Volume 3: The Early Years, 1986-88
5. Human health implications, notification, and slaughter and compensation
Discussion
Collaboration with the Department of Health

5.114 In Chapter 3 we traced the steps taken by the Epidemiology Department of the CVL to identify the source of infection of BSE. By May 1988 this had been identified as MBM in feed with a sufficient degree of probability to lead Mr MacGregor to decide on a compulsory ruminant feed ban.

5.115 While epidemiological investigations were in progress, consideration was being given within MAFF as to what action, if any, should be taken in respect of cattle that developed clinical symptoms of BSE. While they lived there was at least the possibility that they might transmit the disease to other cattle. For some, such as Mr Rees, who saw BSE as an animal health problem, this was the primary consideration.

5.116 Others had concerns about whether it was safe to permit cattle showing symptoms of BSE to be slaughtered for human consumption. In this chapter we have shown how these concerns were first considered within MAFF at the end of 1987. However, it was not until February 1988, after officials had formulated a submission for their Minister recommending slaughter and compensation, that the decision was taken to ask the CMO for his view of the implications that BSE had for human health.

5.117 The CMO's decision was to refer the question to an independent committee - the Southwood Working Party. The Southwood Working Party held its first meeting on 20 June 1988 and immediately advised that animals showing symptoms of BSE should be slaughtered and destroyed. The Order was made on 27 July 1988.

5.118 In an article in the Guardian dated 11 July Mr James Erlichman, the newspaper's Consumer Affairs Correspondent, launched a swingeing attack on MAFF for the delay in introducing this measure. After pointing out that 18 months had elapsed from the discovery of the disease to the Slaughter and Compensation Order, he commented:

Outrageous, you might think, that the authorities could sit on their hands for so long without taking action. ¹

5.119 He went on to suggest that:

We now know that the Government's own scientific advisers warned how important this might be - but they were repulsed by Ministry officials who insisted that a sudden move to compensation and carcass destruction would sap money from the public purse and decrease meat sales by causing unnecessary public alarm. ²

5.120 The facts summarised in the first part of this chapter demonstrate that the attack on MAFF officials had no foundation. There are, however, aspects of this part of the story which constituted a less than adequate response to the emergence of BSE.

Collaboration with the Department of Health

5.121 MAFF officials told us that communication with the Department of Health (DH) should take place on two different levels, depending upon the circumstances. Any aspects of animal health that might be of interest to those responsible for public health could and should be communicated by MAFF officials to DH officials in the course of informal discussions between them. Such communications could take place at junior level.

5.122 Where a policy decision fell to be taken in respect of a matter which had human health implications, there should be formal communication between officials at senior level.

5.123 Mr Cruickshank told us that he would have assumed that initially there would have been contacts between the veterinary staff and the medical staff because at that point what was of interest was of a technical nature. Administrative staff would only have become involved when some decision had to be made about policy. ³

. . . I would draw a distinction between the passing of facts of a professional interest, which as I have indicated I think was more appropriately done by the professional people at whatever level, on the one hand, and on the other hand, the question of correspondence between the Departments on policy issues, saying, 'Here we have a problem, what are we going to do about it?' That I think would be quite appropriate for somebody at Under Secretary level or higher to do, but I distinguish between that and the passing of basic factual information, to put the Department of Health in a position to know what is going on. ⁴

5.124 Mr Rees also drew a distinction between informal discussions on a day-to-day basis and initiating contact with DH on an important policy issue. Whereas his staff had authority to communicate on a day-to-day matter, policy issues had to be raised at Assistant CVO level or above. Approaches about the introduction of new national policies would be made by the administrators. ⁵

Mr Cruickshank

5.125 Mr Cruickshank elaborated on the understanding that he had at the time of the communications that were taking place between MAFF and DH. So far as information communications were concerned, he stated:

. . . the implications of BSE for public health were considered as soon as the similarities with other diseases emerged. For many months the information available was too scanty to permit any conclusions to be drawn. In any case although there did appear to be similarities to certain very rare human diseases, there was also a similarity with the very common sheep disease, scrapie, which had no known implications for human health. The latter point was seen as more significant than the former. Throughout this period my understanding was that DHSS [ie, DH] were taking the same view as MAFF, namely that any decisions on action would have to await further information. This seemed entirely reasonable at the time.

My understanding at this stage was that DHSS were fully in the picture. One of the veterinary staff based at Tolworth was responsible for liaison with the PHLS Communicable Disease Surveillance Centre at Colindale and attended weekly meetings there. I understood that this was the established mechanism for informing DHSS of developing animal health situations which might have implications for human health. It is normal in the civil service to operate on the assumption that information passed to any one part of an organisation will find its way to all parts of that organisation with an interest. This assumption is usually well founded . . .

My understanding of the situation was that DHSS were aware of what was happening, and it would be for them to say, as more information emerged, what the implications were for human health. During this period, DHSS's only expressed concern was with the implications for certain products for human use containing an emulsion of bovine brain. If DHSS had had wider concerns at this stage I am sure they would have aired them. My understanding was that DHSS, like MAFF, found it necessary to await further information before reaching decisions on action. ⁶

5.126 When giving oral evidence Mr Cruickshank said that on two or three occasions during 1987 he asked Mr Rees 'what the Department of Health felt about this and I think his reply was "much the same as us" '. ⁷

5.127 He told us:

My impression was that what we were doing was perfectly acceptable to the Department of Health, in that we were feeding them information, they were getting the information they needed as the disease developed and as our knowledge of it developed. When the time came that we thought we could see a strategy, we could devise a strategy, then we approached them about that. ⁸

5.128 Thus when, at the meeting on 22 July 1987, Mr Thompson asked for a paper to be prepared for Mr MacGregor covering research in relation to the risk to humans (see paragraph 5.20), Mr Cruickshank assumed that the CVL was in touch with DH or the Medical Research Council about this. ⁹

5.129 Mr Cruickshank was asked about his understanding of the statement in Mr Rees's progress report of 16 September that 'DHSS are aware of the problem'. ¹⁰ He said that he understood this to refer to:

All those professionals in the Department of Health who had an interest in this. ¹¹

5.130 As to formal communications between the Departments, once the stage had been reached of taking a policy decision, Mr Cruickshank said that the policy issue was whether there was a risk to human health, and that was 'essentially for the Department of Health to assess'. ¹²

5.131 He went on to say that before December 1987 MAFF had insufficient information to raise the question of policy with DH. December 1987 was a critical month:

I think it really all came together in December 1987, when suddenly I heard then, for the first time, of the theory that ruminant feed material was implicated in the disease. A number of other theories had, of course, been circulated before this, and when I heard this mentioned, this new theory, in December, it was only the latest of a number of theories, but it pretty quickly became obvious it was more than that, it pretty quickly became obvious that this was likely to be the correct explanation, and it was then that I think people's thinking underwent quite a sea change, and we were really able to get to grips with the problem at last. ¹³

5.132 Mr Cruickshank agreed that it would have been useful to write to DH in December 1987 so that they would have been better prepared if MAFF had written shortly afterwards to recommend a slaughter and compensation policy. ¹⁴ They had, however, delayed in anticipation that they would be seeking DH support for such a policy:

. . . in December and January, I think we all believed that we were going straight for a slaughter and compensation policy and that we would be writing to the Department of Health pretty quickly with a recommendation to that effect, and of course, that is not what happened [see below]. ¹⁵

Mr Rees and Dr Watson

5.133 Mr Rees was asked whether, at the time of the preparation of the paper of 29 July (see paragraph 5.21) he had considered informing DH formally about the disease. He answered, no, because it was being investigated as an animal health problem. ¹⁶ He was also asked whether, after being informed by Dr Watson that the Biologicals Sub-Committee of the Committee on Safety of Medicines (CSM) had been informed of BSE, he had given any further consideration to approaching anybody at DH. He answered:

No, I think as far as we were concerned then they were informed. These were fairly senior people, we presumed they would pass this message up the line. If they wanted to know any more they would have come back to us, but they did not. We assumed they were content it was basically an animal health problem at that stage. ¹⁷

5.134 In a written statement, Mr Rees made his position plain:

Although the number of cases of BSE increased in the latter half of 1987, there were no developments that caused me to change my opinion that there was no reason to believe that BSE might present a danger to humans . . .

It is worth noting that if:

(a) I had reason to believe between December 1986 and March 1988 that BSE might present a danger to humans (even though other spongiform encephalopathies, indeed TSEs, were not recognised as a potential danger);
and
(b) a minimum amount of scientific information about BSE had been collated,

I would formally have informed the DHSS, who would have primary responsibility for producing any reasoned examination of possible implications for humans. However, the factors set out at (a) and (b) above were not in my opinion fulfilled. ¹⁸

5.135 Dr Watson took a similar view to Mr Rees. He emphasised that, in his view, there was insufficient information in June 1987 to carry out a reasoned examination or scientific judgement on the possible implications for humans, and that there was no reason to suspect that BSE might be transmissible to man. ¹⁹

Mr Andrews

5.136 Mr Andrews, who had taken up his post as Permanent Secretary of MAFF on 17 October 1987, had no detailed knowledge of BSE at that time. He was aware from a reference in one of his papers that there had been some contact with officials in DH. In February 1988 Mr Andrews received the submission from his officials recommending slaughter and compensation. That submission made no reference to DH. Mr Andrews advised Mr MacGregor that he should not take a decision until MAFF had consulted the CMO (see paragraph 5.53). This was sound advice.

Ministers

5.137 Mr Thompson and Mr MacGregor were asked about their understanding of communications in relation to BSE with DH. They had both read the statement in Mr Rees's progress report of 16 September ²⁰ that 'DHSS are aware of the problem'. Mr MacGregor commented that this suggested that the problem had been discussed 'at an appropriate level' between both Departments. Neither felt able to say whether they would have raised BSE with DH had they not been informed that DH was aware of it. ²¹

Conclusions

5.138 The evidence that we have summarised portrays a breakdown in communications on more than one level. The only informal discussion between MAFF and DH officials before March 1988 was the conversation which we believe took place between Dr Little of the CVL and Mr Sloggem and other DH colleagues in the margins of a meeting of the Biologicals Sub-Committee of the CSM. This did not even result in the CSM being informed of BSE and its possible implications - nor did Dr Little suggest that it was the occasion for this to happen. (Communication between DH and MAFF in relation to the impact of BSE on medicinal products is considered in vol. 7: Medicines and Cosmetics.)

5.139 We were inclined to wonder whether Dr Watson's suggestion that Mr Rees refer to this informal communication in his progress report for Ministers did not indicate a recognition by Dr Watson that DH should have been informed about BSE by this stage. Mr Bradley had formally drawn the attention of Dr Watson to the need to acquaint the medical profession with the news of BSE (see paragraph 5.17) but Dr Watson does not seem to have reacted to this advice. No one had informed Mr Bell that BSE had potential implications for human health, so he did not, it seems, think to mention it on one of his routine visits to the CDSC at Colindale.

5.140 Dr Watson informed Mr Rees of the limited nature of the communication to DH (see paragraph 5.24) on 9 September 1987. Regrettably Mr Rees did not do the same in his progress report to Ministers. The effect of his report was to convey to Ministers the impression that there had been a more general communication of information about BSE to the DH at an appropriate level.

5.141 None of this, however, lies at the heart of our concern. The possibility that BSE might pose a risk to human health was not a consideration which called simply for DH officials to be told informally of the emergence of the disease. It was a possibility which required urgent exploration in collaboration with DH because of its obvious policy implications.

5.142 Mr Bradley appreciated the potential human health implications of BSE from the outset, and did not lose sight of them. Dr Watson has confirmed to the Inquiry that he believed that the risk to humans was minimal. Mr Rees was firmly of the opinion that BSE did not present a risk. At the meeting on 22 July 1987, however, both the MAFF Permanent Secretary, Sir Michael Franklin, and the Parliamentary Secretary, Mr Thompson, emphasised the paramount importance of investigating the potential risk to human health.

5.143 At this stage MAFF should have approached DH to suggest collaboration in the task of assessing whether BSE posed a risk to human health. The stage had not yet been reached for taking a policy decision on action. Numbers of suspect cases were still modest, but they had begun to increase. By the end of July, 46 probable cases had been identified and 18 herds were involved.

5.144 It must have been evident that if the incidence of the disease continued to grow, action would be called for and that the question of whether BSE posed a risk to human health would be likely to influence that action.

5.145 In a written statement to the Inquiry, Mr Bradley observed:

CVL did not have any medically trained staff and was not in a position to make a detailed assessment of the possible risk that BSE could transmit to man. Neither was the necessary expertise to make this type of assessment available elsewhere in MAFF. Assessment of the possible risk to man was a matter for the Department of Health, who had the necessary medical expertise to consider these matters. Initially CVL, and MAFF generally, set about gathering together as much information as possible about the new disease in cattle to allow MAFF to assess the risk to animal health and allow others to assess the risk to human health. ²²

5.146 This is an over-simplification. Both MAFF and DH had contributions to make to the consideration of whether BSE posed a risk to human health. The likelihood that BSE was a TSE had already been recognised at the CVL and was shortly to be confirmed by the experts at the NPU. Assessment of the risk of transmissibility to humans required consideration of all that was known of TSEs in both humans and animals.

5.147 In the same written statement, Mr Bradley stated:

Although there were contacts with DH, the actual carrying out of research was not something which could be done jointly because MAFF and DH each had expertise in different areas and responsibility for their respective area. It was not therefore practical or a sensible use of resources to attempt to carry out joint experiments although NPU was jointly funded by the [Medical Research Council] and [Agriculture and Food Research Council]. ²³

5.148 This comment has limited relevance to events in the latter half of 1987. Transmission experiments could be expected to throw some light on whether BSE posed a risk to humans, but such experiments take a long time. What was required at this stage was joint consideration by MAFF and DH, with assistance from experts in TSEs at the NPU and perhaps elsewhere, of whether BSE might be transmissible to humans. Contingency plans, which would inevitably, as BSE cases escalated, have developed into policy decisions, should also have been considered jointly.

5.149 An example of the practical questions that MAFF officials were bound to be called upon to answer about the risk posed by BSE to human health was the enquiry from Mr Coultous as to how a Meat Inspector should react to the carcass of an animal affected by BSE. That was a matter that MAFF officials needed to discuss with DH. In the event, they were in no position to give guidance to Mr Coultous or to others who might have had similar concerns.

5.150 In the event MAFF officials prepared their submission on policy without consulting DH. Indeed it is notable that, while the submission's recommendation ended 'If Ministers agree with the course recommended, Treasury agreement will need to be sought, followed by discussions with the industry', no mention was made of seeking the approval of DH. ²⁴

5.151 Why did MAFF officials not involve DH in considering the implications of BSE after the 22 July meeting, or indeed at any stage of the formulation and consideration of policy options that led finally to a submission to Mr MacGregor in February 1988? We believe that there were two principal reasons. First, officials continued to regard BSE as essentially an animal health problem. Thus, in a note to Dr Watson reporting on a visit by Mr Rees to the CVL, Mr Bradley reported that although the Minister took the view that human health was the most important matter to consider and research, Mr Rees indicated that in his view it was a veterinary not a medical problem. ²⁵

5.152 The second reason why MAFF did not seek collaboration with the DH was, in our view, a degree of interdepartmental reserve - which is not something that witnesses have been prepared to admit. Nonetheless we have come across repeated indications of this in internal communications within each Department. ²⁶ Mr Cruickshank painted a picture of each Department pursuing its consideration of identical data in parallel and independently. His attitude seemed to be that it was not appropriate for one Department to make a formal approach to the other until it had reached its own conclusions and formulated a policy to propose to the other. We find such a picture bizarre. In the event it did not happen, for DH was given no data.

5.153 We believe that Dr Watson, Mr Rees and Mr Cruickshank all considered BSE to be MAFF's problem to be resolved by MAFF without the need for outside assistance - or interference - from DH. In this they were at fault. Mr Cruickshank accepted that if he had any reason to believe arrangements between MAFF and DH were not working satisfactorily, it was part of his job to deal with this. He told us that he did not believe that the time had come to involve DH in considering policy before December 1987 (see paragraph 5.131). He was wrong. He accepted that he had responsibility for seeing that any action called for as a result of the meeting on 22 July 1987 was taken. ²⁷ Finally he accepted that DH professionals had cause for grievance if - as we find was the case - they had received no communication about BSE from MAFF before March 1988. ²⁸

5.154 There were passages in Mr Rees's evidence which might suggest that he was not responsible for communications between MAFF and DH. ²⁹ We do not believe that Mr Rees intended to assert that he had no responsibility to see that there was satisfactory liaison between the two Departments in respect of matters of common concern to the professionals in each. BSE was - or should have been - such a matter. It was open to Mr Rees to make a direct approach to the CMO for assistance in assessing the public health implications of BSE, or to suggest to Mr Cruickshank that this should be done. He did neither.

5.155 As Director of the CVL we consider that Dr Watson should also have recommended involving both DH and the NPU in consideration of the human health implications of BSE. In the event, in the paper which he prepared for Mr MacGregor pursuant to Mr Thompson's request at the meeting of 22 July, Dr Watson pointed out the problems in the way of experimental research into transmissibility of BSE to humans, without suggesting that assistance might be sought from DH or the NPU. ³⁰

5.156 Mr John Suich, who was head of MAFF's Animal Health Division until April 1989, has since died. In these circumstances we have not found it possible to explore fairly whether he should share in the responsibility for the failure to involve DH in the consideration of the public health implications of BSE before March 1988.

5.157 We have considered the failure to involve DH at the appropriate time in some detail, for we believe it was significant. When asked, out of the blue, in March 1988 for an opinion on the human health implications of BSE, Sir Donald Acheson decided to refer this question to an independent committee. We think it unfortunate that he did so (see paragraph 5.206), but, as he indicated, part of his problem was that the question was put to him without warning:

. . . to be, off the cuff, asking the CMO, at a moment's notice, personallyto give advice to take diseased cattle out of the food chain is a gross misunderstanding of the nature of the job. ³¹

5.158 Had DH been involved with MAFF from the summer of 1987 in considering the human health implications of BSE, we have little doubt that, by the time a policy decision was required, DH would have been at one with MAFF in concluding that it was not safe to eat cattle affected by BSE. There would have been a joint departmental recommendation for a slaughter and compensation policy which might have been introduced as much as six months earlier than it was.

5.159 Further conclusions are more speculative. If from the summer of 1987 the human health implications of BSE had been considered by professionals within MAFF and DH, with assistance from one or more experts in TSEs such as Professor W B Matthews of the University of Oxford or Dr Kimberlin, it is at least possible that the desirability of excluding Specified Bovine Offal (SBO) from the human food chain would have been identified at the same time as the need to slaughter and destroy animals showing symptoms of BSE.