Volume 6: Human Health, 1989-96
6. Events from 1 April to 31 December 1995: human health returns to the agenda
Pronouncements and publicity in relation to BSE from various quarters
Discussion

Discussion

CMO's press release of 5 October 1995

6.341 The CJDSU's Fourth Annual Report covered findings of the Unit up to 30 April 1995. It was released on 5 October 1995, together with a press release issued by DH.

6.342 The press release included a statement by SEAC about the Report, which included the following:

We are reassured that there continues to be no evidence of an emerging CJD epidemic. The apparent rise in incidence of CJD cases in the UK appears to be mainly due to increased ascertainment. This is inevitable when intensive monitoring of a disease is undertaken. Other countries which monitor CJD have experienced similar increases, including countries with no history of BSE.

As with last year's report, there is no strong evidence of changes in the geographical distribution of CJD and no conclusive evidence that particular occupations, such as farming, carry an increased risk of developing the disease . . .

We have no further recommendations to make to Government on the basis of the report and remain satisfied with the adequacy of current controls to protect public health in regard to CJD. ¹

6.343 This was followed by a statement from the CMO:

In the light of the conclusions reached in the report and the Committee's clear statement, the Chief Medical Officer, Dr Kenneth Calman said 'I continue to be satisfied that there is currently no scientific evidence of a link between meat eating and development of CJD and that beef and other meats are safe to eat. However, in view of the long incubation period of CJD, it is important that the Unit continues its careful surveillance of CJD for some years to come.' ²

6.344 We expressed concern to Sir Kenneth Calman that he should have chosen to make a statement in these terms at this time. Since 20 April 1995, the end of the period covered by the CJDSU's Fourth Report, events had occurred which were sufficient to cause concern about the possibility of transmission of BSE to humans.

6.345 Sir Kenneth was aware that slaughterhouse inspections had disclosed failures adequately to separate SBO from material for human consumption and that the results of a further round of visits were pending. ³ On 4 October SEAC held a special meeting to discuss the significance of a possible fourth case of CJD in a cattle farmer with BSE in his herd. ⁴ The Committee concluded that it was 'difficult to explain this as simply a chance phenomenon'. ⁵

6.346 On 25 October, by which time there had been further reports of failures to remove SBO in slaughterhouses, Sir Kenneth met Mr Packer to express his concerns about BSE. These included the slaughterhouse shortcomings and the four cases of CJD in farmers with BSE in their herds. Mr Packer recorded:

However, overall he was not entirely happy with the situation and this would inevitably be reflected in his public utterances. While he would not depart drastically from what he had said previously and, in particular, would continue to maintain a strong presumption as to the safety of beef, he could not be as unequivocal as in the past. ⁶

6.347 We believe that Sir Kenneth had concerns at the time his press release of 5 October was drafted. These are apparent from the fact that the word 'currently' was inserted in the draft press notice at Sir Kenneth's request. ⁷

6.348 Sir Kenneth emphasised to us that his press release was made in relation to the release of the CJDSU Fourth Report. However, the release went beyond commenting on the Report and expressed satisfaction that 'beef and other meats are safe to eat'. It seems to us that, in the light of the matters known to him on 5 October, it would have been particularly desirable for Sir Kenneth to qualify his statement by making it plain that this was dependent upon the proper implementation by slaughterhouses of the SBO Regulations. He should not have made the unequivocal statement that he did.

6.349 In his Annual Report for 1995, Sir Kenneth included a section on 'Understanding the language of risk'. This included the following passage:

The problem for decision-makers is not when the evidence is clear, but when it is weak or incomplete . . . In such instances there is a need for openness and sharing of information, and the establishment of trust between those who make policy and the public at large. That will sometimes mean that the fact that there is reasonable doubt, or that there is no answer to the question, may need to be clearly stated. ⁸

6.350 We do not consider that Sir Kenneth's press release of 5 October satisfied 'the need for openness and sharing of information'.

6.351 We have pointed out that the public message given by Sir Kenneth's press release was in contrast to the concerns that he was to express to Mr Packer later in the month. As we have noted above (see paragraphs 6.186-6.190), it is to his credit that those concerns were pursued with Mr Hogg and with MAFF officials and were instrumental in bringing the issue of MRM back for further consideration by SEAC.

Mr Dorrell's statement of 3 December 1995

6.352 Mr Dorrell has expressed regret ⁹ at agreeing to the proposition, put to him by Mr Jonathon Dimbleby in an interview on London Weekend Television on 3 December 1995, that:

You are saying no conceivable risk from what is now in the food chain. ¹⁰

6.353 We agree that it is a matter for regret that the Secretary of State for Health should have given an assurance in terms more extreme than he could justify.

The role of the MLC

6.354 When representatives of the MLC gave evidence in Phase 1, they explained how the emphasis of the activities of the Commission altered after 1985 from livestock improvement to marketing. ¹¹ They also made the point that there was no recognised channel for the provision of scientific knowledge to the MLC by MAFF or DH. ¹²

6.355 In 1989 and 1990 the MLC was active in a number of respects that were calculated to protect against the possibility of transmission of BSE to humans. On 25 May 1989, on the advice of Mr Maclean, the Chairman, Mr Geoffrey John, wrote to Mr MacGregor urging him to go beyond the Southwood recommendations and introduce an SBO ban that had general effect. ¹³ In the same letter the Minister was urged to raise the level of compensation in respect of the slaughter of clinically affected animals to 100 per cent.

6.356 In June 1990 the MLC supported action in relation to the risk of contamination created by the practice of head-splitting and brain removal in slaughterhouses. ¹⁴

6.357 At the same time the MLC put in hand research work to develop a suction device that would remove the spinal cord of an animal before the carcass was split.

6.358 It was explained to us that these actions were taken not because it was believed that they addressed a risk to humans, but for reasons of presentation in order to reassure purchasers of beef. MLC officials believed that slaughter and destruction of clinically affected animals sufficed to deal with any risk posed by BSE to human health. ¹⁵

6.359 So far as BSE was concerned, MLC saw its major role as one of protecting the market by reassuring customers that suggestions that risks attached to eating beef or beef products were without foundation. MLC officials believed that this fairly represented the position. When giving evidence in Phase 2 Mr Maclean and Mr Curry put the position as follows:

The primary concern of the MLC is actually to make sure that the meat eating habit continues in as large a scale as possible, and that means that it must protect its customers because the minute it loses the confidence of its customers, it has not done its job, and therefore its first priority is obviously human safety and human health.

. . . And its second priority is actually to try to ensure that the communication going to consumers is as reassuring as possible in order to maintain the viability of its industry. ¹⁶

6.360 It seems to us that, by the time of the emergence of BSE, the MLC was seen as a body whose primary function was to promote the beef industry. Professor Richard Lacey commented on its role in 1991:

I knew they obtained advertising income from a levy on animals that were slaughtered to promote the consumption of meat. I also knew that they had some Government funding support, and I also knew that they were headed by senior veterinary officers. I viewed them as the promotional angle of the meat industry. ¹⁷

6.361 More significantly, Mr Packer said that in January 1996 he sought to distance the Government from public statements by the MLC 'because I feared the MLC would wish to make statements in their advocacy to which the Government could not subscribe'. ¹⁸ When asked to explain this, Mr Packer said:

Well, the MLC is a body specifically to advocate and pursue the interests of the meat industry. Now, the Government is also interested - has the interest of the meat industry at heart, quite properly so. The Government has the interest of all industries at heart. If industries succeed we all get richer, and if they fail we all get poorer and that is an important point. But nevertheless the MLC's line is not the same as, and there is no reason why it should be the same as that of the Government. ¹⁹

6.362 Mr Adam Rennie, the Grade 5 Head of the Meat Hygiene Branch in DAFS, ²⁰ observed that:

The job of the MLC in respect of BSE as I perceived it was to seek to do what they could to promote beef consistent with the overall general message which the Government was putting over and consistent obviously with the regulations which were in place. ²¹

6.363 Its perceived role, and some of the over-extravagant comments made in respect of the safety of eating beef to which we have already referred, appear by 1995 to have robbed statements by the MLC in relation to the safety of eating beef of much of their credibility. ²²

6.364 We expressed concern to the MLC that the Position Statement that was produced in July 1995 (see paragraphs 6.256-6.259) was a further example of exaggerating the absence of implications of BSE for human health. The statement 'visibly infected cattle are totally destroyed' ²³ did not recognise the possibility of the occasional clinically affected animal 'slipping through the net'. However, we have concluded that, once ante-mortem inspection had been introduced in all slaughterhouses, it must have been a very rare occurrence for an animal affected by BSE to escape detection, and we would not criticise the MLC for failing to reflect that possibility in its statement. Indeed, in this respect the MLC was doing no more than following the precedent set by MAFF in its Progress Reports of December 1992 ²⁴ and January 1994. ²⁵

6.365 The statement that

all specified offals from all cattle are removed and destroyed before meat enters the human food chain ²⁶

was to prove inaccurate, when shortcomings in the removal of spinal cord came to light later in 1995. The question arises of whether MLC officials had reasonable grounds for believing that the statement was true.

6.366 Mr John Pratt, Head of Veterinary Services at MLC since 1984, told us in Phase 1 of the hearings that 'SBO removals were not always being carried out to the letter of the law' ²⁷ from mid-1994 through into 1995 - information known to others in the industry. He explained that he was speaking of the operation of removing types of SBO, such as spinal cord, from the carcass. ²⁸ Mr Maclean was aware of these reports. ²⁹

6.367 In a statement to the Inquiry, ³⁰ Mr Maclean informed us:

At around the time of the July 1995 position statement ³¹ I believe I had asked MAFF (Mr Meldrum) whether SBO material was being prevented from entering the human food chain. Mr Meldrum had confirmed that it had. I would add that Mr Meldrum had just received a report from Mr Fleetwood that confirmed that 'No instances of failure to separate SBO from material intended for direct human consumption has been reported . . .' (in national surveillance, 31 May-23 June 1995). ³²

6.368 He added:

Having pressed for improved methods, participated in consultation over tighter controls, I received confirmation that no SBOs were getting into the human food chain, and because of the rest of the cascade of controls, MLC felt that it was perfectly legitimate to make that assurance in July 1995. ³³

6.369 We do not believe that Mr Meldrum would have assured Mr Maclean that 100 per cent removal of SBO was being achieved, for he has told us that he did not believe this to be the case. Nor do we believe that Mr Maclean would have accepted that 100 per cent compliance with the SBO ban was being achieved. His oral evidence to us was to the contrary. ³⁴ We find that the July 1995 position statement had a degree of hyperbole.

6.370 Mr Maclean was not personally involved in the preparation of the position statement. We believe, however, that as Director-General of the MLC he had a duty to make sure that statements such as this were accurate. He should not have permitted the position statement to give an unqualified assurance that all specified types of offal from all cattle were removed and destroyed before meat entered the human food chain.

6.371 If the exaggeration in the 1995 position statement had been an isolated case, we would not have singled it out for criticism. It was not, however. It was one of a number of occasions when the MLC fell short of the objectivity that should have been shown by a statutory body with a duty to have regard to the interests of the consumer.

The advertising campaign in November and December 1995

6.372 This campaign included the statement:

British veterinary and abattoir regulations, along with their enforcement, are as strict as the strictest in the world. Altogether, eight separate controls are in place embracing the farm, auction market and meat plant. With such stringency, even the remotest perceived risk is avoided. ³⁵

6.373 This was a further example of exaggeration.

6.374 In October and November there was a series of occasions on which SVS slaughterhouse inspections disclosed failures to remove from the carcass all pieces of spinal cord. This led to Mr Hogg's statement of 22 November disclosing 17 such instances, which he described as 'potentially serious failings' (see paragraph 6.193).

6.375 Over the previous years MLC officials had, on a number of occasions, commendably, urged on MAFF and on industry the importance of compliance with the SBO Regulations. They had done so because they had become aware of reports that these were not being strictly complied with. On 1 November Mr Curry, the Chairman of the MLC, wrote a strong letter to Mr Hogg expressing concern at breaches in the integrity of the SBO system, in particular those leading to four cases in which spinal cord had been found in carcasses that had been passed by meat inspectors as fit for consumption. He wrote:

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

We therefore believe it necessary for MAFF to send a clear signal to the whole industry that breaking the specified offal or ruminant protein bans will be punished extremely severely by prosecuting one of the offending abattoirs (or others not adhering to the rules). ³⁶

6.376 In these circumstances we do not consider that it was appropriate to claim that the stringency of abattoir regulations avoided even the remotest perceived risk. It is true that Mr Hogg went on, in his statement of 22 November, to describe steps taken to tighten up on enforcement of the SBO Regulation, but it must have been plain that these could not take effect overnight. Despite the array of controls, it was impossible to deny the risk that spinal cord from an infected animal might enter the human food chain. Mr Maclean should not have permitted the MLC advertisements to claim that with the stringency of controls even the remotest perceived risk was avoided.

6.377 Thus again we hold Mr Maclean responsible for this inappropriate exaggeration. Mr Curry has told us that, as Executive Chairman, he also must accept responsibility, albeit that he cannot now recollect whether he was aware of the terms of the advertisement. We would not hold Mr Curry personally at fault in those circumstances. He could, we consider, properly rely upon Mr Maclean to ensure that the terms of the advertising campaign were appropriate.

6.378 We have noted in the narrative of this section that a misquotation of the CMO in the advertisement led DH to allege that the MLC had embellished the CMO's words with the MLC's own spin, and that the Advertising Standards Authority upheld other complaints about the MLC's advertisements.

6.379 The repeated hyperbole in the MLC promotional material must, we believe, have led the public to regard it with the scepticism that advertising of this kind tends naturally to generate. The result was that the MLC found that it had lost credibility. It was this that led the MLC to seek to involve in its promotional campaign independent scientists, and in particular members of SEAC and the CJDSU.

6.380 It was understandable that the MLC, or indeed MAFF, should seek to quote the advice or opinions of independent scientists in relation to the risks posed by BSE or, indeed, the risks posed by beef and beef products. At the same time we consider that it was not appropriate that these scientists should make statements for the purpose of providing advertising copy, let alone contribute to advertisements by writing or by televised interview. This applies with particular force to the CMO. It is important that the public should be able to trust advice given by the CMO. To this end he or she must be, and be seen to be, independent of commercial interests and of commercial objectives, whether of Government or the private sector. To a lesser extent the same is true of independent expert advisers.

6.381 With these considerations in mind, we would commend Mr Packer for his appreciation of the danger that the MLC might make use of Professor Pattison's video interview in a manner which might appear prejudicial to his independent standing, and for the prompt action that he took to ensure that this did not occur (see paragraphs 6.329-6.330).

6.382 Mr Meldrum correctly recognised that MAFF had objectives that were complementary, but not identical, to those of the MLC and that there was a need both to protect the perceived independence of SEAC and for MAFF to distance itself from the MLC - to be seen to be disinterested (see paragraph 6.344). Mr Maclean had shown insensitivity in the use he sought to make of members of SEAC; a further instance of which we shall consider in the next chapter.

6.383 We have received quite voluminous evidence from Dr Will and Mr Maclean that bears on the issue of whether Dr Will had expressed concern at the terms of the advertisement that was to include a quotation from an article that he had written. Were we to attempt to resolve this issue we would need to explore this evidence with the witnesses in a further oral hearing. We do not consider that the issue is sufficiently important to justify such a course, and must leave it unresolved.