Volume 6: Human Health, 1989-96
9. Bovine eyeball dissection
Discussion
General comments

Early consideration of bovine eyeball dissection

9.139 We have considered whether officials in DES, DH or MAFF should have pursued further the question whether action was needed in relation to the dissection of bovine eyeballs when it was raised in 1988 and 1989.

9.140 However, we have concluded that they were not to be criticised. From August 1988, BSE-affected cattle were compulsorily slaughtered and their carcasses destroyed. Eyeballs from such cattle would not have been available for dissection. Eyeballs from all other cattle were not included in the SBO ban in November 1989. We believe this was because it was not thought they would be eaten by humans. But it seems to have been thought by some that their omission from the ban indicated that they were considered safe for human consumption: see the point made by Mr Bradley in his minute of 20 November 1989. ¹ It was not until 1995 that the ban was extended to include all bovine eyeballs. Having regard to the terms of the SBO ban, we think it reasonable that those who considered the issue of bovine eyeball dissection in 1988 and 1989 did not pursue it more vigorously at that stage.

Delay within DES

9.141 SEAC advised in July 1990 that eyes from cattle over 6 months old should not be used for dissection in schools. ² It was 2 ½ years before that advice was passed on to schools. Did that constitute an inadequate response to the emergence of BSE, or were there good reasons to explain the delay?

9.142 When considering this question we were interested in the contrasting approach taken in Scotland, where it took just over a month for guidance to be issued from the time when the question was first raised. We have noted that this approach was not without its critics at the time. Mr J McDonald (HMI Chief Inspector) raised a number of concerns about the consultation process leading to the distribution and substance of the advice. ³ We have noted above the comments made by the Scottish Equipment Research Centre.

9.143 We have sympathy with such considerations, and are mindful of the need not to act rashly or with undue haste. Consultation with appropriate parties assists in drawing to the decision-maker's attention the competing concerns. On the other hand, it is important not to allow the consultation process to become over-elaborate or to lose momentum, to the detriment of decisive action where that is called for. These are considerations we have had in mind when looking at this part of the story.

9.144 Had advice to schools been issued in May or June 1991, shortly after Mr Lowson and Dr Pickles approved Mr Jacobs's draft, ⁴ we do not think that criticism of those concerned would have been justified. We can understand what led to that stage of the consultation process lasting some ten months. Although speedier action would have been preferable we do not think, in the circumstances, that this would have been an unreasonable response. However, we were concerned that, far from guidance being issued at that stage, a further 18 months elapsed before that took place.

9.145 When we raised our concerns with Mr Baker he responded with admirable candour. He told us:

I was the senior officer who at the time was given and accepted responsibility for the issue of advice to schools on the dissection of bovine eyeballs . . . and I do not disclaim my major share of responsibility for that delay.

I accepted that responsibility when the handling of the bovine eyeballs business was reviewed within the Department by senior colleagues at the end of 1992, in response to ministers' concerns about the delay in issuing advice. It was then concluded that I had made significant errors in judgement in dealing with this piece of business; in particular in not ensuring that the matter was brought to the early attention of Ministers, and in taking a view on questions of public sensitivity that were probably a matter for Ministers. The outcome for me was a reprimand and a caution as to my future conduct. ⁵

9.146 Mr Baker explained to us some of the reasons that lay behind the delay:

With hindsight, it is clear that the issue of advice to schools should have been regarded as urgent and given a high priority. However, that was less clear to me and others at the time - before any new variant of CJD associated with bovine spongiform encephalopathy had been identified. The advice we had been given was that infection by the BSE agent through accidental inoculation in the course of dissecting bovine eyeballs was a remote theoretical risk. There was no epidemiological evidence of the transmission of the disease to humans, and the scientific literature seemed to suggest that transmission was highly unlikely. I recognise that we were not competent to make our own judgement on these matters and should never have been trying to do so. But my point is that I never believed in any real risk to pupils and saw the issue of advice to schools as an ultra-precautionary measure.

At that time the Branch, and my Division within it, was under very heavy and unrelenting pressure to introduce a statutory national curriculum and associated assessment measures, subject by subject, to an exacting and inflexible timetable determined by Ministers. At the beginning of the timeframe of the DFA this had just been further complicated by a decision to revise completely the statutory orders for science and mathematics almost as soon as they had come into operation: a task that fell on Mr Jacobs and his team under my oversight. Later unexpected work requirements falling on myself and my Division included a review of the English curriculum order and an overhaul of the GCSE examining arrangements. ⁶

9.147 He also identified in more detail some of the matters with which he was concerned between May 1991 and September 1992:

May 1991 to May 1992

By May 1991, although the first stage of consultation appeared to be complete the process had lost impetus. HMI had circulated extracts from the scientific press and were questioning the need to proceed. My Division was heavily engaged in priority curriculum tasks. Mr Jacobs' team was still engaged in the review of the mathematics and science orders. I had been given responsibility for the establishment of music in the National Curriculum, was trying to salvage an expensive curriculum materials development project on 'Language in the Curriculum', and was fighting a rearguard defence of the English curriculum order against critics inside and outside Government.

By about April 1992 it would seem . . . that we should have been in a position to issue the advice so long in gestation. However, delay itself had bred indecision and vacillation. HMI expressed doubts about the educational advantages and the political implications of issuing advice at that point in time. And in May Dr Ernaelsteen expressed the view that the issue of advice was no longer timely, and the advantages would be outweighed by the disadvantages.

June to September 1992

In my mind the exercise had taken a new direction, and the task was now to draft a submission to Ministers advising them against the issue of advice on the dissection of bovine eyeballs. However, the wording of a submission was obviously going to be tricky, and I found the draft put up by Miss Casbon unconvincing. I did not find the time to produce my own draft. I now had other problems. In June I took over responsibility for the conduct of GCSE examining, which raised questions for urgent resolution about compatibility with National Curriculum assessment. Then the publication of GCSE results in August was followed by a published report from HMI calling in question the integrity of examining standards, and Ministers demanded immediate action. ⁷

9.148 Mr Jacobs also displayed admirable candour when we raised the matter with him. He said of the period from May 1991 to February 1992 (when his responsibility for the matter ended):

I accept that, with the benefit of hindsight, I should have produced a revised submission for circulation sooner than I did. I cannot recall that there was any specific reason for not doing so other than my giving the matter a lower priority than my other work at the time. ⁸

9.149 He gave us this explanation of his thinking, and of the other priorities competing for his time:

. . . However, again, I cannot recall being chased by anyone within or outside DFEE about the matter until Mrs Whyte made contact in late October or November 1991. Indeed, I suspect the fact that I was not chased may have meant that as time passed the matter became less of a priority for me. I note that Mrs Whyte in her letter to me of 4th November 1991 states '. . . Kent CC's enquiry appears to have reminded everyone of the proposed advice . . .' I copied my reply to her quite widely within the department as well as to MAFF and Dept of Health, but again no one pressed me to circulate a revised submission or expressed concern that I had not already done so.

. . .

Health Risk

I should emphasise that I always understood that any advice to schools that they should cease bovine eyeball dissection was a precautionary measure. For example, I note that in the first draft of my letter to the CEOs I stated that

'I should emphasise that there is no evidence of BSE transmission to humans and there is no direct evidence that eyeball dissection will be a possible route of such transmission. It cannot be said, however, that there is absolutely no possibility of BSE transmission to humans. To the extent that such a possibility exists there is indirect evidence that injury during dissection could provide a means of transmission of the BSE agent . . . It is recommended that bovine eyeball dissection in schools should be discontinued until the evidence of the possibility of any risk is clearer.' ⁹

I continued to have this understanding of the health issues until I left the post in February 1992. This understanding was reaffirmed by comments such as those found in paragraph 11 of Dr Ernaelsteen's minute of 18th January 1991 where she refers to a 'sensible precaution . . . against a very remote and theoretical possibility', and J Creedy's minute of 19th April 1991, where he states 'I am no human geneticist, but is [sic] seems that a human encephalopathy needs highly unlikely transmission to occur to an individual with a very rare genetic make-up . . . If I am interpreting the facts correctly, two events - each with a one in millions likelihood, need to coincide - are we going over the top in our concern?'. Whilst I now understand that this analysis is probably scientifically incorrect, at the time it reinforced in my mind the ultra precautionary nature of the advice we proposed to issue. At no time did I consider this to be an issue on which human health would be at any real risk unless the advice was put out, nor did I ever get this impression from colleagues within the department, or from Dept of Health or MAFF. I am sure that if there had been any such understanding, or if the commitment made by Mr Gummer had been made clear, the matter would have been dealt with sooner.

Other Work Pressures

This post was my first job in the civil service and throughout the relevant period I was extremely busy. In particular I was heavily involved in what had been the entirely unexpected task of revising the national curriculum for mathematics and for science. This was known as ROMAS (in-house review of mathematics and science), and began at the start of 1991 and continued until the end of that year. Proposals were published in March 1991, with statutory instruments being published in December 1991. The task was the absolute priority for my team and a great deal of the burden of the work fell on myself. During this time I consistently worked at least 50-hour weeks and I travelled to the National Curriculum Council in York about once every two weeks. There was also a great deal of evening and weekend working. I would like the Committee to appreciate the competing demands on me during my time in this post. ¹⁰

Summary

In summary, and with the benefit of hindsight, I accept there were occasions when I did not deal with the question of advice on dissection of bovine eyeballs as expeditiously as I might have. I recognised in February 1992 that it would have been preferable if I had produced a submission sooner, and I accept that I share with Mr Baker some part, but not a major part, of the responsibility for the delay. I can provide no explanation for these delays other than the fact that, in all the circumstances, I gave priority to other work. However, at no time was this matter presented to me as a priority or as something about which the department, the Dept of Health or MAFF, felt strongly. Further, at no stage did I consider that the issue of any advice was anything other than an extremely precautionary measure.

9.150 We have considerable sympathy with the heavy workload that Mr Baker and Mr Jacobs were faced with, and we can well understand that this may have led to a lower priority being assigned to guidance on bovine eyeball dissection than would otherwise have been the case. We also bear in mind the views expressed by others as to the urgency of the matter.

9.151 None the less, we must record that, as they have acknowledged, both Mr Baker and Mr Jacobs should have taken steps to avoid the delay that occurred from May 1991 onwards. There does not seem to us to have been any adequate reason why the guidance was not issued at that stage, and why it was delayed until early in 1992. This does seem to have been an occasion on which the consultation process was allowed to lose momentum, where action to implement the advice of SEAC was called for. Mr Baker, who assumed responsibility for the issue in July 1990, bears a major share of the responsibility for that delay, as he frankly acknowledged. Mr Jacobs, who had day-to-day responsibility for the issue, but reported to Mr Baker, shares with him some part, but not a major part, of the responsibility for the delay until his departure in February 1992.

Dr Ernaelsteen's involvement

9.152 We record first our commendation of Dr Ernaelsteen's involvement in this story from the earliest stages, when she raised the question of bovine eyeball dissection on her own initiative, through to early 1992. We have noted the occasions on which she chased her colleagues in DES to see that progress was made, and her consistent advice until early 1992, in accordance with SEAC's view, that guidance should be issued to schools.

9.153 Dr Ernaelsteen explained to us the reasons why it took her some weeks to reply to Ms Casbon's urgent request ¹¹ of 1 April:

I was attending a DFE/DH Communication-Aids Day Conference on Monday 1^st April 1992 and having personally invited the principal Speaker, was therefore acting as Departmental 'host'. As a result I was unable to deal with the letter immediately. I was also committed to a 5-day long Annual British Paediatric Association conference from 2^nd to 7^th April in York representing the Department. Immediately following this I was booked to go on annual leave abroad. I therefore asked my secretary Ms Hutchens to send an e-mail stating that I would be away until the end of April, to apologise for this delay and to state that I would deal the matter on my return.

Following my return from annual leave on 30^th April 1992, I was faced with an enormous backlog of urgent queries and casework from and in both departments. My personal diary also records that I attended a minimum of 14 scheduled meetings between then and 15^th May. ¹²

9.154 We think it reasonable that Dr Ernaelsteen dealt with the matter as she did. We note that she ensured that Ms Casbon was told of the position on 1 April, giving her the opportunity to contact Dr Ernaelsteen if her suggested timetable was unacceptable.

9.155 However, we were concerned about the content of Dr Ernaelsteen's reply, when it came on 21 May 1992. ¹³ Dr Ernaelsteen explained to us the background to the drafting of this minute. She told us that she remained of the view that guidance should be issued, and that she envisaged merely that it would be postponed by a few weeks:

I had had discussions with Miss Casbon in some depth earlier that day. I had also spoken with officials from HMI, and in particular HMI Mr Creedy, about his major anxieties of causing a public health panic and a major row with the farming lobby. I had genuine reservations about issuing the advice on stopping bovine eyeball dissections at that point in time. I was concerned that in light of the delay which had taken place between SEAC's recommendation and the present time and there being, on the face of it, no ostensible reason for issuing the advice at that particular time, that the public would assume (wrongly) that this was prompted by the emergence of some new scientific evidence which it was not being told about. I was not informed of the reasons for that delay, and it was not my responsibility to issue the guidance - I had simply assisted Schools Branch 3 by advising from a medical viewpoint on the drafting and clarification of the guidance. I had expected that the Branch would take the matter forward as it thought appropriate.

Nevertheless, I believed that it was necessary to issue the advice but simply not at that particular moment. I advised that the Department should stand ready with the agreed draft, able to issue it at short notice should new evidence emerge, questions be asked or anxiety over the issue be demonstrated. I did not envisage an indefinite postponement of the issue of the guidance - rather, that it should be issued when DFE colleagues considered that the time was right. This was a matter of considered judgement for DFE Ministers on the sensitive issue of timing, rather than a scientific issue. My minute raised no new additional medical facts. ¹⁴

9.156 Dr Ernaelsteen also referred us to her minute of 1 June 1992 to Ms Casbon, enclosing the British Medical Journal article. ¹⁵ She said that her reason for highlighting the two paragraphs:

. . . was to stress to Ms Casbon the fact that although extremely small, the risk of transmission to humans was nevertheless present, and therefore my advice was that it should not be a viable option (if it had ever been considered) not to issue the guidance at all. I had also had discussions with Miss Casbon about this. I envisaged that unless specific requests for information were made to the Department in the meantime, the guidance would be issued in some 4-6 weeks, and at a time when its release would not coincide with the screening of the BBC serialisation "Natural Lies", which was about transmission of BSE to humans. Having been asked about the timing of the guidance, my considered view was that to have issued the guidance at that particular time would have risked causing unnecessary and disproportionate public disquiet. My concern at all times during this period was to ensure that the timing of the issue of guidance was not ill-thought out; that it should not be issued in such a way or at such a time that public fears were needlessly aroused, either because the public suspected the DFE had kept information hidden or equally because it coincided with sensationalist media coverage on the subject of BSE which might be likely to provoke public hysteria. ¹⁶

9.157 It remains unclear to us whether Dr Ernaelsteen envisaged the indefinite postponement of the advice, or whether she envisaged that it would be postponed only for a matter of weeks. If it was the latter, then it does not seem to us that she made this clear in her minute of 21 May. In any event, having commendably stood her ground up to May 1992, we consider it regrettable that, in the absence of any new medical facts, Dr Ernaelsteen countenanced any further delay in issuing advice on stopping the practice of bovine eyeball dissection. We do not consider it likely, as was suggested on her behalf, that this delay would have occurred in any event. Her minute was written in response to a request for her 'medical assessment of the weight' that should be given to the points identified by Mr Creedy and it was highly likely that reliance would be placed on her views. It seems to us that, whatever her intention, Dr Ernaelsteen's advice led to a further delay of some three or four months in the issue of guidance to schools.

General comments

9.158 At the beginning of this chapter we said we would return to some general points that emerged from the way the issue of advice on bovine eyeball dissection was handled. As we have discussed above, there were human failings and confusion of professional advice with judgements about handling particular to this case. However, we were also interested in how this story was a case study of some common defects in the way the threat of BSE was addressed by Departments. This seemed to us to hold lessons for the future. We comment in the following paragraphs on:

1. The perception gap about risk
2. Handling the unusual
3. Absence of a frame of reference
4. Putting the best face on omissions.

The perception gap about risk

9.159 Although Dr Ernaelsteen attached importance to implementing the SEAC recommendation, and demonstrated this by her efforts to get guidance issued, that urgency was not perceived by her DES colleagues. Once again the reassuring language used to avoid arousing public alarm sedated the watchdogs, in this case those responsible for ensuring schoolchildren and teachers were not exposed to risk through their work.

9.160 It was not surprising that various officials at the time, each with their own departmental priorities and preoccupations, had concerns about not 'going over the top' or being 'over-zealous' on what they saw as ultra-precautionary measures on a remote theoretical risk. They were far from the front line on BSE. Having sought advice from SEAC and informed DES of this advice, Dr Pickles left it to them to discuss whether there was a need for general advice within England. Nobody was knocking on their Minister's door about it. The Southwood Working Party Report and Tyrrell Committees were unfamiliar oracles far distant from national education policy. Mr Gummer's decree about the handling of SEAC recommendations was unknown to them. Enthusiasm for action languished, and as time passed it became even more unappealing in the absence of any apparent real risk.

9.161 It was plainly a rude shock when Mr Murray's incensed letter of 14 October 1992 tore the veils from their eyes. They were now being called on to justify to the Chief Medical Officer (CMO) and Ministers why they had apparently substituted their own judgement about risk for that of the 'experts'. As Mr Lowson aptly commented to MAFF Ministers in November, they had apparently simply not realised 'the sensitivity of the issue or the status of the Tyrrell Committee'.

9.162 We have some sympathy with the DES in finding itself so ill-informed. We believe that the way the Southwood findings were generally interpreted as having dealt with all the matters needing attention was an initial cause, and that the pains that MAFF and DH took to gloss matters reassuringly - that Ministers were taking further steps on a purely precautionary basis - maintained and fostered that impression. In successive drafts of the submission and guidance DES officials sought to 'strengthen' the assurances, and the advice on timing became open-ended. There was a failure in risk communication.

Handling the unusual

9.163 Although Schools Branch 3 shouldered the task of dealing with the guidance issue without demur, this was undoubtedly on the outer fringes of their field of responsibility. In 1992, when they queried whether the topic might better have rested elsewhere, they were assured that their past role in issuing advice on the giant African land snail was a precedent. We felt that this indicated the topic constituted an exceptional task, an attitude which was confirmed by the descriptions given to us by witnesses of the very different nature of the work on which they were heavily engaged. That was indeed a far cry from health and safety guidance on the dissection of bovine eyeballs.

9.164 The natural relationship of the guidance was with occupational risk advice generally. Indeed, Dr Ernaelsteen drew attention to this 'tension' in a minute to Dr Pickles in February 1990 stating: 'If one points to particular dangers in school, then housewives, butchers, abattoir workers are at equal theoretical risk'. However, it appears that there was no contact with the HSE until spring 1992, when Ms Casbon informed them that she had taken over the topic of bovine eyeball dissection from Mr Jacobs.

9.165 Given the somewhat relaxed performance of the HSE in issuing consistent advice on handling BSE risk tissues to all occupational groups (described earlier in Chapter 8 of this volume), it is doubtful how much faster an association between the DES and HSE initiatives might have moved matters along. However, it seems to us that the idiosyncratic nature of the topic within Schools Branch 3 meant that there was no established procedure within the Branch for dealing with it, and that this did not foster progress.

9.166 This was unfortunate because it was not a straightforward matter to agree policy advice between the different tribes of the DES: the Inspectorate, the different policy branches and the medical and safety experts. A clear and firm lead by those with 'ownership' might have produced a speedier outcome. That happened only after the topic blew up in 1992.

Absence of a frame of reference

9.167 Even in the absence of a more direct HSE role in addressing occupational risk generally, the repeated stranding of the draft guidance might still have been avoided had MAFF and DH been systematically mapping and monitoring action on all potential channels of transmission. We discuss in vol. 7: Medicines and Cosmetics the consequences of the failure to carry out an audit of the uses of bovine tissues at the outset, and how such an audit might have helped avoid matters being overlooked or excessively delayed.

9.168 Had this been done, we believe DES, along with other Departments, would have had a clearer picture of what was expected of them, and how it fitted into a comprehensive and sustained approach. Moreover, systematic accountability for action remitted to them might have averted delays and misunderstandings of the true position. It might also have stimulated better liaison between DES and HSE on their shared interest in BSE risks for those in education. These risks were considered by the Education NIG of the HSE in 1988 in relation to higher education establishments but no action was taken. Concerns about bovine eyeballs arose in the HSE in 1995 and they issued advice in 1996 to researchers handling these. They appear to have been unaware of the consideration being given by DES to this in 1990-92 and the issue of guidance to schools.

Putting the best face on omissions

9.169 These delays and misunderstandings were fostered by DES evasiveness and temporising about what was happening. This is something we sometimes heard said about MAFF, but it certainly did not apply to them in the case of bovine eyeballs. Both they and DH favoured immediate issue of the guidance. By contrast, DES had changed their minds about this, partly because they were concerned that to issue advice at that stage would have been potentially awkward for Ministers. However, they delayed telling MAFF and DH of their change of heart. Nor were their concerns about possible criticism put to Ministers themselves to consider. Until DH found out about the change of heart, they were unable to correct any misapprehension on the part of DES as to their view, or to inform DES about Mr Gummer's commitment to act on SEAC's advice.

9.170 We think this illustrated how things can go wrong where people are under-informed, for what at the time may seem good reasons.