Volume 4: The Southwood Working Party, 1988-89
10. Discussion

10.1 The task of considering the adequacy of the response to the emergence of BSE has required us to carry out a critical review of the Southwood Report and the work of the Southwood Working Party - as indeed of the work of the other scientific committees which provided assistance to the Government in dealing with the BSE crisis. A primary task of the Working Party was to evaluate the risk to human and to animal health posed by BSE and we have considered the basis of that evaluation. The Working Party were also asked to advise on measures to counter those risks. We have considered both their evaluation of risk and whether the measures that they advised were appropriate and adequate.

10.2 We wish to record at the outset that each member of the Working Party agreed, when asked, to serve on it without remuneration. We are conscious that to have been subjected to the demands of this Inquiry some ten years later has been a poor reward.

10.3 The Working Party are to be commended for important recommendations that they made after their first meeting, and for the promptness with which they made them. We have referred at paragraph 2.4 above to the four recommendations which were made at that stage. As to the first (the establishment of an expert group on research), the experience of the members of the Working Party rightly led them to appreciate from the outset that research could not be left to the parochial enthusiasm of MAFF and the CVL. A review of research could have been said to fall within the wide terms of reference of the Working Party, but we believe that they were right to conclude that this task could better be performed by a separate expert committee.

10.4 As to the second recommendation, the setting up of scrapie-into-cattle transmission tests seems an obvious thing to suggest. It was not, however, implemented and we consider why this was in vol. 2: Science.

10.5 The third recommendation emphasised the importance of checking to see whether BSE was vertically transmissible. Mr Wilesmith had made a start in this direction by recording on the computer database the identity of offspring of BSE-infected cattle which had been retained or were to be retained within the adult herd.

10.6 The Working Party did not expressly spell out the reasoning behind their fourth recommendation, the destruction of the carcasses of animals suffering from BSE. It was implicit from it that they considered that both the head and other parts of an animal affected by BSE might be capable of transmitting infection. They did not explain what led them to this conclusion, although the phrase 'at this stage of knowledge' gave the hint that it was a precautionary measure dictated by uncertainty.

10.7 When giving evidence to us, the Working Party emphasised the strength of their reaction on being informed that, although the heads of animals affected by BSE were removed for laboratory inspection, the remainder of the carcasses went into the human food chain. In his written statement to the Inquiry Sir Richard said that all the Working Party were horrified at this. ¹ In oral evidence he elaborated:

We were mostly horrified to think that the spinal cord and the rest of the animal was still going into the animal food chain. That was the most horrifying . . . The idea that these animal bits which were from infected animals, which might have had the disease for three months, which could therefore have a very high titre - that was our guess; and I think it has been proved right - of the material, were going into the food chain for either humans or pets caused us considerable concern. We felt it was our job to stop that happening . . . Immediately. ²

10.8 Sir Anthony Epstein said: '. . . just to take the heads off and put the rest into the food chain is what was so shocking.' ³

10.9 It seems to us that the reasoning of the Working Party followed the same course as that of Mr Cruickshank and Mr Andrews, and was reasoning that would be shared by any scientist, or indeed intelligent layman, who was informed of what was and what was not known about TSEs and BSE. Cattle were succumbing to a fatal disease transmitted by their feed. No precedent existed that gave firm reassurance that infected tissue from cattle so affected could be eaten with impunity by animals of other species. Reactions of horror on the part of the Working Party on learning that carcasses of affected cattle were being fed to humans were appropriate, as was their immediate recommendation that this practice must stop. The decisiveness with which that recommendation was made was commendable.

10.10 The recommendation that carcasses of affected animals should be destroyed was also designed to protect pets by preventing the incorporation of potentially infective material in their food.

10.11 Question 18 of the Key Questions (see paragraph 1.25 and the Annex) had asked what steps it would be prudent to take in respect of clinically affected animals covering, among other things, the use of meat offal and meat products for human consumption and for pet food. Mr Wilesmith had answered:

Given the difficulties in abattoirs of identifying parts of the given carcass it may be prudent to condemn, for any use, the whole carcass of affected animals.

10.12 Dr Pickles, for DH, had responded to the question simply and tersely: 'Not acceptable.'

10.13 It is regrettable that MAFF and DH had not reached and implemented a similar accord in March 1988, rather than deferring the decision. (The reasons for this are explained in vol. 3: The Early Years, 1986-88.) Happily the Southwood Working Party lost no time in giving the advice that was so urgently needed on this point.

10.14 The Working Party, through Dr Pickles, also lost no time in drawing to the attention of the DH Medicines Division and the HSE the need to address the potential risks posed by BSE. At the end of 1988 Sir Richard wrote also to Dr Little of the VPC about the potential risk of using bovine sources for veterinary products. ⁴

10.15 The Working Party were perceptive in urging, after their second meeting, that the ruminant feed ban should be indefinitely extended. Its original imposition for a limited period and its renewal for a further limited period may, as a matter of presentation, have made the ban more acceptable to those affected by it, but may also have diminished their appreciation of the importance of complying with it. ⁵ The Working Party appreciated this danger and were right in judging that there was no realistic prospect that it would be safe to lift the ruminant feed ban in the foreseeable future.

10.16 Another recommendation they made after their second meeting - that milk from cattle suspected of being affected by BSE should be destroyed - represented an appropriate application of 'ALARP' - an approach to risk analysis (see paragraphs 10.38-10.40).

10.17 Having been responsible for the setting up of the Tyrrell Committee to advise on research, the Working Party drew attention to a number of areas where research was needed for further consideration by that Committee. They emphasised, repeatedly, the importance of the study of offspring of affected cattle in order to check for maternal transmission. They recommended the monitoring of CJD cases - the achievement of the CJD Surveillance Unit under Dr Robert Will in identifying the emergence of variant CJD demonstrated the wisdom of this recommendation (see vol. 8: Variant CJD).

10.18 It is right that these benefits of the work of the Southwood Working Party should be recognised. It is also right that we should record that, when the Southwood Report was published, it was generally well received. In particular:

• Sir Donald Acheson advised his Minister that he regarded the Report as 'a thorough study of the problem with sound and balanced conclusions'. ⁶
• 'The International Round Table', a group of experts in spongiform encephalopathies, met in June 1989 to carry out a critical analysis of the Southwood Report and unanimously found the Report 'to be scientifically sound in observations, conservative and sound in conclusions, and understandable to both scientific and non-scientific audiences'. ⁷
• On reading the Report, Professor W B Matthews, a leading authority on spongiform encephalopathies, thought it 'an impressive piece of work'. ⁸

10.19 We have, however, had to carry out our own appraisal and we have given particular consideration to the following questions:

1. On what basis did the Working Party assess the risks posed by BSE to human health as remote?
2. Why did the Working Party advise that manufacturers should exclude certain bovine offals from baby food?
3. Why did the Working Party make no other recommendation in relation to the risks posed by oral ingestion of tissues from cattle subclinically infected with BSE?
4. Did the Working Party adequately address the risks posed by the use of bovine matter in the production of medicinal products?
5. Did the Working Party adequately address occupational risks posed by BSE?
6. Did the Working Party adequately address the risks posed by BSE to animals?