Volume 1: Findings and Conclusions
6. Protecting human health
The false peace - 1 January 1991 to 31 March 1995
Slaughterhouse standards
History of the setting up of the Meat Hygiene Service
Monitoring compliance with the SBO Regulations
MRM on the agenda again
The distal ileum of calves
Advances in knowledge of BSE
Knowledge about dose
Two dairy farmers die from CJD
Vicky Rimmer

675 In this section we take the story on to 1 April 1995, when the national Meat Hygiene Service (MHS) took over the enforcement of slaughterhouse Regulations from the local authorities. This was a watershed event in the BSE story. It led to discovery of the scale of the inadequacies of the implementation and enforcement of the animal SBO ban. This we have described in Chapter 5. It led to the discovery of shortcomings in the clean removal from the carcass of all spinal cord. This we shall consider in the next section. This section covers a period of relative inactivity in the BSE story. ¹

676 We shall begin with a short description of the hygiene standards in slaughterhouses that led to the setting up of the MHS. We shall also describe shortcomings in the regulatory structure which the MHS inherited. These are of relevance in helping to understand why there were failures in implementing and enforcing the obligations to remove spinal cord. They also explain the much more serious inadequacies in the handling of SBO once it had been removed, which we have looked at earlier in this volume. We shall, in addition, describe briefly the political process which led to the setting up of the MHS.

677 Next we shall look at the evidence relating to monitoring of the human SBO Regulations up to April 1995, and at some further consideration that was given to MRM. We shall note an important amendment to those Regulations.

678 During this period knowledge about BSE advanced as results began to be received from the research projects that had been undertaken. We shall consider the extent to which this knowledge was communicated to the public. Events which caused concern to the public, and to government, were the incidence of two cases of CJD in dairy farmers and the first case of a teenager to suffer from this disease. We shall look at the media reaction to these events and the official response.

Slaughterhouse standards

679 In an era of deregulation, a convincing case had to be made out for the introduction of the centralised MHS. Standards of hygiene in British slaughterhouses provided that case. Mr Gummer gave this vignette to the House of Commons Agriculture Committee in October 1992:

'Slaughter hall floor heavily soiled with blood, gut contents and other debris - no attempt to clean up between carcasses. Car cleaning brush heavily contaminated with blood and fat being used to wash carcases. Knives and utensils not being sterilised. Offal rack and carcase rails encrusted with dirt. Missing window panes in roof - birds, flies and vermin entering'. Another slaughterhouse report: 'Filthy equipment and surfaces - congealed and dry blood on offal racks. Effluent discharging across floor under dressed carcasses - risk of contamination. Slaughterman at cattle sticking point not sterilising knife. No sterilisers to wash basins in pig slaughter hall. No fly screening on open windows'.

680 The previous year Mr Gummer had reported to the Prime Minister that 60 per cent of red meat slaughterhouses did not meet European standards. Many plants recorded as satisfactory were only just acceptable. On the introduction of the Single European Market on 1 January 1993, 544 British slaughterhouses sought a temporary derogation from compliance with European hygiene requirements. When EU Veterinary Inspectors carried out surveillance of these establishments in 1994, they found that 68.5 per cent were of concern or of grave concern.

681 MAFF officials initially had little knowledge of how local authorities set about complying with their obligations to enforce Regulations in slaughterhouses. In 1992 Mr Lawrence was appointed to lead an MHS Project Team to investigate this. He discovered an unsatisfactory state of affairs. There were instances of animosity between plant management and Inspectors, and between Official Veterinary Surgeons who oversaw enforcement, usually under contract, and the Inspectors and EHOs on the staff of the Environmental Health Departments of the local authorities. In many cases there was an unclear management chain and lack of teamwork.

682 In January 1992, Mrs Jane Brown, Head of Meat Hygiene Division, forwarded a paper to the Cabinet Office as a basis for discussion by officials of the proposal to create a national Meat Hygiene Service. This recorded:

The State Veterinary Service, who monitor standards, have no real control over LAs. The Official Veterinary Surgeon . . . has little real management control over the meat inspectors in the plant . . . standards of enforcement are uneven across the country.

683 A review in 1992-93 of hygiene standards in a sample of slaughterhouses confirmed this picture and commented: 'In many cases, the Local Authority appeared disinterested.' Many witnesses gave evidence to us to similar effect.

684 We asked MAFF officials whether evidence of poor hygiene standards in slaughterhouses did not raise concerns about the standard of enforcement of the duty to remove spinal cord from the carcass. Each replied that it did not. Some commented that they had imagined that this was a simple operation. Others said that removal of unfit meat from the carcass was so important that they believed Meat Inspectors gave priority to strict enforcement of that obligation.

685 We were at first inclined to believe that poor standards of general hygiene would inevitably go hand in hand with poor standards of compliance with the SBO Regulations. So far as concerned the formalities of disposal of SBO once it had been removed from the carcass, we were proved right. Standards of removal of spinal cord do not, however, appear to have reflected the poor standards prevailing elsewhere in the slaughterhouse. After the MHS took over, inspections disclosed that failure to remove all spinal cord before meat was health-stamped had probably been occurring on average in four cases out of a thousand. Although this level of failure was not satisfactory, it suggests that in general the operation of removing the spinal cord was carried out efficiently and effectively. The occasional failure to remove all the spinal cord had been described in MAFF's paper to SEAC in 1990 as inevitable. Under the structure in place before the MHS took over we believe that it was. After the MHS was in place, by adding resources and monitoring a campaign aimed at ensuring 100 per cent removal of spinal cord, MAFF and the MHS appear to have come close to achieving this goal.

History of the setting up of the Meat Hygiene Service

686 In July 1991 Mr Gummer wrote to Mr Waldegrave, who was at that time Secretary of State for Health, to propose the setting up of what was to become the MHS. Mr Waldegrave replied that he was 'content' with the proposal. In November the proposal was placed before the Prime Minister, who wished to know the reaction of the Treasury. Mr Mellor, Chief Secretary to the Treasury, at first had reservations, but those were dispelled and Mr Major announced on 9 March 1992 that a new Meat Hygiene Service was to be set up.

687 The decision proved controversial. When the Conservative Party was returned to office after the General Election with a greatly reduced majority, there was back-bench opposition from its own MPs to the need for additional hygiene measures. Many, including the meat industry, major retailers and some journalists, considered that MAFF was going too far in pandering to what they saw as European over-regulation.

688 When Mrs Shephard succeeded Mr Gummer, she took a fresh look at the proposal for the MHS. Although she had initial misgivings, she was persuaded by her officials that it was an essential measure. She ran into opposition, however, from Mr John Redwood, who had been appointed Secretary of State for Wales. In October 1993 Mr Michael Portillo, who had been appointed Chief Secretary to the Treasury, also suggested that she should look again at the proposal. Mrs Shephard stood firm, supported by Mr Ian Lang, Secretary of State for Scotland. The following month Mr Redwood and Mr Portillo indicated their acceptance of the project.

689 In 1994 the work of establishing the MHS proceeded. Mr Johnston McNeill was appointed Chief Executive. The new Agency was to inherit the staff in the case of 176 of the local authorities; their existing terms and conditions differed and had to be renegotiated in each instance. In July 1994 Mr Waldegrave succeeded Mrs Shephard as Minister of Agriculture. Once again he satisfied himself of the merits of the scheme. The MHS replaced the local authorities on 1 April 1995.

690 The establishment of the MHS was not a measure taken in response to the emergence of BSE. Accordingly it has not fallen within our terms of reference to consider why so long elapsed between the decision to introduce the Service and the implementation of that decision. The establishment of the MHS had a beneficial impact on the implementation of both the human and the animal SBO ban. It is unfortunate that this was so long delayed.

Monitoring compliance with the SBO Regulations

691 In Chapter 5 we saw how monitoring of the SBO Regulations in slaughterhouses was intensified between 1991 and 1995. This was, however, in response to concerns about the animal SBO ban. The instructions received by the Veterinary Field Service (VFS) required it to concentrate on the handling of SBO after removal from the carcass. The focus of attention was the gut room, not the 'clean' side of the slaughterhouse. The only specific question on the SVS pro forma covering slaughterhouse visits that related to human health asked whether removal of bovine brains involved contamination risk. There was no mention of spinal cord.

692 Records of slaughterhouse visits have been lost for large parts of the period between 1991 and 1995. In 1990 there had been one report of a failure to remove spinal cord from the carcass. That is the only such report of which we are aware. Apart from a few early reports about brain removal, there was nothing to suggest that slaughterhouse operations involved any risk to human health.

693 We have already discussed why it was that the VFS did not discover the deficiencies in compliance with the Regulations in the gut room until after the MHS had taken over. The same reasons apply in relation to the removal of spinal cord. We believe that the principal reason was the difference in rigour of the inspections before and after the MHS took over.

694 Mr Christopher Clarke, who had served as a Meat Hygiene Inspector, told us that it was typical for MAFF Veterinary Officers on their periodic inspections to arrive mid-morning and depart a few hours later, after discussion with the management of the plant and the principal Environmental Health Officer. Such a visit was unlikely to detect the occasional failure to remove a segment of spinal cord, particularly if the focus of the visit was what was taking place in the gut room.

695 It may well be that there was, on occasion, a lack of diligence on the part of the Veterinary Officer making the monitoring visit. It was regrettable that the need to give specific instructions to monitor the removal of spinal cord was not identified when the Regulations were being introduced and particularly unfortunate that, when SEAC was asked to look at slaughterhouse practices, its response was understood to signify that these were not cause for concern. We have no criticism to make of Mr Hutchins, Mr Simmons or their superiors in relation to this aspect of the monitoring duties of the SVS.

MRM on the agenda again

696 On 8 April 1994 Mr Meldrum called a meeting of MAFF officials to review arrangements for disposal of SBO. Although the primary concern seems to have been enforcement of the animal SBO ban, Mr Meldrum suggested that 'one way to increase security would be to prohibit the use of spinal column for MRM'. Impetus was given to this suggestion when, in July, the European Commission's Scientific Veterinary Committee recommended that vertebrae from cattle killed in the UK should no longer be used for the production of MRM. This recommendation was not pursued, but MAFF prepared a paper on MRM for SEAC to consider at its meeting on 30 August 1994. The Committee was asked to advise on the use of spinal column for the production of MRM. Not for the first time SEAC had a heavy agenda, and this item was deferred, to be restored in June the following year.

The distal ileum of calves

697 One experiment carried out by the CVL ² involved feeding calves with BSE-infected brain and then slaughtering an animal every four months (after the first two months had passed) and testing 44 tissues for infectivity by injecting them into the brains of susceptible mice. In June 1994 a positive result was obtained from the distal ileum (small intestine) of a calf slaughtered only six months into the experiment. This was an event of some significance. Hitherto only brain and spinal cord of BSE victims had been found to be infective. Furthermore, tissues from calves of less than six months of age had been excluded from the SBO ban. MAFF Ministers and officials were informed of the result and Mrs Bottomley, the Secretary of State for Health, was informed the same day.

698 It was agreed between the two Departments that SEAC's advice should be obtained before this experimental result was made public. An 'exceptional meeting' was called on 25 June 1994. SEAC expressed the view that any risk to humans from food derived from calves was minuscule, but added that it was not possible to give a definitive answer:

There is a theoretical risk and Government could respond by a limited SBO ban for calves to exclude the intestines.

699 Over the weekend Mr Meldrum and MAFF officials held lengthy meetings with Dr Calman, the CMO. Dr Calman said that he would be advising Ministers that the distal ileum and thymus of calves should be proscribed as SBO. Those present agreed with his conclusion. Officials met with MAFF Ministers the next day. The point was made that the proposed ban would have a serious effect on the export of calves and have a knock-on effect on the price of beef. Mrs Shephard responded that where public health was concerned, trade was the least important consideration. She later met with Dr Calman to discuss the terms of the ban.

700 MAFF at once sent letters to operators of all slaughterhouses, telling them of the proposed extension of the SBO ban and asking them to give effect to it on a voluntary basis, pending amendment of the Regulations.

701 How the news of the experiment result and the action to be taken should be made public was the subject of discussion in the Cabinet. A draft press release prepared by the CMO was considered. It included a statement that the risk to human health was considered to be 'minuscule'. In discussion it was suggested that this should be deleted, so that the statement would indicate that there was no risk at all. Mr Major, in summing up, said that Mrs Shephard should proceed with the announcement as planned.

702 A lengthy press release was issued on 30 June, accurately describing the course of events, and setting out SEAC's advice in full.

703 This decision was a model of how government ought to handle such an issue.

• SEAC's advice was sought as to the implications of the finding in the pathogenesis experiment.
• SEAC limited its advice to the effect this result had on the question of risk of transmission to humans and did not recommend the appropriate policy decision.
• MAFF and DH worked closely together in considering the appropriate response.
• The issue was discussed with Mrs Shephard at a meeting at which the CMO expressed his advice in favour of an extension to the SBO ban.
• The effect that such an extension would have on trade was considered.
• The Minister and the Parliamentary Secretary were in agreement that 'protecting the public health was the first of MAFF's aims'. The CMO's advice would be followed, notwithstanding the potential for serious impact on trade.
• The practical implications were considered.
• The results of the experiment and the Government's response were announced without delay.
• There was swift consultation and prompt action. Slaughterhouses, local authorities and bodies consulted were individually informed of the extension of the Regulations.

Advances in knowledge of BSE

704 Between 1991 and 1995 a lot more was learned about BSE. Advances in knowledge up to about September 1994 were summarised in a Report produced by SEAC in September 1994 and published in February the following year. ³ The following we find particularly significant:

• By September 1994, 57 cats had been confirmed as having contracted FSE, presumptively from feed containing the BSE agent.
• The following animals had contracted spongiform encephalopathies (SEs), in most cases presumptively from feed containing the BSE agent:

- Nyala
- Gemsbok
- Arabian oryx
- Greater kudu
- Eland
- Moufflon
- Puma
- Cheetah
- Scimitar-horned oryx.

705 Strain-typing showed that, in contrast to scrapie, which had a number of different strains, cases of BSE from different parts of the United Kingdom and in different years were indistinguishable from each other but distinct from all previously studied laboratory strains of scrapie.

706 In addition to the natural transmissions set out above, on 14 February 1992 BSE was found to have been successfully transmitted to a marmoset by cerebral inoculation. This was the first transmission to a primate. A meeting of SEAC was immediately called to consider the implications of this. SEAC concluded that as marmosets had in the past been infected with SEs, including scrapie, using similar methods, the results were not surprising and had no implications for the safeguards already in place for human and animal health.

707 We have emphasised those last words, for they were significant. SEAC's 'public advices' on risk tended to focus on the question of whether the precautionary safeguards in place were adequate to protect the public. They did not comment on the effect that events had on the assessment of the risk that BSE might be transmissible to humans. Thus the impression was given that that risk never changed. There is no better illustration of this than the following passage of oral evidence given to us by Mr Gummer:

. . . during the period of time in which I was Minister and my junior Ministers were with me, that science was tested all the time, but it did not change. The advice was and continued to be that the risk to human beings was remote . . . ⁴

708 To the casual reader of SEAC's 1994 Report, nothing had changed. Thus, under the heading of risk assessment, SEAC wrote:

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.

709 The careful reader, however, might have noted this passage which followed:

In conclusion, therefore, our scientific assessment is that the risk to man and other species from BSE is remote because the control measures now in place are adequate to eliminate or reduce any risk to a negligible level. We do however point out that any species exposed already and before any bans were effective could be incubating disease, and therefore continuous monitoring is very important until any possible incubation period has been exceeded.

710 SEAC only evaluated the risk as still remote because precautionary measures, and in particular the human SBO ban, had been put in place. The Southwood Working Party, however, had not taken that view - at least in relation to human food, where they considered the risk remote even without an SBO ban.

711 The advances in knowledge by September 1994 significantly altered the scientific evaluation of the risk that BSE might be transmissible to humans. Professor John Collinge ⁵ told us:

Certainly the appearance in domestic and captive wild cats was a very important development. It demonstrated that you could no longer really plausibly argue that BSE was just scrapie in cows with all the same properties. This agent, wherever it had originated from, had quite different biological properties to scrapie as manifested by the extended host range of affected species, including things like nyala and kudu as well as the cats that had not been affected by scrapie before, so far as we were aware.

712 Dr Tyrrell confirmed that the transmission of BSE to cats and wild cats had shifted his perception of the risk of transmissibility 'a bit'. Dr Kimberlin said that his reaction to the cat was:

Thank God we have got the SBO ban because if it should so happen that the species barrier between cattle and humans is no higher than between cattle and cats . . . then we would have a problem.

713 We do not criticise SEAC for what was a detailed and careful analysis of the existing data. Nonetheless we think it a pity that its Report did not spell out more clearly and simply the fact that perception of risk had changed since Southwood. Had the Committee done so, its Report might have attracted some attention and resulted in the public being better informed about risk. As it was, the Report appears to have attracted no press coverage.

Knowledge about dose

714 One important experimental result did not receive comment in SEAC's 1994 Report. The NPU had succeeded in transmitting BSE to sheep using an oral dose of no more than ½ gram of BSE-infected brain. What is more, the sheep infected were of a breed not susceptible to scrapie. The interim result of this experiment was known in November 1990 and published in the Veterinary Record in October 1993. The significance of this experiment seems to have been totally overlooked by MAFF officials, and indeed by SEAC. We have not been able to discover why this was.

715 The CVL had, in January 1992, initiated an 'attack rate' experiment under which they had fed different quantities of BSE brain to cattle. The smallest quantity was 1 gram and, in September 1994, MAFF officials learned that this had transmitted the disease. There was general surprise and concern that such a small quantity had proved infective. This result demonstrated the importance of avoiding:

• contamination of MBM designed for animal feed with SBO in the course of rendering; and
• contamination of cattle feed with pig and poultry feed containing that contaminated MBM in the feedmills.

716 Had the significance of the NPU experiment been drawn to the attention of MAFF officials in November 1990, the extent of the danger of cross-contamination might have been appreciated four years earlier.

Two dairy farmers die from CJD

717 In May 1990, in accordance with a recommendation of the Southwood Working Party, the CJD Surveillance Unit (CJDSU) had been set up under Dr Robert Will. ⁶ Its main objective was to identify any change in the epidemiological characteristics of CJD cases and to assess the extent to which they were linked to the occurrence of BSE. The CJDSU summarised its progress and findings in a series of annual reports, and Dr Will submitted articles about these to The Lancet. Dr Will was a member of SEAC, and findings of the CJDSU were reported to SEAC when they met.

718 There was a more immediate link with DH through Dr Ailsa Wight who, in September 1991, took over from Dr Pickles the responsibility for provision within DH of medical advice in relation to BSE and CJD and was DH's observer on SEAC. Thus DH and, through DH, MAFF usually received confidential information about victims of CJD well before news of them became public. There was ample time to decide upon the appropriate official response to such news.

719 On 6 March 1993 The Lancet published an article by Dr Will on the first recorded case of CJD in a dairy farmer. He had died the previous October. He had had BSE in his herd. The article concluded that the case was most likely to have been a chance finding and that 'a causal link with BSE is at most conjectural'. The media naturally developed the conjecture that there might be a link between this case and BSE. Professor Lacey did not think that there was. Interviewed on the radio, he gave his opinion that the case had occurred too soon to have been contracted from BSE.

720 The media interest led Mr Gummer to discuss a press release with Dr Calman, who agreed that it was necessary to reassure the public. On 11 March the CMO issued a public statement. This repeated the assurance about the safety of beef given by his predecessor, Sir Donald Acheson, in 1990 that we have criticised above. ⁷

721 We found it open to precisely the same criticism. Dr Calman was seeking to address fears that a farmer had somehow caught BSE from his cattle. Responding to such fears by emphasising that it was safe to eat beef naturally carried the inference that transmission of the disease from cow to human was impossible. That Dr Calman's statement was in fact misinterpreted in this way is demonstrated by The Mirror's report that:

Chief Medical Officer Dr Kenneth Calman had insisted that BSE could not cause a related brain disease in humans.

722 Dr Calman should have been careful not to make a statement in terms that suggested such a belief, for he considered that there was a real potential for BSE to move from cows to humans.

723 On 23 March Mr Lowson commented in a minute for Mr Gummer's attention:

It was not easy to get the CMO to make a statement in response to recent press speculation about a possible link between BSE and human disease.

724 The reason why MAFF wished the CMO to make a statement was, no doubt, because of the damage that public concern about BSE might cause to the beef industry. The evidence suggests that Dr Calman had reservations about complying with MAFF's request for assistance. Having decided to comply with that request and make a public statement, he should have taken great care to ensure that his statement fairly reflected his appraisal of the risk posed by BSE.

725 On 12 August 1993 The Daily Mail recorded the death from CJD, earlier in the month, of a second dairy farmer, who had had BSE in his herd. The CJDSU had been monitoring this case, and had concluded that there was nothing to suggest that it was other than a case of sporadic CJD. A DH spokesman was quoted by The Daily Mail as saying that two cases might occur in dairy farmers by chance and that it was not possible to reach any conclusions about a link between BSE and CJD.

Vicky Rimmer

726 Vicky Rimmer fell ill early in the summer of 1993 at the age of 15. She had a neurodegenerative disease which the medical specialists were unable to identify. In mid-September she went blind and fell into a coma. She remained in a coma until she died on 21 November 1997, over four years later. The CJDSU now attributes her death to CJD, but her illness did not have the characteristics of the cases now classified as vCJD. In January 1994 the CJDSU was unsure whether her illness was CJD.

727 It was in January 1994 that the press first started to write about Vicky Rimmer, quoting her grandmother's belief that Vicky had been infected as a result of eating beef infected with 'mad cow disease'. Dr Stephen Dealler and Professor Lacey were reported to have concluded that this was the first case of BSE infecting a member of the human race through food.

728 In response to intense media coverage, Dr Calman released a statement on 26 January. This stated that:

• no one knew what illness the patient was suffering from; and
• on the basis of the work done so far, there was no evidence whatever that BSE caused CJD and, similarly, not the slightest evidence that eating beef or hamburgers caused CJD.

729 We consider that it was reasonable for Dr Calman to make a public statement to counter media reports which suggested that the link between Vicky Rimmer's disease and eating beefburgers was established. The terms in which he did so were somewhat more emphatic than was desirable, but not to the extent that it would be right to criticise him for his choice of language.

730 Dr Dealler's and Professor Lacey's conclusion that Vicky Rimmer had caught BSE through food was speculative. In the next chapter we shall see the first of the cases that have been identified by the CJDSU as cases of vCJD linked to BSE.