Volume 6: Human Health, 1989-96
7. Human health developments from January 1996 to 20 March 1996
The response to the reports of the February meeting
The lull before the storm
Rumbles of thunder

The lull before the storm

7.204 On 1 March 1996, Mr Eddy sent a minute to Mr Meldrum stating:

1. You will recall my minute of 6th February warned the Minister that the CJD Unit were preparing two scientific papers about the unusual presentation of the disease in young patients. Dr Wight now tells me that more work has been done on this and the results are beginning to look rather firmer that there is a new sub-population of the disease emerging. We had a very brief discussion on this today and she has suggested that it would be wise for MAFF and DH officials and Press Officers to have a meeting to discuss the way in which this will need to be handled. I am sure that that is a good idea and think that you will all want to be involved . . . When you have had time to digest this you may well wish to alert Mr Carden.

2. What I have already agreed with Dr Wight is that it will be absolutely essential, in handling this news, to have some form of statement from SEAC as to the implications. I will keep you posted on developments.

3. I should make it clear that this emerged following discussions that DH had with the CJD Surveillance Unit yesterday and DH did not know this at the time of the visit to Tolworth earlier this week. ¹

7.205 Mr Meldrum told us that he had not attended a meeting of the kind proposed in paragraph 1 of the minute, and had no knowledge of whether it had taken place. ² He went on to say that the minute from Mr Eddy:

. . . would not have been to me a huge surprise. What was of concern to me was the number of cases that were appearing in young people, the presenting symptoms; yes, and the concerns of a number of people. ³

7.206 Mr Eddy also told us that he did not think that the proposed meeting took place because it was overtaken by the two SEAC meetings on 8 and 11 March 1996. ⁴

7.207 In his minute Mr Eddy refers to the fact that the information he was passing on had been obtained in a conversation earlier that day with Dr Wight. In evidence Mr Eddy was asked whether he recalled any other conversations regarding developments in CJD surveillance between the SEAC meeting in early February and 1 March 1996. He told us:

I do not recall any. I mean, the point I would make about this minute is that it does reinforce what I have been trying to say; and that it is that it was Department of Health who were in contact with the unit and were monitoring the situation. And they quite rightly alerted us when they felt that we had reached the next stage of alert, so to speak.

. . .

We had moved to a different stage. They were telling us that the balance of probability had changed, and that their advice to us was we now needed to at least look at this aspect of the problem between the two Departments. That was their advice coming to us, as it properly should have done, as they were the Department which led on that side of things. This was the system working as it should have done. ⁵

Rumbles of thunder

SEAC meeting: Friday 8 March 1996

7.208 SEAC's next (twenty-fifth) meeting took place on 8 March 1996. ⁶ Dr James Ironside, a neuropathologist with the CJDSU, gave a presentation, accompanied by a detailed paper on the Unit's neuropathological study of CJD in young patients. ⁷ The paper stated:

A subset of adults with CJD has been identified with the following features:

Young age at onset

Tendency to a long duration of illness

No PrP gene mutations (Most are MM at codon 129)

Characteristic neuropathology with 'florid plaques' throughout the brain - not previously identified in the CJD Surveillance neuropathology project

Extensive PrP deposition with multiple plaque morphologies combined with pericellular and diffuse deposition - not previously identified in the CJD Surveillance neuropathology project. ⁸

7.209 The paper raised the question whether these cases constituted 'a new or hitherto unrecognised variant of CJD'. ⁹

7.210 Dr Will reported that CJDSU had found that:

. . . there appeared to be two distinct subsets of sporadic CJD cases. The first with extended duration of illness with plaques in the brain and spinal cord, and the second with a short duration of illness which did not show these features. The presence of plaques in the spinal cord might be related to the extended duration of illness which allowed time for centrifugal spread of PrP down the spinal cord. ¹⁰

7.211 Dr Will clarified for us the reasons he had for presenting this description of two subsets of sporadic CJD. Dr Will said that:

The reason I presented this data was in order to ensure that SEAC were fully informed about recent developments that might be of concern. It is important [to] stress that this data on spinal cord neuropathology related to sporadic CJD and not new variant CJD. ¹¹

Turning to the cases of CJD recently identified in young people in the UK, Dr Will said that these had been compared with the 17 cases in patients under 30 years of age that had been found worldwide since 1965. The clinical features and the duration of illness were variable. There was no evidence on the genetics of the cases from other countries. It was also noted that there were no plaques recorded except in the case of a 27-year-old in Italy which could have been GSS. The minutes recorded:

Dr Will and Dr Ironside were of the opinion that the young cases in the UK with their unique pathology and similar clinical features could be a new form of CJD. ¹²

7.212 Dr Ironside left the meeting after lunch and was not party to SEAC's further discussions. ¹³

7.213 During their discussion SEAC members expressed the following views:

1. Professor Collinge said that 'the findings suggested that there was a new risk factor for CJD which may be BSE, and that the existing public health precautions should be reviewed'. ¹⁴
2. 'Several members queried whether these cases could have been identified because of increased ascertainment [ie, increased referrals because of increased awareness] and whether this new form of CJD could have been present, but unidentified, in the population for some time.' Dr Will did not believe so 'because there had been growing awareness of CJD among neurologists over a number of years and in some of these cases identification had not been straightforward and mainly by neuropathology'. Dr Ironside noted that the pathology here was different to the young cases abroad. ¹⁵
3. Dr Kimberlin suggested the need for a 'quantitative risk assessment based on information from the meat industry about the extent to which [SBO] had entered the human food chain since the advent of BSE and possible risk exposures of these young CJD cases'. It was said that 'one new control measure might be to prohibit tissues from older cattle, which were known to have higher titres of BSE in the central nervous system, from entering the food chain'. ¹⁶
4. Several members said that 'young cases of CJD should be investigated further to identify any other potential risk factors such as pharmaceuticals, for example, and indicated concern about sheep which had been fed the same infective feed as cattle . . . The Secretariat should commission a paper on the use of meat, offal and other tissues from sheep and lambs in the human food chain . . .' ¹⁷
5. High priority should be given to strain typing. ¹⁸

7.214 At the end of the discussion Professor Pattison confirmed that SEAC would keep the information confidential pending publication. He would inform the CMO and the CVO of the findings. 'It would be for Ministers to decide whether or not they should be put into the public domain now.' ¹⁹ He told us that he did not inform Dr Metters and Mr Meldrum personally, but that the secretaries from DH and MAFF informed their respective chief officers of the findings, and that SEAC was seeking a review by other neuropathologists. 'I think the CVO and CMO were willing to wait until Dr Will and Dr Ironside had finished those consultations and reported back to us before taking it any further.' ²⁰

7.215 Later that day, Mr Mike Skinner minuted Sir Kenneth Calman and Mr Horam advising them about the presentation to SEAC by Dr Will and Dr Ironside. ²¹ He said:

In the opinion of the Unit all this indicates that these cases have been subject to some new factor which has precipitated the disease. If incubation periods similar to other spongiform encephalopathies have occurred the exposure would have taken place some 8 - 10 years ago. It is of course not possible to link this positively to exposure to BSE in the 1980s but, after SEAC had considered the data, it considered that this is a likely explanation, although other possibilities have to be considered.

7.216 Mr Meldrum told us that he was made aware of the new findings 'a few days' before the 8 March SEAC meeting and that he had been 'acutely conscious that, if confirmed, this was a finding of very great significance'. ²²

7.217 Mr Hogg told us that he had been notified about the results of the SEAC meeting by Mr Packer. Mr Hogg said:

. . . there was one meeting between me and Mr Packer, Richard Packer, which is not referred to in this statement, which is about this time. I suspect it was after 8th March, but I am not sure about that. One night - I mean to say between 6.00 and 7.00, but that is broadly speaking right - Richard came into my office, I said that he often came in. This was late in the evening; Frank Strang may have been there, he was my Private Secretary, but he came in and said something like - the language is not right, but this is the substance of it: 'There is a very dark cloud on the horizon, which is that SEAC think, or are coming to the view, that BSE is transmissible'. I said, 'This is a very serious state of affairs'. He said something like, 'They have not come to that view yet, but they may come to that view'. I said something like this, 'You had better keep very close to Pattison so we can see how this thing is developing'. I remember saying to him, 'But what you must not do is in any way try and shape their deliberations or conclusions, but what you must do is to keep as close as possible, so we understand what is happening and you must keep me fully posted'.

That is not a meeting which is recorded. It was an entirely informal meeting, he just came into the office, and I suspect - I have tried to date it in my own mind, it was probably about ten days before the announcement, and my bet is it was after the meeting of SEAC on 8th March, but I cannot be more precise. ²³

. . .

My suspicion is that I did not at that moment talk to Angela [Browning] or my Ministerial colleagues. ²⁴

7.218 Sir Kenneth Calman told us he became aware of the results of SEAC's meeting on 11 March 1996. ²⁵ He recalled his reaction to being informed of SEAC's discussions, as follows:

I noted that the Chairman of SEAC at that meeting asked the various members for their views on the findings and the need for additional control measures. Professor Collinge suggested that there was a new risk factor of CJD which may be BSE and that the existing public health precautions should be reviewed. Several of the members had queried whether these cases could have been identified because of an increased ascertainment and whether this new form of CJD could have been present but unidentified in the population for some time. I noted that Dr Will did not believe that these cases had come to light because of increased ascertainment, because there had been a growing awareness of CJD amongst neurologists over a number of years. I noted that Dr Kimberlin had suggested that there was a need for a quantitative risk assessment based on information from the meat industry about the extent to which SBO had entered the human food chain since the advent of BSE and possible risk exposures of these young CJD cases. He noted the risk assessment would give a logical basis for introducing any necessary further control measures. I also noted that several members commented that the young cases of CJD should be investigated further to identify any other potential risk factors such as pharmaceuticals.

7.219 Following receipt of this information, Sir Kenneth called a meeting that same morning with Dr Rubery, Dr Metters, Dr Wight and Mr Mike Skinner. ²⁶ The note of the meeting records that in light of the confirmatory work to be done, publication of the new findings was 'unlikely for a month'. ²⁷ It was also noted that Sir Kenneth would call a meeting with MAFF and Professor Pattison for the coming Friday (15 March). However, by the time that Dr Rubery minuted Sir Kenneth's Private Secretary the following day (12 March) she was able to note that the proposed meeting had been brought forward to Wednesday 13 March, at 10.30, to be held at MAFF. Dr Rubery recorded that Sir Kenneth had suggested the possibility of further meetings of officials on 21 March, about 28 March, and during the week of 8 April. ²⁸

7.220 MAFF's proposed publicity material about BSE was also discussed at this meeting. ²⁹ A note of the meeting recorded:

It was agreed that in the light of the new information available to the DH and MAFF on Friday it would be sensible to delay further progress on the leaflet . . . ³⁰

7.221 After the meeting Sir Kenneth Calman wrote to Mr Packer to say that, in view of the new findings, 'it would seem very unwise to disseminate information which could later be seen as falsely reassuring'. ³¹

7.222 Sir Kenneth told us that he later met Mr Dorrell to discuss the new findings. ³² We have found no documentary record of this meeting, and Mr Dorrell made no mention of it in his evidence.

7.223 On 9 March 1996 Dr Matthews produced a note entitled 'Consequences of the SEAC Meeting on 8 March 1996', ³³ which he distributed to senior officials within MAFF. ³⁴ He stated:

The evidence presented by Will and Ironside clearly indicates the presence of a cluster of cases of CJD over a period of less than a year that have clinical and pathological pictures which differ from historical data for patients under 40. Although it is not proof of a link with BSE, it is clear that it affects young people in the UK only, and is contemporaneous with the BSE epidemic. ³⁵

7.224 In his note Dr Matthews set out a number of 'possible action points' in response to this development, some of which had been raised at the SEAC meeting. The possible courses of action ranged from the slaughter of the entire UK herd to less drastic measures such as the slaughter of animals from the same cohort as affected animals. Under the heading 'Possible action points at markets and abattoirs' he stated:

Identify and compulsorily purchase animals over 2.5 years of age;

Slaughter and dispose of such animals to prevent their entry into the human food chain (could any parts be salvaged?);

Extend the specified offals ban to include other tissues, or at least to ensure that carcase meat is not contaminated by tissues currently defined as SBO. In particular this means preventing contamination with CNS tissue;

Extend SBO ban to include calves;

Change meat processing practices to avoid the splitting of spinal column;

All cattle over 2.5 years presented for human consumption should be boned out. This could involve removal of major peripheral nerves and dorsal root ganglia, and trimming of tissues most likely to be contaminated by smearing with spinal cord;

Cattle over 2.5 years only to be slaughtered at specified abattoirs;

Prohibit the salvaging of any constituents of SBO - ie, require total destruction. ³⁶

Monday 11 March 1996: SEAC meeting and visit to a slaughterhouse

7.225 On 11 March 1996, some members of SEAC visited a slaughterhouse. That afternoon SEAC met again (the twenty-sixth meeting) and Mr Meldrum was present to advise the Committee on any issues in relation to meat hygiene that might arise following the visit. ³⁷ Members of the Committee were generally pleased with what they had seen at the slaughterhouse and felt that the SBO was being properly removed, identified and treated. The minutes record that the Committee did not identify any new measures that it felt should be recommended immediately. ³⁸

7.226 The meeting went on to re-examine Dr Will's paper on vCJD and it was agreed that the epidemiology of the human TSE needed further examination by way of:

(a) peer review to ensure that this was indeed a distinct variant of CJD;

(b) a review of the literature by experts to ensure that this presentation was new and had not been seen, possibly in an unidentified form, in earlier years;

(c) review of overseas cases to see whether this variant was unique to the UK or had been observed overseas. ³⁹

7.227 We have already mentioned Dr Rubery's minute of 12 March 1996 to Sir Kenneth Calman's Private Secretary, which described the meeting chaired by Sir Kenneth the previous day (see paragraph 7.219). ⁴⁰ The minute also reported on SEAC's 11 March 1996 meeting, which she had attended. She noted that SEAC had concluded:

. . . in the light of the information provided by Bob Will and James Ironside on Friday and their visit to the abattoir today there was no need to change their advice on the SBO bans . . . ⁴¹

7.228 She also noted that the Committee had concluded:

The data are consistent with BSE causing a subset of CJD which is clinically atypical, with an unusual EEG and amyloid plaques on PrP staining but:

(1) This could also be identification of a disease previously unidentified but present.

(2) The description of the new disease is not necessarily evidence for a causal relationship to BSE exposure of the population, although this is a possible explanation. ⁴²

MAFF updated on SEAC progress

7.229 On 12 March 1996, Mr Eddy minuted Mr Packer (MAFF, Permanent Secretary) summarising SEAC's deliberations at the meetings held on 8 and 11 March 1996. He summarised the information presented by Dr Will and Dr Ironside on 8 March. ⁴³ The minute noted:

My minute of 6 February warned the Minister that the CJD Surveillance Unit were concerned at the emergence of a subtype of CJD in younger patients. They have now firmed up their views and reported . . . that they have identified a new form of CJD in the UK only. The cases are confined to younger patients ranging from 18 to 42. Depending on medical tests still underway there could be as many as 8 or 9 such cases all dating from the past 2 years. Cases in young patients are unusual but not unknown. But we have had more in the past 2 years than in the previous 10 and more than in other countries. Furthermore the disease looks different both clinically and under the microscope where there are 'plaques' which are not found in normal CJD. ⁴⁴

7.230 He added that the CJDSU was confident that the disease was new and that SEAC had been 'extremely concerned and noted that a possible explanation of this new form of the disease occurring apparently only in the UK was that it was related to BSE'. ⁴⁵ Another concern was that 'some sheep would have been fed the same contaminated feed as cattle in the 1980s and could have contracted BSE unrecognised because it might look like normal scrapie'. ⁴⁶

7.231 The minute also mentioned the likely period of infection of the victims of the new disease:

. . . there is . . . no reason to believe that they were not potentially exposed before the SBO controls were introduced in November 1989. It is unlikely in logic that these cases reflect exposure post 1989 given the long incubation period of the disease and the expectation that exposure would be lower after the SBO ban than before; but this is not easy to prove. One of the SEAC members, Dr Kimberlin, will be doing a formal risk analysis calculation to assess the likely risk prior to the SBO ban and since. This will take time but will be important in considering the implications in SEAC and in presenting them to outside scientists. In essence he will be able to calculate odds to help answer the question 'do these cases tell us that BSE was a risk to humans or that BSE still is a risk despite the precautions taken'. ⁴⁷

7.232 Mr Eddy detailed the areas identified by SEAC on 11 March as requiring extra work before publication of the findings. He also commented that 'the mood of the meeting on 11 March was less bleak than that of 8 March and rather more sceptical of the CJD Unit's findings, but some of the leading medical members of SEAC, including the head of the CJD Unit, were not present'. ⁴⁸

DH: a proposal for the 'next steps'

7.233 Included with the minute sent by Dr Rubery on 12 March was a 'status paper'. ⁴⁹ This urged the need to consider a communications strategy for the time when a public announcement on the possible link between vCJD and BSE would be made. Dr Rubery noted a number of ways in which relevant information could be passed on to GPs and other doctors, members of the NHS and Environmental Health Officers (EHOs). The paper also summarised SEAC's discussion on 8 March 1996 and set out 11 'next steps' required to address the hypothesis of a causal link with BSE and to determine the actions necessary. ⁵⁰ These were:

1. Obtaining advice from MAFF on the likely timing of exposure, assuming that the route was via beef and beef products;
2. Obtaining all available data on incubation periods of TSEs that might be relevant;
3. MAFF needed to consider ways to further protect the human and cattle food chains;
4. MAFF and DH needed to consider the same question in relation to BSE in sheep;
5. Consideration by the CMO of what advice he needed to give and when on public health, political and credibility grounds;
6. The setting up of a predictions group to plot out the likely future of the epidemic (with Professors Peter Smith, epidemiologist, and Roy Anderson, Head of Zoology Department, Oxford University involved);
7. Consideration of other routes of exposure, such as catgut, vaccinations and gelatine capsules;
8. Consideration of other possible causes of the new disease, for example recreational drugs;
9. Consideration of how the disease might be present in older people;
10. Urgent assessment of future resource needs for surveillance and research;
11. Urgent development of a communication strategy and a helpline once the announcement was made. Dr Rubery noted a number of ways in which information could be passed to GPs and other doctors, members of the NHS and EHOs, and recommended that SEAC's policy on communication with members of the public be 'sorted out'. She suggested considering the issuing of a press statement after each SEAC meeting, like the Advisory Committee on the Microbiological Safety of Food.

7.234 Dr Rubery told the Inquiry that she could not recall how she had devised this list. However, she thought it would have been based on discussions within SEAC and with the SEAC secretariat as well as with her staff. She would have also have used her previous experience of handling public health issues (such as Chernobyl and salmonella). ⁵¹ She stated that she would have sent the paper in draft form for comment to others in her Division before she finalised it. ⁵²

Wednesday 13 March 1996: meeting with Professor Pattison

7.235 We noted above Sir Kenneth Calman's request, that a meeting be arranged with Mr Packer and Professor Pattison for 13 March. ⁵³

7.236 The meeting was held at MAFF on 13 March at 10.30 am. In addition to Sir Kenneth, Mr Packer and Professor Pattison the meeting was attended by Mr Meldrum, Dr Rubery, Dr Wight, Mr Eddy, Dr Skinner, Mr Carden, Mr Haddon, Mr Taylor, Mr Hollis, Dr Matthews and others. ⁵⁴ Sir Kenneth and Mr Packer agreed on the need to be 'absolutely sure' the data were right before they were published, because of the 'possibly immense implications' of the new findings:

Taking all things into account, the CMO still envisaged that a sub-type of CJD in younger patients was likely to be identified. He needed to plan on the basis that there was a new risk, that there was a new form of spongiform encephalopathy, and that the likely source was BSE in cows. He also had to assume that the whole population had been exposed over a 10 year period . . . ⁵⁵

7.237 Professor Pattison told the meeting that SEAC's slaughterhouse visit on Monday had 'reassured members that the SBO ban could be made to work effectively'. Mr Meldrum said he was 'more confident today than before April last year that the rules were being applied'. ⁵⁶

7.238 In discussion of what new controls might be introduced, Professor Pattison said that SEAC could consider 'tweaking the SBO ban to remove more potentially infective organs, but this would not be rational', and 'removing cows over 2 or 2½ years old from the human food chain. However, this was a very complicated question in view of the economic consequences.' ⁵⁷

7.239 Professor Pattison 'confirmed that SEAC would meet in the next few weeks'. ⁵⁸ He asked for guidance on the limits of SEAC's considerations. Mr Packer advised that:

SEAC should consider what it thought appropriate, although comments on how the situation might have arisen would be helpful. If SEAC made a recommendation, the Government was likely to follow it. Although economic consequences were secondary, clearly any recommendations should be balanced. As evidence came forward, it changed the balance of reasonableness of what we were doing; however, any changes to the rules had to be proportionate. It did not follow from the worst case scenario that the current rules needed to be changed. ⁵⁹

7.240 Mr Meldrum asked Professor Pattison to 'bear in mind the logistical effects of any recommendations, and to consider the wider uses of products such as bonemeal eg. for pig rations'. ⁶⁰

7.241 Sir Kenneth had drafted a press statement dealing with publication of the research, which he read out to the meeting. ⁶¹

7.242 On MAFF's publicity information, Mr Packer told the meeting:

. . . it would be inappropriate for MAFF to issue any more copies of the reassuring publications. Where commitments had been made to send out such publications, these should not be honoured. The briefings planned with local authorities and so on should also be cancelled. ⁶²

7.243 Sir Kenneth pointed out that the Lancet was published on a Friday, 'the wrong day for taking proactive action'. He suggested that they make the findings public and set out what they proposed to do before they were published in the journal. Professor Pattison thought the article would be published in the Lancet within two weeks. Later publications could give rise to leaks. ⁶³

7.244 Mr Packer 'thought it would be difficult to go public other than on the basis of a recommendation from SEAC on further action'. ⁶⁴

7.245 After this meeting Mr Packer held a 'wash-up meeting' with Mr Eddy, Mr Carden, Mr Meldrum and Mr Haddon. ⁶⁵ Mr Packer explained that he 'had some reservations. For example, why were only young people going down with this form of CJD?' Mr Eddy answered that 'Professor Will's explanation was that younger people were more disposed to buy hamburgers'. Mr Packer 'did not find this convincing', ⁶⁶ and he followed up his reservations afterwards in a letter to Sir Kenneth Calman and Professor Pattison (see below).

7.246 Dr Kimberlin's work on a formal risk analysis calculation, as agreed at the 8 March SEAC meeting (see paragraph 7.213), was also discussed:

It was agreed it would be helpful if the work by Kimberlin was completed before publication. The Secretary suggested we offer to pay him to work on this full time. We could also offer to provide a statistician if that would help, unless this might be thought to compromise the findings. In the meantime, we should take the line that SEAC should not make recommendations for the sake of it if they were confident that the controls were adequate. We should also make contingency plans in terms of market support and disposal of carcasses . . . ⁶⁷

7.247 Mr Packer wrote to Professor Pattison shortly after the meeting with further thoughts. He noted the 'very considerable political and economic damage' that might be caused by any public statement of the sort envisaged on the most pessimistic scenario. He wondered whether it was prudent to suggest a link between vCJD and BSE until either there was an increase in the number of CJD cases, and/or until there was a noticeable increase in the number of 'new type' cases being identified, where they were following the same pattern as BSE, rising steadily with decreasing intervals between cases. He also said they needed to discuss why the new variant had been found only in young people. ⁶⁸

7.248 Mr Packer recalls that 'both Professor Pattison and the CMO telephoned to say that they regarded the points I had made to them as valid considerations'. ⁶⁹

Mr Hogg is informed of developments

7.249 Later that day (13 March), Mr Packer minuted Mr Hogg about 'developments on BSE and possible links with CJD which are potentially extremely serious'. ⁷⁰ Mr Packer stated:

SEAC has recognised that given the seriousness of the implications of any statement from an authoritative source to the effect that BSE might well cause CJD, it behoves them to be clear that Dr Will's claims on singularity are accurate. ⁷¹

7.250 Mr Packer stated that, in the light of SEAC's deliberations, MAFF needed to plan on a 'worst case' basis. ⁷² He continued:

. . . if BSE/CJD transmissibility does exist then it is highly probable that cases seen so far result from exposure before any measures were taken against BSE in the middle 1980s. Moreover, since the ban and other measures were first introduced in 1988, measures and enforcement have been progressively tightened up. Accordingly, whatever the position on transmissibility, it does not follow that any further measures were needed now. I said as much to Professor Pattison since elements in SEAC are apparently thinking in terms of recommending a ban on the consumption of beef from animals over two years old and it is far from clear that the cost of such a measure would be proportionate to any reduction in risk.

Nevertheless, on the pessimistic scenario worries about the economic consequences of SEAC recommendations would be academic. If SEAC and the CMO issue statements acknowledging the possibility of BSE/CJD transmission I am sure that the public and market reaction would be such that the political and economic effects would be a disaster of unparalleled magnitude so far as UK food scares are concerned. The consumption of beef would be likely to fall immediately to a small proportion of its former level. ⁷³

7.251 Mr Packer added that he would be talking separately to Ms Kate Timms (Head of Directorate responsible for Agricultural Crops and Commodities) about what might be done in the economic sphere should such a market collapse occur.

7.252 On the question of the timing of an announcement, Mr Packer noted that Sir Kenneth Calman was 'very anxious that all this should be pushed forward as rapidly as possible, not least to avoid leaks'. He also added that 'it is even more important not to rush into public announcements before we are clear that there is a genuine cause for concern'. ⁷⁴

7.253 In his oral evidence to the Inquiry, Mr Hogg stated that he agreed with Mr Packer's recommendations. He stated:

In early December or very late November, there had been a series of television programmes about the unsafety of beef. That did have a very serious though short-lived impact on the consumption of beef. In a sense therefore we were very alert to how febrile public confidence was and therefore I would not have wanted to have run the risks of leaks until such time as I had something positive to say, because I knew what the consequences would be. We had been through it, in a very played down form, in the latter part of 1995. ⁷⁵

7.254 Mrs Browning told the Inquiry:

Since the emergence of Dr Will's theory, it had been a very tense time for Government. We were extremely anxious to have advice from SEAC as soon as possible. We did not feel that we could go to the public with an announcement that BSE and nvCJD might be linked, but without any recommendations as to how to deal with it. We therefore needed SEAC to give firm advice as soon as possible. ⁷⁶

7.255 Mr Packer and Mr Hogg spoke several times on 13 and 14 March to discuss Mr Packer's minute of 13 March. They agreed that a public statement could not be made until SEAC had advised on the accuracy of Dr Will's earlier claims and the steps which the Government should take. ⁷⁷ They also agreed that they should 'avoid seeking to influence in any way the conclusions to which SEAC itself would come'. ⁷⁸ Mr Hogg noted the need to get 'clear advice from the Committee as to the facts and the steps which the Government should take'. ⁷⁹ Mr Hogg agreed that it would be prudent to plan on the basis of the worst case scenario. In addition, he was glad that Ms Timms had been asked to do some preliminary work and he commented that there might be some potentially very serious consequences in the very short term. MAFF therefore needed to move quickly and have worked up the various possible responses with costings for each option. Finally, Mr Hogg agreed to write to Professor Pattison to ask SEAC to submit their advice about a course of action as soon as they were able.

7.256 As a result of these discussions, Mr Hogg wrote to Professor Pattison asking him to submit SEAC's views to the Secretary of State for Health (Mr Dorrell) and himself:

Since the Government will be able to act on any recommendations which you make only once we have received your considered conclusions, I confirm that I shall be looking to you to submit your advice as soon as you are in a position confidently to do so. ⁸⁰

7.257 Mr Packer and Mr Hogg also discussed the possibility that after SEAC's next meeting, which was to take place on Saturday 16 March, Mr Hogg might need to write to the Prime Minister on 18 March 1996 to inform him of developments. Mr Dorrell had informed MAFF that he would be content with this procedure. ⁸¹

DH meeting: 14 March 1996

7.258 On 14 March 1996, Dr Rubery attended a meeting with Sir Kenneth Calman and Dr Wight. In a statement to the Inquiry, Dr Rubery stated:

I attended a meeting with CMO and Dr Wight. She had spoken to Professor Pattison who had in turn spoken to other members of SEAC namely, Richard Kimberlin, James Ironside, Bob Will and John Collinge. The pathology of the new variant CJD cases had been confirmed by three other neuropathologists. The new disease seemed to be real. The CMO concluded that a further meeting of SEAC should be convened for Saturday 16^th March to advise the Secretary of State on the data. ⁸²

15 March 1996: costings for two scenarios

7.259 On 15 March 1996, Mr Cowan (MAFF) minuted Mr Hollis, Ms Timms, Mr Carden, Mr Haddon and Mr Eddy. ⁸³ His minute explained that he had been asked to provide costings for two scenarios:

1. the beef market collapses to the extent that recourse is necessary to intervention buying on a significant scale; and
2. it is necessary to take out of the human food chain animals over two and a half years of age, essentially cull cows.

7.260 Mr Cowan's costings recognised that the two scenarios were not mutually exclusive. We return to Mr Cowan's costings at 7.504 below, in the context of advice provided to Ministers. In concluding his minute of 15 March 1996, Mr Cowan stated:

In addition to the direct costs of removing cull cows and adult bulls from the food chain, one has also to consider the likely consumer reaction. It is inconceivable that a ban on cow beef will not adversely affect consumption of all beef. That effect will be catastrophic unless we are in possession of convincing, indeed compelling, scientific arguments for taking such a draconian step only in relation to animals above a certain age. We should also have to face the argument that banning the consumption of muscle (which has never shown evidence of being susceptible to BSE infectivity) casts doubt:

a) on the measures we have in place currently;

b) on the safety of all beef muscle; and

c) perhaps most worrying, the safety of the most important cow product, milk. ⁸⁴