Volume 1: Findings and Conclusions
6.
Protecting human health
BSE and human health in 1990
Implementation, enforcement and monitoring of the human SBO ban
Bovine brains
Slaughterhouse practices and mechanically recovered meat
Europe and lymphoid tissue
Alarms and reassurances
The cat
The Agriculture Committee
SEAC considers the safety of beef
A look ahead
612 1990 was an eventful year in the BSE story. It saw a number of practical problems raised in relation to the implementation of the human SBO ban and the manner in which government addressed these. It saw restrictions placed on the export of beef by the EU, and their implications for the United Kingdom. It saw the natural transmission of BSE to cats, the alarm that this caused, and the response of government to that alarm. It saw the extension of scientific knowledge about BSE, with experimental transmission to mice, to cattle and subsequently to a pig. These latter events led to the introduction of the animal SBO ban, which we have described in the previous chapter. In this chapter we shall be looking at events that had relevance to the implications of BSE for human health.
613 In 1990 Mr Gummer completed his first year as Minister of Agriculture, Fisheries and Food. He had brought with him a new broom. He sought to draw a clear distinction, within the Ministry, between looking after the interests of the industry and looking after the interests of the consumer. The former he entrusted to Mr Curry; the latter to Mr Maclean. As Minister for Food Safety, Mr Maclean presided over the newly formed Food Safety Directorate. He also chaired a new Consumer Panel. Mr Gummer made it plain that his Ministry would be following a policy of openness of information about food safety. He also announced that the results of all research into BSE would be made public.
614 The same year saw the setting up of SEAC. Mr Gummer was a firm believer in taking the advice of experts and then following that advice. As soon as SEAC was set up he began to seek its advice on a wide variety of topics.
Implementation, enforcement and monitoring of the human SBO ban
615 In the previous chapter we looked at what happened to SBO once it had been removed from the carcass. This assumed importance in relation to animal health. There was never any apprehension that, once removed, SBO would find its way into the human food chain. So far as human health was concerned, the important thing was that the SBO should be cleanly removed from the carcass without contaminating the meat.
616 We have already commented on the poor standards of hygiene prevalent in UK slaughterhouses and the fact that the manner and rigour of enforcement of the Regulations varied from one local authority to the next. 1 Happily these standards were not generally reflected in the diligence with which the Meat Inspectors set about their task of ensuring that SBO, and in particular spinal cord, was removed from the carcass. This was not, however, an easy task. The operation involved sawing the carcass in half down the backbone with a power saw, thus exposing the spinal cord, and then removing the cord. It was inevitable that in the process the spinal cord would sometimes get damaged and that portions of it would remain trapped or hidden within the vertebrae. It would have needed the most meticulous skill and care on the part of the Meat Inspectors to make sure that no carcass that received the health stamp contained any remnants of spinal cord. Skill and care to that degree was not shown during the period with which we are concerned. Meat Inspectors were often rushed, and holding up a production line for inspection was not popular. No one emphasised that removing all the spinal cord could be a matter of life and death, and it was not so regarded. As a result the occasional portion of spinal cord would pass through, undetected, with the health-stamped carcass, and be destined in many cases to be extracted as MRM.
617 We have described earlier the monitoring role of the VFS in respect of compliance with a large number of Regulations applicable in a slaughterhouse. The removal of spinal cord from the carcass was only one of many of the statutory requirements that they had to monitor. They were not instructed to give this particular attention. On the contrary, insofar as they received instructions, these focused on the disposal of the SBO after removal from the carcass, and we had evidence that this aspect of the SBO Regulations was the one with which they were more concerned.
618 In these circumstances we can understand why it is that, prior to 1995, there is only one recorded occasion on which a member of the VFS identified health-stamped meat that contained spinal cord. Only during the national surveillance in 1995, when unannounced inspections were carried out and when VOs were instructed to pay particular attention to the removal of spinal cord, did the fact that there were shortcomings in this respect come to light.
619 One slaughterhouse problem that did quickly become apparent after the SBO ban was introduced related to bovine brains. Before the SBO ban the head meat would normally be removed at a slaughterhouse or head-boning plant, after which the head would be sent off with the brain inside to be rendered. Under the SBO Regulations a head with brains inside had to be treated as SBO. A practice started almost immediately of splitting the skull and removing the brain, so that the head could then be despatched, free of regulation, as BSE-free material. This practice created an obvious contamination hazard in the slaughterhouse.
620 No sooner had the ban come into force than Environmental Health Officers (EHOs) began to raise with MAFF concerns about the risk of contamination as a result of head-splitting and brain removal. There were a number of different techniques for splitting the skull and one method of removing brain that avoided this was by blasting the brain out of the base of the skull with a high pressure jet of water or air. The Institution of Environmental Health Officers expressed concern that all methods involved the risk of contaminating the head meat and urged that the practice of removing the brain be forbidden. A Liberal Democrat MP, Mr Matthew Taylor, took up this cause. MAFF officials took the view that any contamination was likely to be too small to worry about. Mr Hutchins, an SVO in the Meat Hygiene Veterinary Section, carried out a survey. He advised that there was no reason to prohibit the open-skull method of brain removal, although he had reservations about the high-pressure method. Mr Gummer was not persuaded, and promised Mr Taylor that he would ask an outside expert to consider the matter.
621 The chosen expert, Mr A M Johnston, expressed reservations about all the methods of brain removal and advised that, whenever possible, head meat should be removed before any cut was made in the skull. Both Mr Maclean and Mr Gummer expressed continued concerns about brain removal. Officials reassured them that draft guidelines on the techniques of brain removal were being prepared which would reduce contamination to a minimum. The problem was minuscule. The financial consequences of restrictions would be considerable. None should be imposed. Ministers were minded to accept this advice, but there followed a further spate of protests about the practice from many quarters. On 21 May 1989, pressed about the practice in a parliamentary debate, Mr Gummer stated that it would be referred for consideration by SEAC.
622 SEAC considered draft guidelines prepared by the Meat Hygiene Division at their meeting on 13 June and gave them short shrift. They advised that it was not consistent with common sense to permit the removal of the brain before the head meat was harvested. Mr Gummer directed that guidelines be issued reflecting this advice. Mr Meldrum sent them out the following day. They directed that bovine head meat had to be recovered from the intact skull before the brain was removed.
623 On 10 July 1990 the Agriculture Committee published its report on BSE. One recommendation was that MAFF's guidelines on head-splitting should be enshrined in legislation at an early opportunity. Ministers accepted this recommendation. On 12 March 1992 Regulations were introduced which:
624 No reasoned application of the ALARP principle was carried out by MAFF. MAFF officials assumed that contamination would be too minuscule to matter. Ministers were justified in their reservations about this, and did well to call for independent advice. SEAC was not an appropriate body to consider technical questions of head-splitting techniques. It was, however, well qualified to express a view as to whether risks of contamination from such practices were acceptable. SEAC did not attempt any quantification of the amount of contamination liable to result from brain removal. Nor did it weigh in the balance the financial consequences of the various options. The Committee applied a robust common sense in assuming that contamination was liable to be significant and advising accordingly. The outcome was satisfactory. The same cannot be said of SEAC's next venture into the world of the slaughterhouse.
Slaughterhouse practices and mechanically recovered meat
625 We have referred to concerns expressed about the removal of spinal cord and MRM in the course of consultation about the proposed SBO Regulations. These continued after the Regulations were brought into force. Mr Corbally of the Institution of Environmental Health Officers expressed the concern of its members about this. On 18 April 1990 he wrote to Mr Keith Baker: 2
Do you consider that the continued use of mechanically recovered meat from bovines is acceptable? . . . MRM could contain significant quantities of spinal cord nervous tissue.
626 On 21 May Dr John Godfrey of the Consumers in the European Community Group, at a meeting with Mr Meldrum and Mr Maclean, questioned whether dorsal root ganglia might not be as infectious as spinal cord. Two weeks later, Mr Meldrum wrote to Mrs Attridge expressing concern that MRM might be significantly contaminated. He told us that it was peripheral nervous tissue that had given rise to his concern.
627 Calls for the banning of the practice of recovering MRM from the spinal column of cattle came from:
628 Concerns about the practice were expressed to the Agriculture Committee from a number of quarters. Of particular note was a submission from Dr Gerald Forbes, Director of the Environmental Health (Scotland) Unit, who wrote of MRM:
Can any guarantee be given that parts of the central nervous system of cattle do not enter this product? I would suggest that this is not possible and whether or not the practice of producing mechanically recovered meat can be considered safe is very much open to doubt.
629 As we have seen, Mr Gummer decided in May that slaughterhouse practices should be referred to SEAC. MAFF set about preparing a paper that would provide SEAC with the information that it would need to consider these. The drafting of this paper was a major undertaking involving input from the Meat Hygiene Division, the Food Standards Division, the Food Science Division, Mr Meldrum and officials in the Animal Health Division. The final draft was not produced until October. The paper gave SEAC the following information about slaughterhouse practices:
- The spinal cord will inevitably receive some damage during carcass-splitting.
- Inevitably
some nervous tissue can remain and some contamination of the vertebrae
with CNS tissue can occur as a result of:
630 Those responsible for preparing the paper had reached the conclusion that some action was called for. Originally they had been prepared to place before SEAC a series of alternative options:
Of these, option (c) was to be advanced as the preferred option, coupled with a recommendation that certain specified research be carried out to ascertain the extent of the contamination of MRM that was occurring.
631 In the event it was decided not to refer to these options, but simply to ask SEAC to advise:
. . . whether any action or guidance is required in relation to slaughterhouse practices, and whether any new R&D is needed.
632 What then occurred was this. SEAC members decided that they would visit a slaughterhouse and see for themselves the procedures involved. Most of them did so and were given a 'Rolls-Royce' demonstration of carcass-splitting and removal of spinal cord. Those who saw this concluded that spinal cord could be extracted from the carcass without difficulty. At SEAC's next meeting, slaughterhouse practices was one item of an over-charged agenda. SEAC dealt with that item by advising, in the case of some members on the basis of what they had seen, that so long as the rules were properly observed and proper supervision was maintained, there was no need to recommend further measures on grounds of food safety. MAFF officials and Ministers treated this as reassurance that all was well, and no further consideration was given to MRM for some years to come.
633 It does not seem that there was any discussion at the meeting about MRM. Dr Tyrrell suggested to us:
I suspect that what happened was that we reckoned there was not really a problem with MRM if the vertebral column was being cleanly cut and dissected.
634 The events that we have summarised demonstrate a serious breakdown of communication. MAFF officials knew, as their paper expressly stated, that a degree of contamination of the spinal column with spinal cord was inevitable. Some members of SEAC, Dr Tyrrell among them, proceeded on the basis that clean removal of spinal cord was easy and thus something that could be achieved in practice. It was on the basis of that assumption that they advised that there was no need for any action. MAFF officials, however, understood that SEAC was indicating that the degree of contamination described in the paper as 'inevitable' was no cause for concern.
635 We do not consider that this sorry story is a matter for individual criticism. There are, however, lessons to be learned from it. What went wrong?
- SEAC had too much on its plate. The agenda did not allow sufficient time for a detailed discussion of MAFF's paper on slaughterhouse practices.
- The advice sought from SEAC was not targeted. SEAC's expertise lay not in slaughterhouse practices but in the potential consequences of consumption of spinal cord. As we shall see, the Committee had been considering infectious dose for the purpose of advising the CMO. It based its advice not on this consideration, but on its conclusion about slaughterhouse practices. SEAC should have been asked expressly whether the contamination described in MAFF's paper was cause for concern.
- SEAC was not informed of the options which MAFF officials had identified. We consider that it would have been helpful if SEAC had been told about these.
- SEAC was unaware of the concerns that had been expressed about the removal of spinal cord and the safety of MRM.
636 Had SEAC been aware of all these matters, we think it likely that it would have endorsed the suggestion that further research be carried out in order to quantify the amount of spinal cord material getting into MRM. This might have led to SEAC endorsing the further option of recommending a ban on the extraction of MRM from the bovine vertebrae. There can be no certainty that it would have done so.
637 Had MAFF officials been left to advise Ministers unaided by SEAC, we think it likely that they would have recommended option c) of those they had identified, as set out in paragraph 630 above. If not, they would surely have recommended options a) and b). It was unfortunate - and possibly tragic - that the intervention of SEAC should, as a result of a breakdown of communications, have left MAFF officials and Ministers falsely reassured about the safety of MRM.
638 The slaughter and compensation policy and the human SBO ban protected consumers of beef products in both the United Kingdom and countries to which these were exported. The European Commission decided, however, to take additional measures to protect Continental purchasers of British beef. These included a requirement 3 made in June 1990 that the UK should certify all boneless beef for export to other Member States as being 'fresh meat from which during the cutting process obvious nervous and lymphatic tissue has been removed'.
639 MAFF carried out a survey to discover the extent to which the cutting procedures employed in UK plants satisfied this requirement. It was discovered that the procedures varied widely from those plants which removed virtually all lymph nodes to those which removed very few. Alarmingly, 'healthy' lymph nodes which had been removed were used in meat products for human consumption or rendered for either human food or animal feed.
640 Consideration was given to legislating to add lymph nodes to the list of SBO. There were, however, intractable problems with such a course. Not all lymph nodes could be prescribed, for they were to be found throughout the carcass. It would not be practicable to have Regulations which prescribed 'obvious lymphatic tissue', for this would lack certainty. Furthermore, lymph nodes were often not removed until meat was being dressed in the butcher's shop, and it would be difficult to devise Regulations that would cover that situation.
641 In the event it was decided to issue guidelines, designed both to enable the UK to comply with the EC Decision and to set a common standard for beef, whether it was to be consumed in the United Kingdom or exported.
642 On 16 June guidelines were issued which provided that:
All lymphatic and nervous tissue that is exposed during normal cutting operations must be trimmed off, so that such material is not visible on the cut surfaces of the meat.
Lymphatic and nervous tissue that is removed must not be used in meat preparations or products that are intended for human consumption. 4
643 We consider that the response to the Commission Decision was reasonable. It had, however, one consequence which we do not believe was appreciated. Because lymphoid tissue was not brought within the definition of SBO, it continued to be available for rendering for animal feed after the animal SBO ban was introduced.
644 We now turn to a quite different topic, one of great interest to our Inquiry - the communication of risk to the public. By 1990 BSE had been transmitted to a number of different species - for the most part experimentally. Transmission naturally, through feed, had occurred in a number of exotic species in zoos. The range of species in which transmission had occurred was wider than that observed with scrapie. These transmissions were, to put it neutrally, consistent with the possibility that BSE was transmissible to humans. Few put it neutrally, however. The media, focusing on the comments of some independent scientists, were quick to draw the conclusion that instances of cross-species transmission demonstrated that humans were at risk. Government officials were at pains to emphasise that experimental conditions were not reproduced in nature and that no implications as to human risks could be drawn from transmission to animals. Reassurances were given about the safety of beef. The Meat and Livestock Commission (MLC) regarded its principal role as the support of the meat and livestock industry. The MLC was particularly assiduous in seeking to counter the suggestion that it might be dangerous to eat beef. Regrettably this enthusiasm led on occasion to statements which were not scientifically correct.
645 In January, The Independent quoted scientists at the NPU acknowledging a 'remote possibility' that BSE might move from cows to people, and the comment from one of them that nothing would induce him to eat sweetbreads, spleen or brain. 'A human would have to eat an impossible amount of pure cow brain at the height of infection' to reach an equivalent dose to that needed to infect a cow, riposted Mr Colin Maclean, Technical Director of the MLC. He should have resisted this absurd exaggeration.
646 By this time Professor R M Barlow at the Royal Veterinary College had succeeded in effecting oral transmission of BSE to mice, and preliminary results of experiments at the CVL had demonstrated that inoculation of cattle with BSE-infected material had transmitted the disease. MAFF delayed making public the results of the mouse experiment until 1 February 1990 for presentational reasons. They considered it essential for the results of both sets of experiments to be announced at the same time. MAFF's press release received consideration by Mr Andrews and by Mr Gummer. It included this comment:
The BSE results therefore provide further evidence that BSE behaves like scrapie, a disease which has been in the sheep population for over two centuries without any evidence whatsoever of being a risk to human health.
Thus the first oral transmission of BSE to another species was presented as reassuring. Not everyone found it so. An official who visited the NPU in January reported:
The researchers I spoke to are obviously very troubled about the ability of this disease to jump species. If it can be passed from cattle to mice, then what about humans? 5
The press contrasted MAFF's statement with views expressed by Dr Helen Grant, Consultant Neuropathologist:
My gut feeling is that some genetically susceptible people may have become infected with material by eating meat products.
647 From March 1990 the media began to give prominence to the views of Professor Richard Lacey, a Professor of Clinical Microbiology at Leeds University. Today reported him as predicting:
In the years to come our hospitals will be filled with thousands of people going slowly and painfully mad before dying.
648 In April Humberside County Council banned beef from school meals. Other local authorities were to follow their example. Then came the cat.
649 On 6 May 1990 officials at MAFF and DH reported to their Ministers that Bristol University had diagnosed a 'scrapie-like' spongiform encephalopathy in a domestic cat. Here was a bombshell. The public was likely to conclude that the cat had caught BSE from eating contaminated beef. And if this could happen to a cat, why should not human beings suffer the same fate? Yet it was far too soon to jump to any such conclusion. It was possible that there had always been the occasional case of feline spongiform encephalopathy (FSE) which had gone unrecognised. Nonetheless, if a cat had caught BSE from food, it was cause for concern. CJD had been transmitted experimentally to a cat by inoculation, but attempts to transmit scrapie had not succeeded. Here was an indication that BSE might be more virulent than scrapie.
650 On 10 May Mr Gummer and Mr David Maclean, the Parliamentary Secretary, met with officials to discuss how to make public the news of the cat. A note of the meeting prepared by Mr Gummer's Principal Private Secretary recorded that Mr Meldrum 'confirmed the Minister's assumption that there was no likely connection between this case and BSE'. We have already noted (paragraph 363) that there was no basis for this degree of reassurance and Mr Meldrum should have been more cautious.
651 Mr Meldrum found himself under pressure from the media to comment on the implications of the cat. He emphasised that this was the first known case of FSE and that there was no known connection with other animal encephalopathies, but that investigations into the case were continuing. The risk to humans was no greater than before the diagnosis; the cat was no cause for concern.
652 We think that Mr Meldrum played down the potential significance of the cat more than an objective appraisal would have justified. But he no doubt had in mind the part played by the media in previous 'food scares', such as salmonella in eggs and listeria, and was seeking to counter extreme statements about the implication of the cat which went much further than justified on what was then known. In the circumstances we do not think it would be fair to criticise him for his defensive public stance.
653 Intense media coverage followed. The Sun published an article stating that BSE could be the biggest threat to human health since the Black Death plague. British beef was reported to have been banned in Russia and in schools up and down the country. Professor Lacey called for the slaughter of every herd with a case of BSE.
654 Again the MLC leapt into the breach with too much vigour. Mr Colin Maclean was responsible for the text of a video to be distributed to local authorities which on one reading erroneously suggested that it would be necessary to eat an impossible amount of brain and spinal cord in order to be at risk. In a press release he stated that 'even if no further action had been taken following the outbreak of the disease there was considered to be no risk to consumers from eating beef'. We do not believe that Mr Maclean intended to mislead, but both these statements were capable of doing so. We think that he should have been more careful.
655 Of more importance were the official statements. MAFF issued two press releases on 15 May, for the terms of which Mr Gummer was himself responsible. These were directed to the safety of beef. Mr Gummer made unequivocal statements that it was safe to eat beef, but he made it plain that he did so on the basis that the slaughter and compensation policy and the SBO ban provided protection for the consumer against any remote risk which might otherwise exist. This qualification was vital and, in the light of it, we would not criticise these press releases.
656 The following day, BBC Newsnight featured television footage of Mr Gummer attempting to feed his four-year-old daughter Cordelia a beefburger. We understand that Mr Gummer had been challenged by a newspaper to demonstrate his confidence in beef in this way. Mr Gummer was faced with choosing between two unattractive alternatives. It may seem with hindsight that, caught in a 'no win' situation, he chose the wrong option, but it is not a matter for which he ought to be criticised.
657 Sir Donald Acheson was pressed by MAFF to add his reassurance that it was safe to eat beef. His press officer told him that, having regard to the media pressure, it was essential that he should make a statement. He managed to discuss the terms of his statement with three members of SEAC - Dr Tyrrell, Dr Will and Dr Kimberlin. He then issued the following press release on 16 May:
I have taken advice from the leading scientific and medical experts in this field. I have checked with them again today. They have consistently advised me in the past that there is no scientific justification for not eating British beef and this continues to be their advice. I therefore have no hesitation in saying that beef can be eaten safely by everyone, both adults and children, including patients in hospital.
Later, in a television interview, he stated that 'there is no risk associated with eating British beef'.
658 Sir Donald told us that when he learned of the cat he 'remained deeply concerned about the possible implications of a further 'transpecies "jump" of BSE'. He told us that his statement about the safety of beef was made, as were Mr Gummer's, 'on the confident assumption that the SBO ban was already fully implemented'.
659 In contrast to the press statements made by Mr Gummer, Sir Donald's statement did not explain that his confidence in the safety of beef was premised on the removal of all SBO. It gave no indication of any concern about the cat. It was, we feel, a statement that was likely to convey the message not merely that 'beef is safe', but that 'BSE is no risk to human health'.
660 We do not consider that, as Chief Medical Officer, Sir Donald should have restricted his public statement in the way that he did. The development of a spongiform encephalopathy in a cat had raised a concern that BSE might be transmissible in a way that scrapie was not. Sir Donald was in no position to allay that concern. He avoided addressing it by limiting his statement to the safety of beef. He did not explain that he considered beef safe only because the parts of the cow that might be infective were being removed from the food chain. His statement was likely to give false reassurance about the possibility that BSE might be transmissible to humans and we think that he should have appreciated this. The possibility that BSE might have been transmitted to a cat was cause for concern and needed to be investigated by the scientists. He should have explained that he believed that beef was safe to eat because of the precautionary steps that had been taken to guard against the possibility that BSE might be transmissible in food.
661 Sir Donald's unqualified statement that it was safe to eat beef was to set a pattern. Public concerns about the dangers arising from BSE were met by statements limited to giving assurance that it was safe to eat beef. Members of the public tended to equate those statements with assurances that BSE posed no risk to humans. It was natural that they should do so. It is no wonder that when, on 20 March 1996, the Government announced that there was probably a link between BSE and vCJD, many felt that they had been deceived.
662 On 16 May 1990 the public concern generated by the cat led the Agriculture Committee of the House of Commons to institute an inquiry into BSE. Over a period of just over a month an impressive body of evidence, both oral and written, was received. The Committee reported on 18 July. The Committee observed that while scientists believed that there were too many unknowns to say anything about the disease with absolute certainty, no evidence had been forthcoming that it did pose a risk to human health. It concluded:
The Government has already acted to cut off the presumed source of the disease in cattle and has banned the sale of all specified cattle offals for human consumption. We believe these measures should reassure people that eating beef is safe.
If the ban on the sale of specified cattle offals for human consumption is properly policed in slaughterhouses, full public confidence can be maintained.
SEAC considers the safety of beef
663 At the request of Sir Donald Acheson, SEAC held an emergency meeting on 17 May 1990 to consider the implications of the cat. Sir Donald had hoped that SEAC would produce a letter endorsing the statement that he had made about the safety of beef. At their meeting the Committee members found themselves unable to agree on the terms of this. Not until 24 July were they able to give final agreement to the terms of a letter to the CMO and an accompanying annex dealing with the safety of beef.
664 There were unsatisfactory features both about the manner in which these documents were prepared and about the terms in which they set out SEAC's advice. The letter set out briefly the reasons for SEAC's conclusion that:
In our judgement any risk as a result of eating beef or beef products is minute. Thus we believe that there is no scientific justification for not eating British beef and that it can be eaten by everyone.
The annex spelt out in greater detail the reasons for that conclusion.
665 The origin of the annex was a paper that Dr Pickles had prepared to brief the CMO before his appearance before the Agriculture Committee. She explained to him:
The arguments are those that have or should have been discussed by the Tyrrell Committee [ie, SEAC].
666 It was subsequently adopted by SEAC as the basis for their advice to the CMO. The draft annex was, however, circulated widely by Dr Pickles and Mr Lowson within DH and MAFF, so that officials could suggest amendments to the draft. Mr Thomas Murray 6 of DH expressed concern that 'the Annex will give us considerable presentational problems and do little/nothing to reassure the public about the safety of British beef'. In MAFF it was forwarded to Mr Gummer and Mr Maclean for approval, but only after a process which had led Mr Lowson to note that 'the most inflammatory pieces of drafting in earlier versions have now been edited out'.
667 We were unhappy about this editorial process. It seemed to us that there might well be a conflict between officials' desire that the annex should not contain inflammatory matter and the desirability that the annex should fairly and objectively summarise SEAC's views on risk.
668 Dr Tyrrell accepted that, had there been time, it would have been preferable for the Committee to have formulated its own view, but defended what had occurred because SEAC was under time constraints. We do not believe that the editorial process resulted in any distortion of SEAC's views, but remain of the opinion that it would have been preferable if the Committee had been left to do its own editing of the draft annex.
669 We turn to the substance of SEAC's advice. The passages that gave us concern were those that dealt with dose. The question of the amount of infective material that might suffice to transmit the disease was of practical importance when considering the precautions that needed to be taken against transmission, whether to other animals or to humans. SEAC commented more than once that 'very large doses' were needed for oral transmission. The Committee members explained to us that they were speaking of the titre of infectivity, not the quantity of physical material that held the dose. Once this was explained, we could follow SEAC's reasoning. Nonetheless, we felt that the language that they had used tended to suggest that they were speaking of the amount of infective material. Here is an example:
. . . the incubation period in mice was longer after large oral doses of BSE-infected cattle brain than after much smaller parenteral injections - in these, as in other animal experiments, large doses appear to be needed for successful disease transmission.
670 SEAC submitted to us that the letter and its annex were prepared for the CMO and would have been likely to circulate among readers who were familiar with the concept of dose. We accept that point and have concluded that it would not be right to criticise SEAC for the language used. We believe, however, that the annex was circulated within MAFF and fear that it may have given rise to misunderstanding. The evidence shows that in 1990, and indeed for some years thereafter, there was a perception on the part of many within government that a substantial quantity of infective material would be required orally to transmit BSE to a cow and that the same would be true of transmission from cow to human, if indeed such transmission was possible. It is at least possible that SEAC's annex contributed to this belief.
671 In the period up to 1990, MAFF had taken the lead in addressing the possibility that BSE posed a risk to the safety of human food. Although Dr Metters and Dr Pickles had played a diligent role, albeit a secondary one, in considering which tissues should be included in the human SBO ban, they had done so in the belief that the ban was not scientifically justified.
672 The attitude of Dr Metters at this time was demonstrated by a response that he sent in October 1990 in answer to a suggestion by Mr Murray that DH should ensure that a continuous flow of appropriate BSE information should be sent to Directors of Public Health, Consultants in Communicable Disease Control and Environmental Health Officers. Dr Metters wrote that he was concerned that such activity might raise the implication that:
. . . somehow the disease poses a risk to human health. Every effort has thus far been made to underline the Government's position, based on advice from the Southwood and Tyrrell Committees that the disease is not a risk to humans. That principle lies behind this Department's low-key approach to publicity.
Dr Metters should not have given this response, which seems to us to convey quite the wrong message.
673 In the years ahead DH continued to play a subordinate role in addressing the food risks relating to BSE - so much so that, in the final days before 20 March 1996, it did not occur to Mr Hogg and Mrs Browning that Health Ministers should even be consulted about appropriate measures to enhance the protection of human health.
674 The first case of FSE was not merely of concern to the general public. It was of concern to SEAC. The Committee was unable to draw conclusions without knowing whether the cat had contracted the disease from BSE. It advised that there was an urgent need for research. In due course, as the number of cases of FSE grew, it became accepted that they had probably caught the disease from eating bovine offal infected with BSE. Mr Meldrum commented in evidence to us that no specific observations or recommendations were ever made on the effect of FSE on the risk to humans. In this he is correct. We had evidence from a number of scientists that transmission of BSE to cats was an event which altered their belief that BSE posed no greater risk to humans than scrapie. The public were never told that scientists' appraisal of that risk had changed. On each occasion that public concerns were raised about BSE, they were met with the same refrains - 'There is no evidence that BSE is transmissible to humans'; 'It is safe to eat beef'. Risk communication in relation to BSE was flawed.
1 See Chapter 5, para. 389 above
2 Assistant CVO, Meat Hygiene
3 Introduced by European Commission Decision 90/261/EC
4 YB90/6.14/3.3
5 YB90/1.9/3.1
6 Head of Section, Environmental Health and Food Safety Division
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