edward Smith, the Deputy Secretary at MAFF. In his covering minute, Mr Cruickshank remarked:

We do not know where this disease came from, we do not know how it is spread and we do not know whether it can be passed to humans. The last point seems to me the most worrying aspect of the problem. There is no evidence that people can be infected but we cannot say there is no risk.

This was an acute analysis of the position so far as humans were concerned. Mr Cruickshank's analysis of this aspect of BSE was not to be bettered, or even significantly augmented, by the scientists who were to consider the problem in the months to come.

230 The submission itself observed that it was uncertain whether the disease was transmissible to humans, and continued:

We could therefore be criticised for allowing affected animals to be sold for human consumption. MAFF are already being asked to advise on whether there is any risk to humans.

231 The option recommended was a policy of slaughter of affected animals with payment of compensation, the principal advantage of which was to enable the Government to answer criticism about human health implications. The submission took some pains to emphasise that payment of compensation was appropriate as the measure would be taken mainly for public health reasons, not in order to eradicate the disease.

232 Mr Smith forwarded the submission to the Permanent Secretary, now Mr Derek Andrews, adding that as the policy was in the interests of public health, it would not be appropriate to look to the industry to fund it.

233 It is remarkable that MAFF officials had prepared this submission, whose recommendation was based essentially on an evaluation of risk to human health, without involving anyone at DH. The expressions of concern in the summer of 1987 by Sir Michael Franklin and Mr Thompson, coupled with the growth of the epidemic, called for joint consideration by MAFF and DH, with assistance from experts in TSEs, as to whether BSE might be transmissible to humans. Had this course been followed, we have little doubt that a joint submission would have been made to both MAFF and DH Ministers to the same effect as that which went forward to Mr MacGregor, but backed by conclusions as to the uncertainty about risk to humans that would have carried more weight than those of MAFF officials alone. It might moreover, as we shall see, have brought together those licensing veterinary and human medicines to consider their shared problems.

234 We sought explanations for the failure to involve DH from Dr Watson, Mr Cruickshank and Mr Rees. We have summarised their explanations in Volume 3. ² We find that the true reasons were (i) a belief on the part of some that BSE was an animal and not a human health problem and (ii) a degree of interdepartmental reserve which led Dr Watson, Mr Rees and Mr Cruickshank to conclude that BSE was their problem to be resolved without the need for outside assistance - or interference - from DH. In this, each of them was at fault. The consequence, as we shall show, was a lengthy delay in reaching a decision as to the precautionary action to be taken.

Mr MacGregor's reaction

235 Mr MacGregor's previous office had been Chief Secretary to the Treasury. We believe that MAFF officials anticipated that he would have reservations about a policy that involved paying compensation out of public funds to farmers for the slaughter of sick animals. In this they were correct. Mr MacGregor's initial reaction to the submission was to be 'very cautious'. He expressed concern that if compensation were paid for slaughtering cattle with BSE, there would be a 'read across' to situations where the destruction of diseased crops had been ordered without payment of compensation. Rhizomania, a disease of sugar beet, was an example.

236 Mr Cruickshank told us that he and his colleagues considered Mr MacGregor's reaction to the submission to be a peremptory rejection. Sir Derek Andrews demurred at this description, and so would we. Mr MacGregor's initial reaction to a policy that involved payment of compensation was unfavourable, but he nonetheless agreed that the advice of the Chief Medical Officer (CMO) should be sought. His reaction affected, however, the manner in which the CMO, Sir Donald Acheson, was approached. The intention had been to tell him that MAFF wished to introduce a slaughter and compensation policy and to ask him to advise whether or not BSE posed a risk to humans. Had that approach been adopted, we think it likely that Sir Donald would have endorsed MAFF's proposed policy. As it was things took a different turn.

237 It was unfortunate that Mr MacGregor did not share his officials' view of the merits of the slaughter and compensation policy. It would not, however, be fair to criticise him for his reservations, for they did not lead him to reject the policy. His decision to consult the CMO before reaching a final decision fell well within the range of responses that were reasonably open to him.

Sir Donald Acheson's advice

238 Mr Andrews wrote to Sir Donald Acheson on 3 March 1988. He described the nature of BSE. This was the first that Sir Donald had heard of the disease. Mr Andrews then raised the question of whether BSE might be transmissible to humans. He wrote:

It would be very helpful therefore to have your advice on the view we should take of the possible human health implications and how we should handle questions about the risks to human health.

239 This put the ball of recommending what action should be taken into Sir Donald's court, and with no warning at all. Sir Donald's reaction was to call an interdepartmental meeting to consider the matter.

240 Those present at this meeting were not able to form a firm view as to whether or not BSE posed a risk to human health. It was agreed to recommend to Health Ministers that a small group of experts be set up to advise on the human health risks and possible preventive measures. Sir Donald commented that he thought it highly likely that the advice would be that carcasses of affected animals should not go for human consumption.

241 We found this decision disappointing. MAFF officials had formed the view that unless one could be confident that they posed no risk to humans, sick animals should not be permitted to be slaughtered for food. The Southwood Working Party, set up on Sir Donald's recommendation, was to take the same view immediately it met. This was, we feel, no more than common sense. Referring the matter to an expert Working Party was bound to result in significant delay. A better and more robust response would have been to recommend that the practice of eating diseased cattle should cease at once. We have concluded, however, that it would not be fair to criticise Sir Donald for the course that he took. He was put in an invidious position, being asked for advice without notice on policy that had significant consequences. Those whom he summoned to help him decide on what to do expressed uncertainty. In these circumstances, we find that the decision to recommend that the matter be referred to an expert group fell within the range of reasonable responses open to Sir Donald.

242 Delay did indeed result, however. Over three months were to elapse before the Southwood Working Party was constituted and met for the first time. During this period MAFF came under increasing pressure to take action. On 22 April 1988 a front page article in Farming News accused MAFF of seriously underestimating the extent of BSE and referred to disquiet about whether the disease posed a danger to humans. By then there had been 421 cases confirmed in 352 herds.

243 Mr MacGregor continued to set his face against any suggestion that the Government should fund a compulsory slaughter and compensation scheme. He accepted a recommendation that BSE should be made a notifiable disease - a measure designed to give MAFF a better picture of the incidence of the disease and the power, if necessary, to impose movement controls on animals. BSE was made notifiable in June 1988 by the same Order that introduced the ruminant feed ban. The rate of reporting leapt almost overnight from 60 cases a month to 60 cases a week. The Order required that the heads of all these cases be surrendered to MAFF; the brains were then removed and examined by the CVL. So far as the proposal for compulsory slaughter was concerned, discussions were carried on with the farming industry to explore the possibility of an industry-funded scheme. Industry was told that there was no question of government funding being provided. Industry's response was that it was for the Government to fund compensation if compulsory slaughter were to be introduced.

244 On 4 June 1988 an article in the British Medical Journal, co-authored by a doctor and a dietician, pointed out that if BSE were transmissible to humans it might be years before infected individuals succumbed. The authors wrongly assumed that animals showing signs of sickness would not enter the food chain, but went on to say that it was 'naïve, uninformed and potentially disastrous' to assume that animals incubating the disease but not yet showing signs posed no risk to humans.

245 On 20 June the Southwood Working Party met for the first time. ³ They were horrified to learn that animals sick with BSE were being slaughtered for food. The next day Sir Richard Southwood wrote to Mr Andrews recommending that carcasses of BSE-affected animals should be condemned and destroyed. Mr MacGregor's officials advised him that compulsory slaughter should be introduced and that the Government would have to pay compensation under the Animal Health Act 1981 - they recommended that this should be fixed at 50 per cent of the value of a sound animal. Mr MacGregor wrote to Mr John Major at the Treasury urging, though with reluctance, that payment of compensation at this level be approved.

246 At the same time, Sir Donald Acheson informed Mr David Mellor, the Health Minister, that destruction of the carcasses of clinically affected animals was essential on the grounds of risk to humans. It was on this basis that the consent of the Treasury was given to the payment of compensation. Mr MacGregor had suggested that the cost of this measure would be around £250,000 a year on the basis that cases would continue to be reported at a rate of about 60 a month. He cannot yet have been aware of the increase of the reporting rate consequent upon the notification requirement.

247 The Order providing for compulsory slaughter and destruction of cattle suffering from BSE came into force on 8 August. Nearly six months had gone by since MAFF officials had first recommended this course.