Volume 1: Findings and Conclusions
6. Protecting human health
Chinks in the armour - April-December 1995
Action at last on MRM
Cause for concern
Public debate
A campaign of reassurance

731 In this section we shall consider, from the viewpoint of public health, the revelations that followed the takeover by the MHS of enforcement of Regulations in slaughterhouses. We shall consider how government responded to what was discovered. We shall look at growing concerns caused by further cases of CJD in farmers and in young people and we shall look at official statements and media comment in relation to the risk posed by BSE to humans. We shall cover the period up to the end of the year. ¹

732 The MHS took over on 1 April 1995 with Mr Johnston McNeill as Chief Executive and Mr Philip Corrigan as Head of Operations. Mr Corrigan was succeeded in August 1995 by Mr Peter Soul. The MHS commissioned a survey of standards at slaughterhouses from Eville & Jones, a firm of private veterinarians which provided Official Veterinary Surgeon (OVS) inspection services. Deficiencies summarised in its report which existed at the time of takeover on 1 April 1995, included widespread lack of awareness of SBO legislative requirements and instances of incomplete removal of spinal cord. The report noted significant improvements over the five months between April and August 1995. When Dr Cawthorne at MAFF learned of this report, he asked himself why these deficiencies had not been drawn to the attention of the SVS or the Meat Hygiene Division. We think that the explanation must have been poor OVS/local authority/VFS liaison.

733 The MHS also organised an internal survey of slaughterhouse standards by its own Hygiene Advice Teams. These teams encountered occasional failures fully to remove tonsils, thymus and spinal cord, but felt able to report that SBO removal in the slaughterhall was carried out in accordance with the legislation.

734 VFS staff were instructed to visit slaughterhouses once every two months and carry out a thorough inspection in company with MHS staff. They were instructed to examine, in particular, methods used to separate SBO from material intended for human consumption as well as staining and disposal of SBO. As we have seen, when looking at animal health, inadequacies in the handling of SBO led to the institution of a period of national surveillance.

735 In May 1995 Mr Meldrum gave instructions that Meat Hygiene Inspectors (MHIs) should be told to take particular note of the operation of removing the spinal cord from the vertebrae. This led to an Information Note being circulated to all MHIs and OVSs instructing them to ensure the complete removal of spinal cord from the vertebral column. In July the question was raised as to whether a Meat Hygiene Inspector could refuse to apply the health stamp on the ground that not all spinal cord had been removed. MAFF lawyers replied in the affirmative. We think it significant that this should be in doubt over five years after the SBO Regulations were introduced.

736 The July report on the results of the first round of national surveillance found widespread deficiencies in the handling of SBO, but made no mention of deficiencies in removing SBO from the carcass. In a submission to Mr Hogg, Mr Packer noted that the implications of the failures in the controls were for animal health, not for human health. Mr Meldrum confirmed that there was no public health problem because there was no question of SBO entering the human food chain.

737 By the time of the second round of national surveillance, the importance of ensuring the complete removal of spinal cord had been specifically drawn to the attention of the VFS in accordance with Mr Meldrum's instructions. On the second round of inspection, three instances were discovered of failure to remove SBO from the carcass. When this was reported to Mrs Browning, the Parliamentary Secretary, and to Mr Hogg, both were perturbed. Mr Richard Carden ² suggested that enforcement should be tightened up and prosecutions launched where companies repeatedly infringed the Regulations. Mr Hogg agreed that this should be done.

738 The surveillance results were reported to DH. Mr Meldrum assured Dr Metters that specific and detailed instructions had since been issued by the MHS to their staff on the checks necessary to ensure compliance with the legislation. Dr Calman received copies of this correspondence and resolved to look carefully at the next round of surveillance in order to see whether or not the deficiencies that had been discovered were isolated incidents.

739 On 23 October Mr Meldrum wrote to Dr Calman informing him that SVS staff had found a further four cases of health-stamped carcasses with portions of spinal cord attached. He described these results as 'disappointing', but added:

It is inevitable that instances of the type referred to will continue to be reported albeit at low frequencies since no system operated by humans can deliver at 100 per cent efficiency all the time.

740 Two days later Dr Calman met Mr Packer to 'express disquiet about the position on BSE'. Dr Calman said that he 'could not be so unequivocal as he had been in the past' about the safety of beef. In a confidential file note he recorded:

The issue remains, however, that the uncertainty has increased, rather than decreased. Urgent action is required to reassure the public that all steps are, and have been, taken to minimise any possible risk. ³

741 When Mr Hogg learned of Dr Calman's concerns, he called a council of war of his junior Ministers and senior officials. We have already recorded, when looking at animal health, Mr Packer's advice that Mr Hogg should read the riot act to the MHS and the slaughterhouse industry. In the formal instructions that Mr Hogg proceeded to issue to Mr McNeill, he instructed him that his staff:

. . . must ensure that all SBO is removed from a carcass before they give it a health stamp. Failure to do so should be viewed extremely seriously.

742 This led the MHS management to introduce what one union officer described to us as a 'disciplinary purge'. Immediate and emphatic instructions were issued to the workforce that failure to ensure that all spinal cord was removed would be treated as a serious disciplinary offence. Mr Hogg for his part met with representatives of slaughterhouse operators and told them robustly that he would only be satisfied with 100 per cent compliance with the rules and that those who did not provide this would be prosecuted.

743 On 1 November Mr Don Curry, the chairman of the MLC, wrote a strong letter to Mr Hogg expressing concern at breaches in the integrity of the SBO system, in particular those leading to the four cases in which spinal cord had been found in carcasses that had been passed as fit by meat inspectors for consumption. He wrote:

We detect an attitude in the industry which says, 'you have told us this disease was not a threat to humans so why do we need all these controls?'. The danger that such an attitude engenders to our market, both at home and overseas, is very worrying indeed.

744 This was one of a number of occasions in and after 1994 that the MLC commendably urged the importance of compliance with the SBO Regulations both on MAFF and on the industry. We would remark, however, that the attitude of which Mr Curry complained may well have been encouraged by some of the exaggerated reassurances that had been given earlier by the MLC.

745 On 7 November Dr Calman and Dr Metters met Mr Hogg, Mrs Browning and Mr Packer. Dr Calman did not mince his words. He said he found the attitude of the farming industry and the slaughterhouses astonishing. While there was no evidence that meat was not safe, it could not be said with confidence that no contaminated offal had entered the food chain. If pressed on the safety of food containing MRM, he would be in a difficult position.

746 On 20 November 1995 MRM was discussed at a meeting between Dr Calman, Mr Meldrum and other officials from both MAFF and DH. Dr Calman suggested that it was impossible to be 100 per cent certain that spinal cord was not being included in MRM derived from spinal column. Mr Meldrum confirmed that this was the position. It was agreed that SEAC should once again be invited to consider MRM.

747 On this occasion it was DH that had played the lead role in pursuing an issue arising from BSE in respect of the safety of food. Dr (now Sir Kenneth) Calman is to be commended for the vigour of his reaction on learning that segments of spinal cord were escaping the attention of slaughterhouse operatives and meat inspectors. By pursuing this matter with Mr Hogg, and subsequently with Mr Meldrum and other MAFF officials, he was instrumental in ensuring that the question of MRM was brought back before SEAC.

Action at last on MRM

748 We saw that a paper on MRM was placed before SEAC in August 1994 and deferred. A revised paper was prepared for its meeting on 21 June 1995. This annexed MAFF's paper on slaughterhouse practices that had been before SEAC in 1990 and the EU Scientific Veterinary Committee's recommendation that spinal column of cattle slaughtered in the UK should not be used for MRM.

749 The paper informed SEAC that the transfer of responsibility of meat inspection to the MHS:

. . . should ensure that no carcass is permitted to leave the slaughterhouse for human consumption unless the spinal cord has been completely removed.

750 The paper recommended that:

In the light of the changes which are to be made to the controls on SBO and the methods of enforcing these controls . . . SEAC is recommended to advise that the use of spinal columns from cattle born and slaughtered in the UK for the mechanical recovery of meat may continue.

751 SEAC duly concluded that:

. . . provided in the slaughtering process the removal of spinal cord was done properly, the MRM process was safe and there was no reason for the Committee to change its advice. ⁴

752 Just as in 1990, SEAC's advice was premised on the total removal of spinal cord.

753 When SEAC met on 28 November, it had a new chairman. Professor (later Sir) John Pattison, who had been a member of the Committee since January 1995, had replaced Dr Tyrrell. SEAC was informed that there had been 14 instances, involving at least 25 carcasses, in which SBO had been left attached to carcasses after dressing. The Committee was told of the steps that had been taken to tighten up enforcement of the Regulations. After protracted debate, SEAC decided that until it was clear that removal of spinal cord was being undertaken properly in all cases it would be prudent, as a precaution, to suspend the use of vertebrae from cattle aged over six months in the production of MRM.

754 SEAC's advice was accepted by both Mr Hogg and Mr Dorrell. Despite considerable resistance from the industry, the Order ⁵ banning the use of bovine vertebral column for the recovery of meat by mechanical means was made on 14 December 1995 and came into force the following day. For practical reasons, no exception was made in respect of calves aged less than six months.

755 The minutes of SEAC's meeting suggest that the decision was a close-run thing, with arguments from Dr Will and Professor Pattison winning the day. Would the decision have been the same, if the Committee had not known about the result of the attack rate experiment and had been unaware of concerns raised by incidents of CJD in farmers and young people? Would SEAC in 1990 have taken the same decision, if aware then of the extent of the failures to remove spinal cord identified in 1995? We do not believe that a confident answer can be given to either question.

756 As to preventing fragments of spinal cord getting into human food, SEAC's decision was to a large extent a case of shutting the stable door. Measures were in hand to ensure effective implementation of the duty to remove all spinal cord from the carcass. The more significant benefit of the new Order was that it kept dorsal root ganglia out of human food. The benefit was not appreciated at the time. The pathogenesis experiment had not yet shown these to be infective - the positive result was to come later.

757 Has MRM infected humans with BSE in the years up to 1995, and if so on what scale? It is too early to attempt to answer this question. What is, we think, now clear is that this was the route by which infectious material was most likely to end up in human food during that period.

Cause for concern

758 In the second half of 1995, the public learned of the death from CJD of a third, and then a fourth, dairy farmer. The third had died in December 1994. There had been two cases of BSE on the farm where he worked. SEAC held a special meeting to consider this case on 13 January 1995. They concluded that the occurrence of three cases of CJD in dairy farmers with BSE in their herds was worrying, but that more information was needed before any conclusions could be drawn. The death of this farmer was reported in the national press on 29 September. On that day the CMO learned of a suspected fourth case.

759 Again SEAC met in special session. The fourth farmer was still alive, but suspected of having CJD. His herd had had a single case of BSE in 1991.

760 At this special meeting, SEAC considered that although four cases were likely to be more than might be expected as a chance phenomenon for the known population frequency of the disease, analysis of CJD in Europe showed that the incidence of the disease in farmers was similar in countries with no or very few cases of BSE. An important factor was that the clinical and pathological features of these cases were no different from those found in classical sporadic CJD. SEAC released a statement of its conclusions.

761 These findings remain unexplained. Among occupational groups exposed to BSE, farmers remain the exception in having such an excess over the incidence of CJD for the population as a whole. Recent transmission studies in mice indicate that the causal agent in these cases has various characteristics, including incubation period and neuropathology, which are distinct from both vCJD and BSE.

762 Thus they appear to have been typical cases of sporadic CJD, although it is not easy to accept that these four cases were simply a statistical anomaly.

763 The farmers were not the only cases of CJD that were causing anxiety. Two more adolescents had been diagnosed as having contracted the disease. SEAC released a statement saying that it was not possible to draw any conclusions from these cases, which needed to be studied in great detail. SEAC added that cases of CJD had been found in the same age-group in other countries. This was true, but such cases were extremely rare. Sporadic CJD almost always attacks the elderly.

764 Further reports of suspected cases of CJD in young people were received by the CJDSU. By the year-end, ten cases of patients aged under 50 had been referred to them. Three of those had been confirmed by neuropathology.

765 The scientists of the CJDSU were not alone in becoming concerned about cases of CJD in young people. Professor Collinge, who was conducting BSE experiments with transgenic mice, recognised these cases as extraordinary and feared that they could represent the transmission of BSE to humans. At a meeting with Dr Calman at the end of October he told him of his fears. In December 1995 Professor Collinge accepted an invitation to become a member of SEAC.

Public debate

766 Other scientists expressed their concerns more publicly. Dr Stephen Dealler and Dr Will Patterson had been carrying out calculations of the number of cattle subclinically infected with BSE that must have been slaughtered and eaten. Their conclusion that these totalled 1.5 million received wide publicity in the press. 'Most beef eaten already exposed to mad cow agent' was the headline in the Daily Telegraph.

767 On 1 December Sir Bernard Tomlinson, Emeritus Professor of Pathology at Newcastle University, said in a radio interview that he would not eat a beefburger and that all offal should be kept from public consumption. His views received wide press coverage. In The Times, he was quoted as saying:

I have become more cautious because of recent CJD cases in dairy farmers and teenagers. These seem to be more than coincidences. My feeling is that it is possible that BSE is transmitting to humans.

768 In a television interview on 3 December, Mr Dorrell explained that the Government had removed from the food chain all organs which could possibly carry the risk of transmission of BSE - even if it were transmissible. 'So there is, you are saying, no conceivable risk from what is now in the food chain; that's the position?' asked the interviewer, Jonathan Dimbleby. 'That is the position', confirmed Mr Dorrell. Mr Dorrell told us that he regretted that answer because it went further than the words of his Chief Medical Officer. We think that it was regrettable that he gave a public assurance in terms more extreme than he could justify. He told us that it led to his being quoted in the press the next day as saying that there was no conceivable risk from eating beef.

769 The words of the CMO, to which Mr Dorrell referred, had been included in a press release in October to mark the release of the CJDSU's fourth annual report. Dr Calman stated:

I continue to be satisfied that there is currently no scientific evidence of a link between meat eating and development of CJD and that beef and other meats are safe to eat. However, in view of the long incubation period of CJD, it is important that the Unit continues its careful surveillance of CJD for some years to come. ⁶

770 We do not think that Dr Calman should have gone out of his way on this occasion to volunteer the unqualified statement that he was satisfied that beef and other meats were safe to eat. We believe that at this time Dr Calman had concerns about slaughterhouse practices, which he expressed to Mr Packer later in the month. He also had concerns about the dairy farmers that had contracted BSE. If he was going to make a statement about the safety of beef, he should have made it plain that this depended on an improved standard of compliance with the SBO Regulations by those who worked in slaughterhouses.

771 Neither Dr Calman's assurance about beef in October, nor Mr Dorrell's assertion that there was no conceivable BSE risk from food, did much to quell the alarm raised by Sir Bernard Tomlinson. The Local Authorities Catering Association received hundreds of calls from worried parents and head teachers about school meals, and advised school cooks to substitute turkey, chicken and pork for beef. On 8 December The Independent reported that 1,150 schools had taken beef off the menu or were offering alternatives.

772 On learning that schools and caterers were beginning to remove beef from the menu, Dr Robert Kendell, the Chief Medical Officer for Scotland, decided to make a public statement. He did this on 7 December in these terms:

The Government's independent scientific advisers are saying consistently that there is no evidence at all that eating beef or other foods derived from beef is dangerous. My general advice to people is therefore to carry on eating what you want to eat as you were before.

We have no evidence of any connection between BSE and CJD. However, both conditions are being monitored and studied by scientists, in this country and abroad, as there is much about both that is still unknown. ⁷

773 We have the same concerns about this statement that we had about Dr Calman's. Dr Kendell told us that, from early 1995 onwards, he was becoming increasingly concerned that BSE might have implications for human health. He told us that some of his concerns were allayed by Mr Hogg's firm stance on the SBO Regulations and the ban on the use of bovine vertebral column for the recovery of MRM. We think that Dr Kendell should have made it plain in his statement that the safety of eating beef was dependent on strict compliance with the precautionary measures introduced by the Government.

774 BSE was discussed in the Cabinet on 7 December. Mr Hogg explained about the problems discovered in slaughterhouses and the action that he had decided to take in relation to MRM. In summing up the discussion which followed, the Prime Minister said:

. . . that there was a disturbing degree of public anxiety over BSE once more and that the Government must be ready with an immediate and coherent response. The key element in that response should continue to be the assurance from the Government's chief professional advisers that there was no evidence that the disease could be transmitted to humans. ⁸

A campaign of reassurance

775 MAFF Ministers and officials met the same afternoon to discuss the way ahead. They decided to use SEAC to try to get the message across that beef was safe. Professor Pattison would be invited to draft a letter to the press. Mr Hogg instructed Mr Eddy to draft a questionnaire for SEAC with the intention that the answers that they gave should be made public.

776 On 8 December The Independent published a lengthy article by Dr Will. The tone of this was generally reassuring, although it contained a caveat that the possibility of a link between BSE and CJD could not be excluded for many years because of the long incubation period. It ended:

I do not believe it is reasonable to conclude that there is significant risk from eating beef. I have therefore not altered my consumption of beef or beef products, and neither have any of my colleagues at the CJD Surveillance Unit.

777 On the same day Professor Pattison and Dr Will, acting on behalf of SEAC, sent a long letter about the safety of beef to The Times. The Times was only prepared to publish this in an edited form, an offer which was declined. The letter was adapted and turned into a letter to Mr Dorrell and Mr Hogg, and presented to the press at a press conference on 14 December, attended by Mr Hogg, Mrs Browning, Dr Calman, Professor Pattison, and Mr McNeill (of the MHS). The letter, after describing the precautionary measures that the Government had taken, and the strengthening of those measures, stated that:

On the basis of the measures taken SEAC has a high degree of confidence that the beef reaching the shops is safe to eat.

778 This was a message that those who gave the press conference did their best to reinforce.

779 It is apparent to us that members of SEAC were pressed by government to intervene in the public debate about the safety of beef. We believe that this is something that was likely also to be apparent to members of the public. SEAC's proper role was to provide expert advice to the Government - advice which it was normally desirable to make public. If it appeared to the public that members of SEAC were being used to provide publicity to bolster the beef market, SEAC's credibility was likely to be damaged. We consider there was a danger of that on this occasion. When we look back on events in December 1995, we think that it would have been preferable if SEAC had not become involved in the public debate in this manner.

780 But for the intervention of Mr (now Sir Richard) Packer, Professor Pattison would have become even more embroiled in the 'beef is safe' campaign. After the press conference on 14 December, the MLC filmed an interview with Professor Pattison with the intention of using this as part of its advertisements for beef that were to be televised. When Mr Packer learned of this, he was concerned that it might 'be interpreted as associating Professor Pattison unduly with the beef lobby, or in other words, could be used to justify claims that he lacked independence'. Mr Packer intervened and Mr Colin Maclean of the MLC reluctantly agreed that the recorded interview with Professor Pattison should not be used for advertising purposes.

781 We consider that Mr Packer's concerns were well founded. We commend him for his prompt intervention. This was an incident in a vigorous advertising campaign which the MLC ran in 1995. In the course of that campaign there were occasions when hyperbole displaced accuracy. Our criticisms of these can be found in Chapter 6 of vol. 6: Human Health, 1989-1996. Although he was not always personally involved in the choice of wording in the MLC's promotional material, Mr Maclean has accepted that as Director-General he was responsible for it.