Volume 3: The Early Years, 1986-88
2. Dissemination of information
Discussion
Failure to involve the Neuropathogenesis Unit
Delay in informing the Veterinary Investigation Centres
Restrictions on dissemination of information by VI Service staff
Compulsory notification

2.137 We have set out the evidence about dissemination of information in some detail because we have not found it possible to reconcile this with the oral evidence given to us by some witnesses. The contemporary documents suggest that up to July 1987 there was a policy of restricting, even within the State Veterinary Service, the dissemination of any information about the new disease. During the month of July, wider dissemination was permitted at specialist meetings, but an embargo was maintained on any general publication which drew attention to the similarities between BSE and scrapie.

2.138 This evidence conflicts with that of witnesses who suggested that any restrictions on dissemination of information were designed to do no more than ensure that the information given was accurate. We are in no doubt that the contemporary documents paint the more accurate picture.

2.139 The events that we have described evidence a tension between:

1. the desire on the part of the pathologists at CVL, and Mr Wells in particular, to be the first to publish a scientific paper describing, on the basis of satisfactory data, the discovery of the new disease and its characteristics;
2. anxiety lest reports of the emergence of the disease would damage the export market in cattle, semen and embryos;
3. the need to encourage reporting of possible cases of BSE in order to establish the scale of the epidemic and to confirm its characteristics; and
4. the duty to disclose to the outside world scientific information that had serious potential implications.

Failure to involve the Neuropathogenesis Unit

2.140 The leading expertise in the field of research into scrapie in the United Kingdom was at the Neuropathogenesis Unit (NPU). The CVL did not invite the NPU to collaborate in research into BSE until June 1987. Had they sought their assistance immediately, we think it likely that the scientists at the NPU would have confirmed the pathological similarities between BSE and scrapie by February 1987.

2.141 Dr Hope told us that he could have identified the presence of the abnormal form of prion protein in BSE brain sections within a day. ¹ Dr Fraser and Dr Moira Bruce told us that the pathological evidence available by the end of February gave very strong indications of a TSE. ² Unfortunately, because the CVL's contacts with the NPU were limited and informal, Dr Hope was unaware of the discovery of the new disease and Dr Fraser did not receive sufficient data in June to satisfy him as to its nature (see paragraph 2.62).

2.142 The scientists at the CVL were unaware of the refinement by Dr Hope of the western blotting technique, which permitted rapid identification of the presence of protease-resistant prion protein (PrP). They were, however, well aware that the NPU was pre-eminent in the field of scrapie research. It must have been plain that the NPU was in a position to give valuable guidance on the significance of the pathology of the early cases of this new disease in cattle.

2.143 Mr Wells told us that working with the NPU did not feature at the time in discussions at all. The CVL was defining a disease in the field and not at that stage contemplating a 'burgeoning research programme'. ³

2.144 There was plainly excitement at the CVL at the possibility that they had identified an important new disease in cattle. This had occurred shortly after a somewhat critical inspection report of the CVL generally, when low morale and staff shortages had been a problem. ⁴ We suspect that natural scientific rivalry may have made the pathologists reluctant to invite the involvement of the NPU at an early stage.

2.145 In a statement to us, ⁵ Dr Alan Dickinson, who was then the Director of the NPU, expressed the view:

At the earliest stage of the BSE outbreak, when cases with symptoms suggesting a scrapie-like disease had been found, I consider that the matter should have been referred to the NPU for rapid confirmation of diagnosis and we should have been given control of the necessary research and been in the forefront of advising on the actions to take . . . However, in the event CVL did not take the earliest opportunity to notify me of the BSE outbreak and discuss where control of the research should be placed for the most expert handling.

This illustrates the possibility of rivalry between the NPU and the CVL as to who should be in the driving seat in controlling the research to be carried out into BSE. It also illustrates, however, the fact that the NPU was best placed to assist with an early diagnosis of the nature of the disease.

2.146 We think that an initiative to involve the NPU should have come from Dr Watson, Director of the CVL. He pointed out to us that he discussed BSE with Dr Kimberlin of the NPU at the joint Research Club meeting on 29 May. ⁶ We believe that, rather than this informal conversation in May, a formal approach for assistance in diagnosis should have been made to the NPU at the outset. Dr Watson told us that he considered this, but that it would have been premature at a time when only two or three cases had been identified. ⁷ We do not agree. A disease in cattle with similarities to scrapie called for the involvement of the NPU. Dr Watson should have ensured that they were involved from the outset of 1987.

2.147 At this time the Director of Research at the CVL and Dr Watson's Deputy Director was Dr Brian Shreeve. He has told us that because of the close involvement of Dr Watson and the appointment on 3 June 1987 of Mr Bradley as CVL Research Coordinator on BSE, he had very little role to play in relation to BSE research and largely concentrated on his other duties as a result. ⁸ We initially expected that Dr Shreeve would have discussed with Dr Watson the research needed to resolve the uncertainties that existed when BSE was first identified, and that he would have canvassed the merit of seeking assistance from the NPU. However, Dr Watson has since confirmed that he was taking the lead in relation to BSE, and in these circumstances we would not have expected Dr Shreeve to have taken a separate initiative.

2.148 If the NPU had been involved from the outset, Mr Wells would have had its endorsement of his conclusions in February. In the event, he did not receive that endorsement until July. Confirmation in February 1987 by the NPU that the new disease appeared to be a TSE could well have accelerated the perception within MAFF of the need to disseminate information about the disease.

Delay in informing the Veterinary Investigation Centres

2.149 Mr Wells, when urging against what he considered to be premature disclosure of the discovery of a possible new disease in cattle, suggested 'we do not need to know the prevalence of the disorder at present'. ⁹ While this may have been true from the viewpoint of the pathological investigation, Mr Bradley and Dr Watson perceived the desirability of ascertaining the extent of the incidence of the disease by encouraging the reporting of possible cases (see paragraphs 2.27-2.29).

2.150 No decision was taken to circulate within the VI Service the short paper that Mr Wells had prepared for that purpose until the middle of May. Dr Watson was unable to recollect the reason for the delay. He told us that he was not against the publication in Vision. His thinking at the time was that they should get the information out, and Vision was a means of doing it within the Service. ¹⁰ Dr Williams told us that he was involved in discussions from March onwards about informing VIOs of BSE. He agreed that the information needed to be communicated though he doubted whether Vision was the most effective means of achieving this. He understood that delay in publication was because Mr Wells and Dr Peter Dawson expressed the view that any publication would be premature. ¹¹ Mr Rees said that he had had no involvement in discussions about the publication in Vision. ¹²

2.151 Dr Watson has provided us with further information about the decision not to publish Mr Wells's article in March. He stated that, contrary to Mr Rees's recollection, he did discuss the article with him. Mr Rees was particularly concerned that such an early publication might affect our export trade, with no proper justification for the alarm that would be caused. ¹³

2.152 Dr Watson also said that he was influenced by Mr Wells's concern that publication would be uninformative and unhelpful, and that early publication might damage the work of the CVL in discovering the nature of the new disease. ¹⁴

2.153 Thirteen years on it is not surprising that memories are hazy and that witnesses' accounts are in conflict. Mr Rees had become involved in decisions on publication about BSE by 14 May (see paragraph 2.34 above). We do not, however, think that he was responsible for the decision not to publish an article in Vision in March. We have concluded that Dr Watson was responsible for this decision and that in reaching it he was influenced by Mr Wells's vehement plea against publication.

2.154 We do not consider that Dr Watson should have acceded to Mr Wells's objection to the publication in Vision. The object of that publication was to inform the VI Service of the clinical symptoms of the disease and of the CVL's desire to receive details of any similar cases. It was highly desirable that the CVL should receive such information - not so much to assist in the identification of the nature of the disease, but to learn of the extent of its incidence. Members of the VI Service needed to be told of the CVL's interest if the passive surveillance system was to be at its most effective.

2.155 We do not see how the proposed publication in Vision in March could have damaged the work of the CVL in 'discovering the nature' of the new disease. We feel that Mr Wells's anxiety was that it might damage the CVL's prospects of being the first to publish the discovery of a new disease. Dr Watson should not have permitted this concern to prevail over the desirability of effective surveillance.

2.156 Turning to the position after March, Mr Bradley's minute of 14 May records that an article to be published in Vision was to be cleared by, among others, Mr Williams. Mr Williams expressed reservations about the use of Vision for this purpose and the next day Mr Bradley minuted that, 'By agreement with The Director [Dr Watson] we will circulate the proposed "Vision" notice to VICs in England and Wales only as a separate Directive providing it is otherwise approved by Line Management.' ¹⁵ Dr Williams has stated that his reservations about the use of Vision arose because he felt that a publication solely devoted to BSE would be more effective:

I was aware that in some instances Vision articles were not receiving immediate attention from VIOs because of their routine nature and because often the articles related to matters of little interest to particular centres. ¹⁶

2.157 We found this unconvincing. Individual issues of Vision had in the past been used exclusively for the purpose of informing VI Service staff about new bovine diseases and was the obvious means of informing VICs in Great Britain about BSE.

2.158 Dr Watson's evidence and a minute from Mr Bradley dated 22 May 1987 suggest that the reasons for issuing a separate directive was to restrict publication to England and Wales rather than give it wider circulation via Vision. Dr Watson explained that publication in Scotland was considered unnecessary because there were no cases of BSE there and the Scottish VICs were not part of MAFF, but reported to the Scottish Colleges of Agriculture. ¹⁷ Recently he has elaborated this point. He has said that it was not for the CVL to make policy decisions about publication of information to VICs in Scotland. That was the responsibility ofthe ACVO for Scotland, the CVO and ultimately the Scottish Office.

2.159 We have concluded that the decision not to publish in Vision was taken in order to prevent information about the new disease being passed to VICs in Scotland. There was no justification for this. The fact that no case had been reported in Scotland was no reason why Scottish VICs should not be told of the cases discovered in England. On the contrary, we think that it was desirable that they should have this information, so that they would recognise the importance of reporting any similar cases in Scotland. Far from following a policy of denying them this information, Dr Watson and Dr Williams should have been keen that they receive it.

2.160 The decision not to use Vision was taken in the context of a policy to restrict dissemination of information about BSE. We believe that Dr Williams's suggestion that Vision should not be used and Dr Watson's agreement with that suggestion were part of the implementation of that policy. In reaching this conclusion we have been influenced by other actions that accorded with this policy, which we discuss below. For the reasons we have given we consider that neither Dr Watson nor Dr Williams should have impeded the publication in Vision.

2.161 Dr Watson has made the point that it was not for him to suggest whether or not publication about BSE should take place in Scotland. He has also urged that he was not involved in any 'formal' policy to restrict dissemination of information. The policy of restricting dissemination about information was not a 'formal' policy, and we are satisfied that it was the policy which Dr Watson joined in implementing. In supporting Dr Williams's suggestion that Vision should not be used, Dr Watson was supporting that policy.

Restrictions on dissemination of information by VI Service staff

General suppression of information

2.162 Dr Williams decided that an instruction should be added to the directive to VI Service staff not to discuss BSE with or consult workers at Research Institutes or University Departments. He told the Inquiry that he felt that information should not be transmitted at that stage because MAFF's knowledge of the disease was imperfect; he was concerned that some of the VICs could only provide very limited information on the clinical aspects of the disease; and the information in the draft by Messrs Wells and Dawson (see paragraph 2.43) was insufficient for briefing Research Institutes and University Departments. He felt it was important, therefore, that statements intended for a wider audience should be cleared at Directorate level in order to preserve quality control. ¹⁸ Dr Watson has informed us that he understood Dr Williams's concerns about disseminating information to other Research Institutes. He commented that if they had involved other institutes at such an early stage, new potential cases of BSE might not have been referred to the CVL, but to other institutes. This would have prevented the CVL from building up a history of the disease as quickly as it did. The end result would have been that several institutions would have had very little knowledge of BSE, rather than the CVL having as much knowledge and information as was available. Such an outcome would have been a disaster, as it would have prevented the CVL from learning about the disease as quickly as it did, and thus enabling everyone to deal more quickly with the crises that eventually emerged. ¹⁹

2.163 We find this reasoning unconvincing. If members of the VI Service had been instructed to notify cases of the new disease to Tolworth, we do not see how it would have impeded research at the CVL if they had also been permitted to discuss the disease with other research establishments.

2.164 In commenting further on this issue, Dr Watson has said that there were very few experts in this field. The only real experts in the UK were at the NPU and the Royal Veterinary College, and they had been consulted at an early stage by Mr Wells. Had the information about the new disease been circulated widely at an early stage, it was likely, according to Dr Watson, that it would have encouraged other Research Institutes and University Departments to take an interest in it. However, MAFF would have had little or no control over the research being carried out by other Research Institutes and University Departments; the timing of the release of information, and its content, would have been decided by those Institutes or Departments. We found this reasoning equally unconvincing. It seems to us that it would have been desirable for other Research Institutes and Universities to have taken an interest in the new disease. We see no good reason why the CVL should have wanted any control over the research carried out by them or over the release of information in relation to it. The argument merely reinforces our belief that MAFF wished to control the release of information about BSE.

2.165 We are therefore unable to accept the explanation given by Dr Williams and Dr Watson for the embargo on discussing the new disease with Research Institutes and Universities. Dr Williams gave the following reasons at the time:

Because of the nature of the disorder, its political implications and possible effects on exports. ²⁰

We believe that this was the true explanation, and a further example of the implementation of the policy of restricting dissemination of information about the new disease.

2.166 We are satisfied that Dr Williams should not have suggested a ban on discussing the new disease with research establishments and that Dr Watson should not have acceded to this suggestion. We consider that advancement of knowledge about the new disease would have been best promoted by encouraging collaboration and competition among scientists.

2.167 The third example of the policy of suppression of the dissemination of information about the new disease was the withdrawal of permission for the publication in the Veterinary Record of Mr Hancock's and Miss Paull's letter. Dr Williams's letter to Mr Hancock evidenced discussion between Mr Rees, Dr Williams and Dr Watson stating that:

. . . because of the possible effects on exports and the political implications it had been decided, at this stage, no account should be published. ²¹

Neither Mr Rees, nor Dr Williams, nor Dr Watson recollected this discussion.

2.168 Mr Rees commented:

. . . it is obvious that the letter does not record the full reasons for the decision. ²²

He went on to comment:

. . . in a broad sense we all had the same attitude to publications at this time i.e. that if the CVL were not happy that there was sufficient information, then premature publication could cause unjustified damage to the industry. ²³

2.169 Dr Watson made very similar comments. He went on to add that the decision not to publish was that of Mr Rees. He could not remember his attitude to that decision, but he would not have thought it unreasonable. He took seriously the concern of his staff that information should not be released that was inaccurate and speculative.

2.170 Dr Williams said that his letter:

. . . represents a simplification of the reasons behind the decision and must be seen in the context of the lack of information available at the time. ²⁴

He added that the decision on policy was taken by Mr Rees and Dr Watson. He did not enjoy the expertise or the seniority to oppose their decision. ²⁵

2.171 We are satisfied that there was good reason for Mr Gallagher and his colleagues to conclude that they were faced with a 'total suppression of all information'. ²⁶ According to Mr Sibley, the chairman of the British Cattle Veterinary Association:

Throughout most of 1986 and 1987 most veterinary surgeons in practice, who were in the front line of disease diagnosis and control, were ignorant of the presence of this disease, and were not informed of its clinical signs or its significance as a potential national disease problem. ²⁷

2.172 Mr Sibley wrote to us to express his criticism of the failure on the part of MAFF to inform the veterinary profession of the emergence of BSE. He stated:

Better and more formal communication with veterinary practices and practitioners would have allowed a two way flow of information where all parties would have gained and BSE control might have been more effective from an earlier stage. ²⁸

2.173 Mr Rees, in his evidence, questioned Mr Sibley's standing to speak for the veterinary profession as a whole and disagreed with his suggestion that MAFF had not done enough to bring the emergence of BSE to the attention of veterinarians in private practice. His evidence was that the normal communications between farmers and private veterinarians and between private veterinarians and VICs, in effect the passive surveillance system, would suffice to bring cases of BSE to the notice of the CVL. ²⁹

2.174 We do not agree with Mr Rees. Unless private veterinarians and farmers were informed of the clinical symptoms of BSE, alerted to the importance of identifying cases of the new disease and urged to report suspect cases to VICs, there was likely to be significant under-reporting of cases of BSE. Mr Rees himself attributed the increase in numbers of cases reported at around the end of 1987 to increased awareness of the disease (see paragraph 2.124). Even if, as we believe, this was true only in part, those numbers suggest that a substantial number of cattle must have died from BSE without the significance of their illness being appreciated and without the State Veterinary Service being informed of it. MAFF could have told farmers and private veterinarians, and indeed members of the Veterinary Field Service, about BSE in a variety of ways: ADAS Bulletins, or newsletters sent out by VICs; an article in the Veterinary Record asking for cases to be reported; or a request to the National Farmers' Union for assistance in conveying the message to farmers.

2.175 The evidence demonstrates a clear policy of restricting the disclosure of information about BSE. The position was accurately summarised by Mr Bradley in his BSE update of 30 June 1987, when he stated that apart from knowledge communicated within MAFF on a need-to-know basis, other knowledge was 'gleaned by the grapevine'. ³⁰

2.176 The ultimate responsibility lay with Mr Rees. The contemporary documents show that Dr Watson and Dr Williams gave effect to that policy without any record of dissent. Had they not been prepared to support the policy, they should have sought to dissuade Mr Rees from pursuing it. Had they done so, and been overriden by him, that is something that they would be likely to remember. Our conclusion is that they supported his policy. All three have sought to justify the policy on the basis that not enough was known about the disease to justify publication. We consider that lack of knowledge was the principal reason why publication should have been permitted, at least within the veterinary profession. We consider that Dr Watson and Dr Williams should have urged the merits of publication and Mr Rees should not have resisted it.

Embargo on references to scrapie

2.177 Once Mr Gallagher's amended article had been published in the Veterinary Record, on 11 July 1987, publication by SVIOs of similar notes in their newsletters was permitted. What was not permitted at that stage was any wider publication that pointed out similarities with scrapie. This was true not just of BSE, but of Dr Jeffrey's paper on the nyala.

2.178 The memorandum circulated by Mr Bradley about Dr Jeffrey's nyala paper stated that the CVO had not authorised the publication and that:

It is unlikely that approval will be given to publish if comparisons are made with scrapie or this is mentioned. ³¹

2.179 Mr Rees told us that he was unaware of the memorandum, that he had been misunderstood and that Mr Bradley's memorandum was incorrect:

At no stage did I prohibit all references to scrapie.

What I was concerned about was the right balance, and not over-emphasising the similarities without pointing out the differences that at that stage we did not know to scrapie. And you have referred to the differences of opinion both at Weybridge [ie, the CVL] and in other places as to the true aetiology of this condition.

I think it was not until August that the pathologists at the CVL and the NPU agreed on the pathology. We had not at that stage gone very far with our investigation into the aetiology and the epidemiology. So drawing too close a comparison at that stage would have been misleading. ³²

2.180 Mr Wells understood in June 1987 that his draft article for the Veterinary Record would only be approved for publication if all reference to scrapie was deleted. He believed that this was the requirement of Mr Rees who was concerned about any scientific statement - however tentative - of an association of BSE with scrapie. ³³

2.181 Once again Mr Rees told us that this was a misunderstanding. There was no policy of rejecting any reference to scrapie. Those who were dealing with the draft knew perfectly well what his view was. The senior veterinary staff at Tolworth agreed with his viewpoint. ³⁴

2.182 Dr Williams supported Mr Rees's evidence. In a written statement he said he was not aware of a policy prohibiting references to scrapie in publications or presentations. However:

My understanding was that the CVO had prohibited BSE being referred to as 'bovine scrapie'. ³⁵

2.183 Dr Peter Dawson told us that he was aware of the CVO's line in relation to scrapie and any implication which it might or might not have had in relation to exports. When asked precisely what that line was, he said he found that difficult. He knew that the CVO was opposed to describing the disease as 'bovine scrapie'. The prohibition was in respect of a 'direct comparison with scrapie'.

2.184 We have not found the evidence of either Dr Williams or Dr Peter Dawson to be reliable on this point. Had Mr Rees's objection been simply to the use of the term 'bovine scrapie', neither Mr Wells's nor Dr Jeffrey's paper would have been objectionable to him. It was Dr Peter Dawson who, on instructions from Mr Rees, put a line across Mr Wells's paper which censored all reference to scrapie.

2.185 Mr Rees said that he had no recollection, after 12 years, of reading this paper or drawing a line beyond which he would not sanction the draft. We see no reason to doubt the contemporary evidence that this line reflected Mr Rees's decision on publication. Nor do we doubt that the refusal to permit Dr Jeffrey's paper on the nyala to be published, because of its reference to scrapie, reflected Mr Rees's policy.

2.186 In short, we do not accept the evidence of Mr Rees or those who appear to support him. Furthermore, at the time when publication of Mr Wells's and Mr Jeffrey's papers was refused, there was no reason to consider either to be unbalanced or unscientific.

2.187 The most notable - and alarming - aspect of BSE was that its victims had a histopathology that was very similar to that of scrapie-infected sheep. We believe that it was Mr Rees's policy up to August 1987 that this feature of the disease should not be made public.

2.188 The pathological similarity to scrapie was a fact. The similarity did not prove that BSE was scrapie in cattle, or that the nyala had contracted scrapie. It was, however, cause for concern that BSE might be transmissible in the same way as scrapie. Mr Rees confirmed that he did not want people to jump to the conclusion that BSE had the same unattractive attributes as scrapie until there were reasonable grounds for reaching that conclusion. ³⁶ The only way to avoid this, however, was to prevent communication of the facts that might lead people to jump to that conclusion. It was that which Mr Rees sought to do.

Should the CVO have restricted dissemination of the information?

2.189 We sympathise with Mr Rees's anxiety to protect the British agricultural industry from a reaction that was irrational or disproportionate. Any foreign trade embargo in the early days of BSE might well have seemed that. At the same time, however, it might not have been irrational or disproportionate for individual purchasers of British cattle breeding stock to seek alternative sources of supply unless and until the doubts raised by the emergence of BSE were favourably resolved. The withholding of information robbed those who would have had an interest in receiving it of the chance to react to it, whether in a rational or irrational fashion.

2.190 More particularly, the embargo on anything that drew a comparison between BSE and scrapie had the result of preventing the publication of material which would have drawn the emergence of BSE to the attention of veterinarians in private practice and to farmers. Mr Rees should not have imposed this embargo.

2.191 The effect of the restrictions on dissemination of information about BSE was probably to delay the stage at which the wider public became aware of the emergence of BSE by some months. While a case might have been made for restricting information for a short initial period to within the State Veterinary Service in order to make a thorough appraisal of the facts, we do not consider that the positive censorship that persisted until August 1987, in respect of reference to the similarities between BSE and scrapie, could be justified.

2.192 The consequences of the restrictions on dissemination of information about BSE in the early days may well have been significant. It must, as we have observed, have resulted in a significant degree of under-reporting. Mr Sibley expressed the view that:

The rate of referral would have been considerably higher had veterinary surgeons been informed of the presence of the disease from the outset. ³⁷

This is clearly correct. We believe that the disquiet, both within and without MAFF, which led ultimately and indirectly to the slaughter and compensation policy, was stimulated by the growing number of cases reported and the awareness of their nature. Had both of these factors occurred earlier, remedial measures might also have been advanced.

2.193 So far as reaction on the part of foreign importers is concerned, Mr Rees's apprehensions were not realised. One British farmer in Portugal decided not to import cattle from Britain when he heard of BSE. When writing to the British Embassy in Lisbon about this on 2 February 1988, Mr Suich of MAFF observed:

In the European Community context it is only the Dutch who have so far shown an interest in BSE. No other Member State or the Commission has, as yet, suggested that it is worthy of discussion in Brussels. ³⁸

2.194 It does not seem to us likely that if the emergence of BSE and its similarity to scrapie had been publicly disclosed a few months earlier than the end of October, that is, when the numbers of confirmed and suspected cases were more modest, any adverse trading consequences would have followed. It is a matter of regret that cases of BSE in Portugal, Switzerland and France may well have had their origin in the export from Great Britain of cattle infected with the disease. However, it would not be fair to conclude that these can be specifically attributed to the delay in making public the details of the emergence of the disease.

2.195 We have considered whether the CVO delayed unduly in waiting until June and July 1987 before informing the MAFF Permanent Secretary (Sir Michael Franklin) and, through Mr Suich, Ministers of the emergence of BSE. We raised this question with Sir Michael. He did not consider that he should have been informed earlier than he was. At the time that he was informed, the disease had been confirmed in seven herds. ³⁹ Mr Cruickshank had been aware of the disease from the outset. With hindsight it is easy to suggest that the potential seriousness of the disease was such that the Permanent Secretary and Ministers should have been informed earlier. We do not, however, consider that Mr Rees is to be criticised for choosing this point in time as the stage at which the matter should be placed before the Permanent Secretary and Ministers.

2.196 What of the reaction of Mr Bradley, Dr Watson and Mr Crawford to Mr Coultous's enquiry and the suggestion of an article in Environmental Health Journal? (see paragraph 2.126 above) This raised the question of whether carcasses of BSE-affected cattle should be condemned as unfit for human consumption. That is a question we consider in Chapter 5. Until the issue was resolved MAFF was not in a position to give advice on the matter to Environmental Health Officers. In the circumstances we consider that the reaction to Mr Coultous's suggestion for an article was reasonable.

Compulsory notification

2.197 On 14 June 1988 Mr John MacGregor signed the Bovine Spongiform Encephalopathy Order, the provisions of which included a compulsory notification requirement in respect of suspected cases of BSE. When recommending this provision to Mr MacGregor, Mr Rees had commented that the Government would be seen to be taking positive steps, while providing a better overall picture of the spread of the disease by reducing the number of unreported cases. ⁴⁰

2.198 This led us to question why a compulsory notification requirement had not been introduced very much sooner. Mr Sibley asserted in his written statement:

Once practitioners became familiar with the disease through experience and knowledge gleaned from publications and personal contacts, many cases presented to them were dealt with directly and without referral to the VI Service. There was no incentive to refer and indeed it generated a cost to the practice and the client. The disease could be diagnosed on clinical signs reasonably reliably and carried a hopeless prognosis. There was little point in involving the VI Centre with diagnosed cases and these went unrecorded. It was only when the disease was made officially notifiable in June 1988 that the incidence was truly known. ⁴¹

2.199 Mr Rees did not agree with Mr Sibley. He said that up to December 1987, 20 per cent of the cases reported proved to be negative. This was a fair indication that there was not under-reporting. In 1987 there had been insufficient cases to establish the criteria of the disease necessary to make a notification requirement effective. None of this was very impressive. We do not see how the pattern of reported cases, or the proportion that proved negative, enables one to draw any conclusions as to the extent to which cattle showing symptoms of BSE may have been slaughtered prior to the requirement to notify. Nor were the clinical symptoms so uncertain or ill-defined as to render the imposition of a notification requirement impractical or ineffective. ⁴²

2.200 We are satisfied that there was substantial under-reporting before the introduction of compulsory notification. We had evidence of this from a number of sources, but it suffices to refer to a passage in the evidence given by Mr Kevin Taylor (of MAFF's Notifiable Diseases Section):

Now clearly, when you have voluntary notification, which is what we had up until 21 June, however well it is publicised, the number of cases which come to the attention of the State Veterinary Service, because they were heavily involved at that time, is only a proportion of the cases which are actually occurring.

We had anticipated on the basis of the information coming to the VI Service and to the CVL that when the disease was made notifiable we would be dealing with about 60 suspect cases every month.

Of course, we immediately had 60 a week, and that is a measure, if you like, of the under-reporting which was going on beforehand. ⁴³

2.201 Mr Rees told us that he was not aware that compulsory notification had ever been introduced for the sole purpose of gathering information about a disease. ⁴⁴ The evidence of Mr Taylor was that there were precedents for requiring notification as a stand-alone measure. ⁴⁵ Normally, however, compulsory notification is introduced as an ancillary requirement to other action.

2.202 Compulsory notification in respect of BSE only received serious consideration once the stage was reached where slaughter and compensation was being contemplated. It is a draconian measure to introduce for the purpose of fact-finding alone. Mr Bradley drew attention to a number of problems that would flow from such a policy in his minute of 1 December 1987. ⁴⁶ Only some of these were presentational. We believe that Mr Taylor was right to question the desirability of making a disease notifiable without doing anything else. ⁴⁷

2.203 We would not criticise Mr Rees and his colleagues for failure to recommend compulsory notification as a stand-alone measure. The incidence of reported cases of BSE grew so rapidly in the course of 1987 that we do not think there was any stage at which it would have been reasonable to consider notification without also considering compulsory slaughter. Whether there was undue delay in considering the two together is a question which we address in Chapter 5.