The Politics of BSE

The Politics of BSE

Richard Packer

The Politics of BSE

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The Politics of BSE

Richard Packer Permanent Secretary at the Ministry of Agriculture, Fisheries and Food (MAFF), 1993–2000

© Richard Packer 2006 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2006 by PALGRAVE MACMILLAN Houndmills, Basingstoke, Hampshire RG21 6XS and 175 Fifth Avenue, New York, N.Y. 10010 Companies and representatives throughout the world. PALGRAVE MACMILLAN is the global academic imprint of the Palgrave Macmillan division of St. Martin’s Press, LLC and of Palgrave Macmillan Ltd. Macmillan® is a registered trademark in the United States, United Kingdom and other countries. Palgrave is a registered trademark in the European Union and other countries. ISBN-13: 978–1–4039–8529–3 ISBN-10: 1–4039–8529–4 This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. A catalogue record for this book is available from the British Library. A catalog record for this book is available from the Library of Congress. 10 9 8 7 6 5 4 3 2 1 15 14 13 12 11 10 09 08 07 06 Printed and bound in Great Britain by Antony Rowe Ltd, Chippenham and Eastbourne

Contents List of Figures and Tables

viii

List of Abbreviations

ix

Chronology

xi

Introduction

1

1 The Cattle and Ancillary Industries Agriculture in Britain The animal feed sector Slaughterhouses The rendering industry Head-boning plants Mechanically recovered meat (MRM) Knackers and hunt kennels Gelatine Other industries Consumers

7 7 8 9 10 10 11 11 12 12 12

2 Science and Research Introduction Advances up to 1986 The current theory

14 14 14 20

3 Slaughterhouses Public attitudes The state of the UK slaughterhouse sector in the 1980s/early 1990s The decision to establish a national meat hygiene service The putting in place of the MHS Assessing the reasons for support for and opposition to the MHS

23 23 23 27 28 30

4 A Chronicle of Events until 20 March 1996 The period up to early 1988 1988: first policy responses 1988 onwards: independent scientific advice to government; the Southwood Committee, the Tyrrell Committee and SEAC 1989: the decision to impose the human SBO ban Late 1989 to early 1990: pressure for an animal SBO ban Other developments in 1990 Late 1990: new evidence leads to an animal SBO ban Taking stock: the protective measures in place from Autumn 1990

33 33 36

v

41 50 55 58 64 66

vi

Contents

A relatively quiet period: late 1990 to 1994 1994: a reassessment of the success of the animal health controls From 1 April 1995: the establishment of the meat hygiene service transforms the situation SEAC concludes that cases of CJD in young people reflect exposure to BSE

66 77 80 90

5 The Establishment and Conduct of the BSE Inquiry The establishment of the Inquiry The conduct of the Inquiry

99 99 102

6 The Findings of the BSE Inquiry Section I: the origin of the disease and the science Section II: Southwood Committee Section III: the overall government response Section IV: the actions of commercial enterprises Section V: the detailed government response Section VI: communication of risk Section VII: ‘contingency planning’ Summary of the main findings of the BSE Inquiry

108 108 111 113 114 114 123 125 126

7 Consideration of the Inquiry’s Findings The status and standing of the Report Section I: the origin and science of the disease Section II: the Southwood Committee Section III: the overall government response Section IV: the actions of commercial enterprises Section V: the detailed government response Section VI: communication of risk Section VII: ‘contingency planning’ Further comments

129 129 130 131 133 134 135 143 146 153

8 Events after 20 March 1996: (A) The Period of Conservative Government until 1 May 1997 The first two weeks after the announcement From Easter (5–8 April) until the Florence Agreement (21 June 1996) From Florence (21 June 1996) to the End of the Conservative Administration (1 May 1997) 9 Events after 20 March 1996: (B) The Labour Government from 1 May 1997 Onwards The period up to the election After the election Taking stock Setbacks for the prospects for UK beef exports A proposal for a revised certified herd scheme resubmitted: consideration is given to an additional export scheme

158 158 172 187 208 208 208 211 211 212

Contents vii

Cattle-traceability: choosing a location for the headquarters of the British Cattle Movement Service (BCMS) Progress on lifting the ban Beef on the bone The BSE Inquiry The date-based scheme: Blair’s frustration boils over The cattle movement service is launched Worries about the possible transmission of vCJD via blood transfusions EU rules to protect the public from BSE: BSE outside the UK The press, the government machine and the strange interest of Mr Anthony Bevins 10 Conclusions Conclusions as regards BSE Conclusions as regards politics Long-term effects of the BSE crisis and lessons to be learned Index

212 217 218 221 222 227 227 229 232 245 245 246 247 251

List of Figures and Tables Figures 4.1 BSE cases in Great Britain confirmed by passive surveillance, by month and year of clinical onset 4.2 Confirmed cases of BSE in Great Britain with known dates of birth, by month of birth 9.1 BSE cases in Great Britain confirmed by active surveillance, by month and year of slaughter

68 69 233

Tables 9.1 BSE: selected international statistics

viii

232

List of Abbreviations BABs

Born after the ban. Cattle succumbing to BSE after it became illegal to include ruminant protein in ruminant feed. BCMS See CMS. BSE Bovine Spongiform Encephalopathy. A TSE in cattle. CAP Common Agricultural Policy of the European Union. CHS Certified Herd Scheme. Permitted exports. CJD Creutzfeld–Jacob Disease. A neurological disease of man discussed in Chapter 2. CJDSU CJD Surveillance Unit, located in Edinburgh. CMO Chief Medical Officer for England. There are separate CMOs for each of Northern Ireland, Scotland and Wales. CMS (British) Cattle Movement Service. CVL Central Veterinary Laboratory, the main veterinary laboratory within MAFF located in Weybridge, Surrey. CVO Chief Veterinary Officer, the most senior vet within the State Veterinary Service. The CVO is a MAFF official. DBS Date Based Scheme. Another scheme permitting UK exports of beef. DoH Department of Health. EHO Environmental Health Officer, an enforcement officer employed by local authorities. ELISA A chemical test for the presence of specified substances, for example animal protein or even bovine protein. Can be very sensitive. EU European Union. FCO Foreign and Commonwealth Office. IEHO Institute of EHOs. LA Local Authority. MAFF Ministry of Agriculture, Fisheries and Food. MBM Meat and Bonemeal. A protein residue which with tallow is derived from processing animal carcasses normally after the meat has been removed. MHS Meat Hygiene Service. Body established on 1 April 1995 for enforcing rules in slaughterhouses, originally part of MAFF. MLC Meat and Livestock Commission, a quango for advancing the interests of the meat industry. MRM Mechanically Recovered Meat. Meat recovered from the bones left following normal butchery in slaughterhouses. NFU National Farmers’ Union of England and Wales. There are separate unions for Scottish and Northern Irish farmers and a Welsh union which caters mainly for small, Welsh-speaking farmers. NPU Neuropathogenesis Unit. A government research institute outside MAFF located in Edinburgh. ix

x List of Abbreviations

SBO

Specified Bovine Offal. Parts of bovines which it is believed can harbour BSE infectivity and which from 1989 have been removed from carcasses and kept from human consumption. Later SBO became SBM (‘Material’ instead of ‘Offal’). This book uses SBO throughout. ScVC The European Commission’s Scientific Veterinary Committee, an expert advisory committee. SE A spongiform encephalopathy not (yet) proved to be transmissible as in TSE. SEAC Spongiform Encephalopathy Advisory Committee. The government’s independent scientific advisory committee on BSE, members of which were appointed jointly by the Minister of Agriculture and Secretary of State for Health. Earlier versions of SEAC were known as the Southwood and Tyrrell committees after the name of the chairmen. SVC Standing Veterinary Committee. A committee of officials from member states which meets under a chairman from the European Commission and decides on many technical veterinary matters. It was the SVC which decided on the export ban on UK beef in 1996. SVS State Veterinary Service. The group of vets in MAFF under the CVO. TSE Transmissable Spongiform Encephalopathy. A group of diseases including BSE in cattle and CJD in man discussed in Chapter 2. UKASTA United Kingdom Agricultural Supply Trade Association, a trade association for animal feed manufacturers. vCJD A type of CJD in young people apparently caused by exposure to BSE. VIS Veterinary Investigation Service. A part of MAFF consisting of a number of veterinary laboratories covering the whole country, though over time their number has been reduced. One of their tasks is to check dead animals for disease.

Chronology 1986 November 1987 11 July December 1988 21 April 18 July 8 August 1989 27 February 13 June 1990 3 April 10 May 16 May 8 June 24 September

A spongiform encephalopathy in a bovine, BSE, first identified by examination of an infected brain at CVL. Information on new disease first published in the Veterinary Record. MAFF epidemiologist concluded that MBM derived from ruminants was implicated in the spread of BSE. Government established an independent scientific advisory committee chaired by Sir Richard Southwood. Order prohibiting the use of ruminant protein in ruminant feed, the ‘feed ban’, came into force. Slaughter/compensation scheme for animals showing clinical symptoms came into force. Southwood Report published: Tyrrell heads successor. Human SBO ban announced which came into force on 13 November. SEAC established following on from Tyrrell. Discovery of SE in a cat. John Gummer fed daughter, Cordelia, a beefburger. Council of Agriculture Ministers agreed rules for export of UK cattle and beef to rest of EU. Announced that laboratory transmission of BSE to a pig had been achieved. Animal SBO ban brought in straight away. Prohibited use of SBO in any animal feed.

1991 27 March 1992 4 March 9 March 1993 14 July

First BAB announced. Announced that BSE had been transmitted to marmosets. John Gummer announced the intention to create a national Meat Hygiene Service. 100,000th case of BSE. xi

xii Chronology

1994 2 November

Human SBO ban extended following experimental results.

1995 1 April

SBO required to be stained with a distinctive dye.

15 August 15 December 1996 20 March

27 March 3 April 21 May 11 June 21 June 16 December 1997 31 July

MHS takes over slaughterhouse enforcement from local authorities. Extensive extra controls on SBO including requiring dedicated lines for rendering SBO. Manufacture of MRM from bovine spinal column banned. Government announced that SEAC had concluded that the occurrence of CJD in young people was probably due to exposure to BSE before the 1989 SBO ban. EU export ban introduced. 30-months scheme announced. John Major announced policy of non-cooperation in the EU in response to export ban. Export ban lifted for gelatine, tallow and semen. Framework for lifting export ban agreed at Florence European Council. Non-cooperation ceased. Backlog of animals under 30-months scheme cleared.

16 December 22 December

Announced that a GB cattle tracing organization would be established at Workington. SEAC first recommended all UK blood for use in transfusions be leucodepleted. Beef on the bone banned. Announcement of BSE Inquiry under Lord Phillips.

1998 16 March 28 September

Limited exports from Northern Ireland restarted. Cattle-tracing system launched.

24 October

1999 1 August

16 December 17 December

Scheme (Date-Based Export Scheme) allowing some exports of UK beef came into effect. Leucodepletion of UK blood for use in transfusions made obligatory. BSE Inquiry concludes oral hearings. Beef on the bone ban lifted.

2000 26 October

Report of BSE Inquiry published.

2004 16 March

Recipients of blood transfusions banned from giving blood.

1 November

Introduction

BSE (Bovine Spongiform Encephalopathy or Mad Cow Disease) is still with us in that animals regularly succumb to the disease, though in much smaller numbers than was the case a few years ago. Sadly young people are still dying of the human form of the disease, variant Creutzfeld–Jacob Disease (vCJD) believed to result from past exposure to BSE in food or in some other way, though the numbers appear to be declining. Occasionally an outbreak in some country where the disease was previously unknown, such as that in the USA in 2004/05, makes the newspapers, normally because trading partners have immediately banned imports of cattle and beef from that country. New scientific advances on the nature of BSE and its sister diseases regularly appear in the scientific press and occasionally make the general media. However, the public interest and alarm that this excites now is a very pale shadow of what happened a decade ago. Then government policy on BSE was discussed – and often denounced – with real passion. BSE came to public notice towards the end of the 1980s and gained increasing salience throughout the first half of the 1990s. Throughout this period every new twist in the story produced an explosion of media interest with each peak in the cycle higher than the last. Virtually without exception comment was negative and highly critical of all concerned, especially the public authorities. This process reached its crescendo in March 1996 when it was announced that the government’s independent scientific advisers had concluded that cases of a new form of CJD in young people probably resulted from exposure to BSE years earlier. BSE remained a major issue for some time thereafter not least because it became mixed up with the UK’s difficult relationship with the European Union (EU) via the EU beef ban and the UK’s retaliatory non-cooperation policy. Nevertheless interest slowly diminished with the last major peak of interest occurring in autumn 2000 when the official BSE Inquiry published its findings. Throughout the crisis the media coverage was unrelentingly critical. It became almost universally accepted that the crisis stemmed from serious policy failures and that government secrecy, cover-ups and mendacity were the main causes and culprits of the whole wretched saga. In case memories have faded and it might be thought I am exaggerating, let us consider an article by the respected journalist Andrew Rawnsley published in the 1

2

The Politics of BSE

Observer on 22 November 1998. His first paragraph consisted of 24 words. Among them were ‘secretive civil service’, ‘mendacious politicians’, ‘greedy farmers’, ‘complacency’, ‘incompetence’, ‘buck-passing’ and ‘cover-ups’. He went on to refer to ‘more than twenty former Ministers associated with the gravest failure of public administration in post-war history’. He implied ‘deregulation’ was to blame in part. ‘The BSE scandal is Suez, the poll tax and thalidomide rolled into one.’ ‘We might hope for condign punishment of the guilty men.’ He claimed Tory Ministers had misled Parliament about past risks. He concluded by asserting that Nick Brown the then Minister of Agriculture had been captured by his Permanent Secretary (me) who had (inevitably) poisoned his mind against the proposed Food Standards Agency. At the time Rawnsley’s observations were not dissimilar in tone to those of other commentators. However, the claims he and others made were very serious ones and we will examine them carefully against the evidence. Some aspects of the popular explanations for the perceived failures of policy on BSE became so embodied in public thought that they even infected government itself. In December 1999 the Home Office circulated to other government departments including the Ministry of Agriculture, Fisheries and Food (MAFF) draft speaking notes for the second reading in the House of Commons of the Freedom of Information Bill, one of the Labour government’s manifesto pledges. On the first page the draft stated: Madam Speaker, there are just three letters which spell out more starkly than anything else what can happen when the default setting is for secrecy not openness… Those three letters are BSE. BSE – three letters which serve as a constant reminder of how the previous government’s… approach to a looming problem was to get their heads down, and try to keep Parliament and the public in the dark. This was at the time a fairly standard criticism of the Conservative government’s handling of BSE and would probably have seemed unremarkable to most people. The difficulty was that it was already known to be untrue to anyone who had followed the deliberations of the BSE Inquiry which had finished hearing evidence the previous month. It was apparent from the trend of their hearings (all held in public) that apart from one incident in 1987 secrecy was not an issue. Confident claims that BSE had been bedevilled by excessive official secrecy had been made to the Inquiry at an earlier stage but no evidence had been produced to support them apart from the minor case mentioned. This incident was instructive. Over a period of years it had become firmly established in the public mind that policy on BSE had been defective in a number of fundamental ways, for example by the existence of ‘a culture of secrecy’ to the extent that a major department of state assumed it was true even though they knew nothing about the matter. In the event, MAFF commented on the draft speaking notes to the effect that the references to BSE were misguided for the reasons given above and they were

Introduction 3

deleted. This was fortunate for the Home Office which would otherwise have justified to Parliament their flagship policy by a claim which opponents could later have pointed out had been refuted by an enquiry (the BSE Inquiry) they had themselves instituted. But if one popular perception accepted by virtually all, even parts of government, was in fact wrong, what about the others? This is one of the questions which it is the purpose of this book to answer. It will be shown that many other popular perceptions are equally wrong, but that, nevertheless, mistakes were made and we will analyse their malign effects in due course. In brief, BSE was undoubtedly a national trauma but public perceptions of many aspects of the saga are well wide of the mark. This book sets out the facts distinguishing them from the fantasies which, as we have already seen, are especially prevalent in the area. It is the first book to cover all the ground, covering both the politics and the science.

Book layout and structure I have tried to structure this book to be as helpful as possible to readers who are not necessarily expert in agriculture, in science or indeed in politics. Chapters 1 to 3 give relevant background in these three areas, while throughout I have treated matters with the minimum degree of detail needed properly to understand what went on. Until 20 March 1996 scientific opinion, with scarcely a qualified dissentient, was that BSE was unlikely to have implications for human health. On that day it was announced that the UK government’s independent scientific advisers had concluded that cases of a new form of CJD in young people were probably the result of their exposure to BSE some years previously. Thus before 20 March 1996 policy-makers were operating in a world where BSE was believed not to pose a threat to human health, while from 20 March the opposite was true. Obviously policy-making was very different before and after 20 March. Moreover, the BSE Inquiry, which we will need to examine in some detail, was concerned with the period up to 20 March 1996 only. It is, therefore, a natural cut-off date. Accordingly, in the following text I first trace events from the first known cases of BSE in the mid-1980s up until 20 March 1996 and then consider the establishment, procedures and conclusions of the Inquiry (including any defects in any of those). I then discuss developments after 20 March first under the Conservatives and then under Labour. In general I have let the facts speak for themselves and I hope that in the main they do so. However, on occasion, particularly where I believe the BSE Inquiry has misread the evidence, I have explained at rather more length why I take a different view since readers are likely to be especially careful in considering claims of that kind. It would not be right to set out conclusions before the evidence on which they are based, though as I have already made clear one theme of this book is that a number of common beliefs about the handling of the BSE epidemic are simply wrong. I come to them in due course. I would add one point, however, at this stage.

4

The Politics of BSE

It is naïve1 to expect that the ‘real’ truth about political crises is that they result from major, intentional wrongdoing by those in public office or those working for them.2 While such cases arise they do so only very rarely and, to put my cards on the table, did not occur in the case of BSE. However, that is precisely what has often been alleged about BSE; a careful reading of the literature will find frequent references to ‘lies’, ‘cover-ups’ and the like. The real questions are likely to be more subtle and nuanced. For BSE they include such points as whether policy decisions were sound in the light of what was known at the time and whether those concerned were appropriately frank about the risks to the public. These are real issues the answers to which can lead to significant praise and criticism. However, if we judge that someone made a mistake after an investigation of this type we are not automatically claiming he or she was a villain of darkest dye. We do not need to frighten ourselves with goblins.

Conventions employed What is now the European Union (EU) was previously known successively as the European Economic Community (EEC) and the European Community (EC). For convenience I use the term EU throughout even where, strictly, this is anachronistic. The enquiry headed by Lord Phillips (as he became subsequently) described itself as ‘The BSE Inquiry’. Except where the context clearly shows otherwise, references to the ‘Inquiry’ are to this body. When referring to other investigations I refer to ‘enquiries’. I treat the Inquiry as a collective requiring a plural verb. I refer to qualified veterinary surgeons by the colloquial but brief designation ‘vets’.

Sources Much the best source for all matters until 20 March 1996 is the Report of the BSE Inquiry,3 in the shape of both its voluminous Report and the evidence submitted to it and preserved on the internet.4 After that date there is no source of comparable authority. One needs to rely on Hansard, newspapers, departmental notices and the like. I was conscious from 20 March 1996 that I was living through momentous times and took notes, sometimes detailed ones. I have a copy of my engagement diary for the period 1995–2000.

Personal involvement I was Permanent Secretary at MAFF from 1993 to 2000, and it may help to say a few words about the position of Permanent Secretary. He or she is normally the official head of the department in question5 obviously under the Minister. He or she6 is responsible for managing the department and some incumbents devote almost all of their energies to this task. However, he also has two other principal functions which will concern us. First he is the most senior adviser on policy and

Introduction 5

second he has personal responsibility in relation to the expenditure of public funds. He fulfils these latter responsibilities as the Accounting Officer. In this capacity he must ensure that value for money is obtained for all expenditure and that all the department’s financial actions and expenditure meets the highest standards of propriety. On these financial responsibilities the Permanent Secretary/Accounting Officer is responsible not only to his own Minister but also to the Treasury and to Parliament7 via the powerful Public Accounts Committee (PAC), always chaired by a senior member of the Opposition. Permanent Secretaries are regularly grilled by this committee on any and all aspects of departmental expenditure and if they are wise they make enormous efforts to prepare themselves for the occasion, since their performance will impinge on their reputation. There is a special though rarely used mechanism which Accounting Officers can and must use if they believe that financial proposals are unsatisfactory in terms of propriety and/or value for money. They can object and formally seek a direction from the Minister – that is a written order – to proceed with the matter in question. Without such a direction the Accounting officer can instruct officials not to proceed. The Accounting officer’s request for a direction and the Minister’s reply must be copied to the Treasury and the National Audit Office which reports to Parliament and is thus close to the PAC. There is clearly a potential tension here. The Permanent Secretary works for the Minister yet he can, indeed has the specific responsibility to, thwart the latter’s wishes in potentially embarrassing circumstances if he judges they do not meet certain standards. As we shall see this can lead to problems. As Permanent Secretary I participated in many of the more important discussions and incidents which occurred when BSE was a major issue. When I took up post I quickly found that to act effectively on BSE I needed to examine who had done what previously (that is before 1993) and why. Also, since Ministers were officially debarred from taking any role in the BSE Inquiry’s processes, I had to authorize departmental submissions to it in 1998 and 1999 covering the period before as well as after 1993. I therefore gained a solid grounding in the history of the disease back to its beginning in the mid-1980s. It also helps that my university degrees are in a scientific subject (chemistry). I believe that the history of BSE is fascinating and in some ways instructive even if – indeed because – the facts are different from popular perceptions. I also believe, perhaps immodestly, that I am in as good a position as anyone to write an account which needs to cover events, the political dimension and the science. Readers will judge for themselves whether this represents self-knowledge or self-delusion. The word ‘politics’ covers a host of matters from major issues of elevated principle to minor matters of interest to a few individuals only. This is because politics is a reflection of human nature, which while sometimes aspiring to the heavens is often concerned mainly with self. Accordingly, sometimes this book moves suddenly between the large and lofty and the small and rather grubby. I make no apology; it would not be an accurate account without both dimensions.

6

The Politics of BSE

Notes 1 In present UK circumstances. Elsewhere in time and space matters may be/have been different. 2 I acknowledge that, as I revise these pages in 2005, some might consider that the current High Court case involving Railtrack perhaps refutes this claim. However, whatever the merits of that case the proposition as put remains true. 3 Report, evidence and supporting pages of the Inquiry into the emergence and identification of Bovine Spongiform Encephalopathy (BSE) and variant Creutzfeld–Jacob Disease (CJD) and the action taken in response to it up to 20 March 1996. Stationery Office 2000. 4 At www.bseinquiry.gov.uk 5 Some larger departments have more than one Permanent Secretary, but if so one will be designated as the most senior. 6 I use ‘he’ subsequently to save repetition. 7 Departmental expenditure is authorized by specific Parliamentary votes.

1 The Cattle and Ancillary Industries

It will help in considering the emergence of BSE and the response of the government to the epidemic to have some concept of the industries concerned and how they are organized.

Agriculture in Britain Very broadly as we move eastwards across Britain average rainfall lessens and soil fertility increases. As one consequence the importance of arable farming (crops) also increases as we move eastwards. Thus the importance of cattle and sheep1 farming increases as we move the other way – westwards. Agriculture has been profoundly changed by the scientific revolutions of the last two hundred years, the pace of change seeming to get ever faster. However, not all sectors have been equally affected. Arable farming has been most affected, while dairy farming, too, has been very much altered by improved animal genetics, nutrition and milking techniques. The farming of beef cattle and sheep has been perhaps the least altered though even here observers from a century ago would be surprised by what they found. BSE is primarily a disease of cattle2 and in 1986 – when BSE was identified – the total UK cattle population was over 12 million spread over 120,000 farm holdings. Many thousands of people were economically involved in cattle (including dairy) farming and many more in the related ancillary industries. Cattle are big business. In 1986 the output of milk and cattle was valued at over £5 billion at 1990 prices and this figure does not include the large value added by a host of ancillary industries. All aspects of agriculture and trade are covered by the EU Treaties; hence it is primarily EU rules that apply in these areas and there is little scope for independent national action. In particular the production of and trade in milk and beef3 falls within the ambit of the common agricultural policy (CAP). The CAP is renowned for high prices and production subsidies;4 nevertheless, at times of crisis there are inevitably demands that support should be increased. Hence the politics of the CAP impinges on policy on BSE. 7

8

The Politics of BSE

Fortunately milk has never been implicated in the spread of BSE so I will therefore mention only the industries based on the processing of cattle carcasses and not those concerned with the processing of milk. In 1986 about two-thirds of beef output came from animals produced by the dairy sector, that is from dairy cows at the end of their working lives and from calves most of which were reared until 18/24 months of age. Beef also comes from specialist, ‘suckler’ herds.5 These animals are generally kept on less-productive land than dairy cattle though the resulting beef is of better quality. Farming is more than facts and statistics. Many producers are proud of inheriting their role from fathers, grandfathers and not infrequently more distant ancestors. Many are equally conscious that the impersonal forces of economics are likely to make them the last of their line in farming. ‘Family farms in peril’ is how the farming press tends to put it. Attitudes towards the amalgamation of holdings and increased farm size vary, but it would be fair to say many see these trends as regrettable. This factor has its political significance and is reflected in the pressures faced by policy-makers when disasters occur.

The animal feed sector Most feed consumed by most cattle is in the form of grass either eaten direct from the sward or preserved as hay or silage. To this day some cattle never consume anything other than grass and their mother’s milk. For about a century, however, many cattle have been fed in part on the output of the animal feed industry. In particular milk output can be increased by the feeding of ‘concentrates’.6 Dairy calves need special feed until they can consume grass, since their mothers’ milk is not available to them. Like other young mammals they need feed rich in protein. In recent decades the nutrition of cattle and other farm animals has become better understood. Clearly there is an equation which links the increase in output to be gained from feeding an animal with a particular feed and the cost of the feed. Nowadays computers are used to determine optimum economic choices. The largest component of cattle feed is usually cereals, but from the perspective of BSE the most significant was the frequent inclusion (until 1988) of meat and bonemeal (MBM), produced in part from cattle carcasses. MBM was included primarily as a source of protein. Probably one of the more widely known facts about BSE is that it was spread by cattle consuming feed containing MBM derived from cattle contaminated with BSE. Articles of the ‘how could they have allowed cannibalism’ sort have been common for years. The advent of BSE has indeed demonstrated the dangers of allowing cattle to consume bovine MBM. But before we assign blame we need to examine the circumstances which were helpfully researched in detail by the BSE Inquiry. They showed that: MBM was already used in ruminant feed in the UK in the 1920s; that the same practice was followed in the USA also in the 1920s and in Australia and New Zealand certainly by the 1930s: that in the UK during the Second World War MBM was specified as an obligatory component of animal feed: and that the use of MBM grew after the War, partly on the basis of official

The Cattle and Ancillary Industries 9

recommendation. In the UK by the late 1980s production may have amounted to 400,000 tonnes per annum of which 10 per cent may have been included in feed for ruminants. Thus for many decades before the arrival of BSE a large number of people in many countries7 – everyone concerned in fact – saw nothing untoward with feeding bovine MBM to cattle. There is no record of anyone protesting. The inescapable conclusion would seem to be that before BSE nobody saw anything wrong with feeding bovine MBM to cattle;8 and that later claims that it is obviously wrong in principle owe everything to hindsight. Those who claim otherwise are seeking scapegoats after the event. Any such scapegoats would have to include virtually all those working in the field of animal nutrition in every developed country stretching back over many decades.

Slaughterhouses All farmed animals, including those reared primarily for another purpose, such as the production of milk, eventually go for slaughter. With trivial exceptions all farmed animals such as cattle are required to be killed in licensed slaughterhouses.9 The deficiencies of the hygiene controls in UK slaughterhouses in the 1980s and early 1990s, the denial by some that those deficiencies existed, and the difficulty the government had in improving matters is an important part of the BSE story, sufficient to justify a chapter of its own (Chapter 3). Here I deal with other aspects of the sector. It is noteworthy that in some cultures10 those involved in animal slaughter are required to separate themselves from society at large. There are deep-seated human taboos about killing things. This has important consequences in that, one suspects, slaughterhouse workers are a more robust group than would be found by randomly sampling the population at large. In recent decades economic forces, notably the advantages of maximizing the utilization of equipment and of production lines – economies of scale in short – have brought about the concentration of the industry into fewer and larger enterprises. In 1971 there were 1,890 slaughterhouses in Great Britain; by 1986 the number was under 1,000, by 1995 it was under 500. It has continued to go down subsequently. Preparing cuts of meat from a slaughtered animal involves a large number of processes many of which are likely to make the average person feel somewhat uncomfortable. The Report of the BSE Inquiry contains an excellent list11 of 19 such processes including ‘stunning, pithing,12 shackling and hoisting, sticking,13 bleeding, removal of horns, feet and udders, removal of head, tonsils and tongue, pulling of tail and dropping of bung’14 and so on. For our purposes we only need to remember that slaughterhouse practices cover a wide range of activities, many of them messy. In the mid-1980s slaughterhouses processed about four million cattle annually which produced about one million tonnes of beef and the same amount of other material, that is bones, intestines and all the messy stuff produced by dead bodies.

10

The Politics of BSE

A million tonnes of such material cannot be dumped and in developed societies most of the material from slaughtered animals that does not go for human consumption is passed on to renderers.

The rendering industry Rendering is the process by which the material left over after the meat has been removed from carcasses,15 which would otherwise decay unpleasantly, is transformed into two relatively stable products – tallow, and meat and bonemeal (MBM). Until the advent of BSE both had value, so that slaughterhouses were paid by renderers for their waste material. Though processes vary slightly, essentially rendering involves crushing and heating. The heating drives off water and eventually the material separates into two fractions, one consisting mainly of protein from which MBM is produced, and the other consisting mainly of fat (tallow). Traditionally tallow was the more valuable product and was used for candles. It is still used for that purpose but now it can also be used in the manufacture of numerous other products including, notably, soap. The main uses of the protein fraction were in animal feed and fertilizer. Rendering has traditionally been a lightly regulated industry with commercial demand determining standards. In 1981, however, a government Order specified that ‘processed protein’ must be salmonella16 free, though how that was achieved was left open. Nevertheless, one of the explanations of the BSE crisis put forward after 1996 was that it resulted from ‘deregulation’ of the rendering industry. In fact there was not much regulation of rendering before BSE and its advent resulted in various extra requirements being imposed on the industry. At no stage was there any deregulation.

Head-boning plants There really is (or more accurately was) an industry going by this name. Its objective was to extract maximum value from bovine heads by removing as much as possible of the meat, which is found mainly in the cheeks and tongues. Removing meat from heads could not be fully mechanized and was done by operatives skilled in the process using circular electric knives. The specialist nature of the task led to its often being done apart from other slaughtering processes. In 1995 there were about 40 head-boning plants. BSE turned attention to head-boners since it was soon realized that brains were a main repository of infectivity. This led to successive tightenings of the controls on the industry until the coup de grace came in March 1996. Following scientific advice that cases of CJD in young people were linked to exposure to BSE, an Order was made requiring the whole head except the tongue to be treated as SBO. This prevented the recovery of meat from skulls. Thus the advent of BSE resulted in the disappearance of an industry while those concerned received no compensation. They were among the victims of the disease. It is also worth noting that what had previously been an economic resource – bovine heads

The Cattle and Ancillary Industries 11

(except tongues) – was after 1996 treated as a pollutant at considerable cost to producers and society at large.

Mechanically recovered meat (MRM) Maximizing the amount of meat recovered from a carcass has obvious economic advantages. In the 1960s automatic machines were developed which could accomplish this with greater efficiency than had been achieved previously. Typically the machines operate by subjecting bones to high pressure and forcing the resultant slurry (MRM) through a series of sieves. MRM resembles a puree and, unless treated, does not look like meat as normally understood by most people. In 1995 most MRM was made from chicken, but about 5 per cent was made from bovine material. The vertebral column and ribs were the main source of bovine MRM. It was relevant, therefore, that the spinal cord was known to be a source of infectivity. The unfortunate events which resulted in the production of bovine MRM from vertebral columns not being banned until 1995 is set out in Chapter 4. The whole concept of MRM has been attacked in recent years as being abhorrent in some way. Television programmes have shown close ups of puree emerging from the manufacturing process in the clear expectation that viewers will find it distasteful. Is there something inherently unacceptable about the product? Some manufacturers took a critical view of MRM well before 1995 and claim never to have used it. They were concerned at the virtual impossibility of tracing the origin of the animals processed which would be useful if there were an outbreak of disease. These individuals were prescient, though this does not mean that others following the rules are to be blamed. We are constantly exhorted to protect the environment and the earth’s resources by recycling and avoiding waste. The production of MRM (and indeed the inclusion of MBM in cattle feed) could be said to have achieved both. Perhaps the correct conclusion is not that MRM was an inherently unacceptable product, but that all practices should be constantly kept under review and that we should be prepared to alter the rules quickly in the light of new evidence.

Knackers and hunt kennels The production of meat is a messy business and the gory ramifications do not stop with MRM. In the UK there have long been enterprises that cope with those animals that cannot be slaughtered in licensed premises either because they have already died on farm or are ill or injured and need to be slaughtered directly and/or would not be accepted for human consumption. In the UK such animals are traditionally processed by knackers and hunt kennels. In the early 1990s there were just over 100 knackers and rather fewer than 300 hunt kennels. By definition, meat from knackers does not go for human consumption. The plants’ importance in the context of BSE lies in the possibility that they might have acted as sources of infection for animals. Theoretically they could have done so either by the direct sale of meat as petfood or via the waste eventually sent by

12

The Politics of BSE

knackers to renderers, which could have found its way into cattle feed if not correctly handled. Meat from carcasses sent to hunt kennels is fed to the hounds. After November 1990 any SBO ought not to have been fed to the hounds (or any other animal). MAFF investigations showed as late as 1995 that this provision was not always complied with, but fortunately BSE has not yet been found to cause illness in dogs. Historically knackers, the more important of the two types of enterprise, undoubtedly fulfilled a useful function, but by 1986 most were struggling.

Gelatine One wonders even now how many people realize gelatine is made from pig and cattle carcasses. Specifically it is made from the hides and bones of pigs and cattle which are treated with either acid or alkali and the resulting extract heated. The treatment is thought to be sufficiently rigorous to deactivate the BSE agent. The product is very widely used in foods, in the manufacture of pharmaceuticals, in photography and in numerous other industries.

Other industries The industries discussed above are not the only ones involved with cattle. To name only two it does not cover the leather industry nor retail butchers. The industries discussed are, however, those of most importance in the context of BSE.

Consumers Obviously production is only viable if there exist willing consumers for the relevant output. It is therefore important that starting in about 1970 (some would put the date a bit earlier) the interest of consumers in food production and diet and in the related official standards and rules increased enormously. Consumer bodies and pressure groups of many kinds have decided views on what ought and ought not to happen and constantly seek to publicize their views in order to influence the public, while also lobbying government to act in their preferred manner. Responding to such pressures is a major task for all in the food chain, notably farmers, manufacturers and retailers, and also for government. This book is only indirectly concerned with what has been reasonably called the consumer revolution, but it is important to realize that all the decisions discussed below had to be taken in the knowledge that they would be rigorously scrutinized not only by political opponents but also by consumer groups which, experience showed, were often both critical of government action and successful in gaining media attention. Notes 1 These days pigs and poultry are considered as being in effect processed cereals, hence the industries are concentrated in the east. This had its significance in the BSE saga (see p. 72). 2 Though the possibility that it originated in sheep has not yet been definitively disproved.

The Cattle and Ancillary Industries 13 3 And most products made by processing milk or beef. 4 Very recent (2003) agreements to make changes to the CAP may make this less true in future. However, most observers would accept that the above statement was true from the beginning of the CAP in the late 1950s until 2003 at least. 5 ‘Suckler’ because the calves suckle their mothers which is not usually the case for dairy calves. 6 Concentrates are animal feed with a high concentration of protein. 7 In effect all developed countries. 8 However, note Sir Richard Southwood’s reaction explained in Chapter 4, p. 44. 9 This is accomplished in a roundabout way – meat cannot be sold unless it comes from an animal killed in a licensed slaughterhouse. 10 For example Japan. 11 Figure 2.3 on p. 7 of Vol. 13. 12 The insertion of a rod or coiled wire through the hole in the skull of cattle made by the captive bolt to destroy the brain and spinal cord. 13 The act of severing some of the principal blood vessels. 14 Tying the rectum with the neck of the bladder to prevent faecal contamination of carcasses. 15 Renderers also made some use of other material, such as whole carcasses from animals that had died on farms (fallen stock) and waste from butchers’ shops. 16 The thinking presumably was that anything sufficiently rigorous to eliminate salmonella would also eliminate other bacteria and viruses. This is correct, but unfortunately the same is not true of BSE.

2 Science and Research

Introduction BSE is (mainly) an affliction of cattle. A human affliction now known to be closely related to it is called CJD. One objective of this chapter is to set out enough of the science of this group of afflictions to enable readers to appreciate the nature of the problem posed when BSE was identified. Another is to help them to appreciate why when faced with BSE those involved acted in the ways set out in the following chapters – and to judge whether these actions were satisfactory. Of course over time science moves on and more becomes known enabling better decisions to be made. However, decisions often cannot be delayed and have to be made in the light of the information available at the time and of the theories which best account for the known facts. The passage of time may reveal that the facts have been wrongly assessed or the theories accounting for them were deficient. In that case previous decisions may not have been optimal. This is inevitable and history abounds in examples of catastrophes caused in effect by ignorance. I describe below one such where young people treated with human growth hormone extracted from corpses were infected with CJD. In these cases the direct consequence of a medical treatment prescribed for the best of reasons was an appalling, early death. The class of disorders to which BSE belongs is a highly unusual one. For the purposes of this book I believe it will be most helpful if I first describe the relevant facts as they became established over the years up to the discovery of BSE in 1986. This was the state of knowledge when the initial policy decisions on dealing with BSE had to be taken. I will then turn to how these facts are now explained.

Advances up to 1986 Scrapie This approach requires us to start with scrapie which has been recognized as an affliction of sheep (and goats) for centuries. There was a particularly widespread and virulent outbreak in Germany in the eighteenth century, and contemporary accounts show that the disease existed in the UK at the same time. 14

Science and Research 15

Signs of scrapie do not normally occur until sheep are ‘middle-aged’, that is around three years old. They include scratching, for example against a tree or post, often until the wool and even the skin is rubbed away. The resulting half-naked look is what is often most noticeable. Affected animals are easily startled and difficult to control with dogs. They are unsteady on their feet and have a peculiar and distinctive gait. Affected animals do not recover; eventually they collapse and die (if not disposed of beforehand). Over time it was noticed that some breeds and families of sheep were much more susceptible to the disease than others. This suggests that the genetic constitution of an animal is relevant to whether or not it becomes infected. Later in the twentieth century it was established that some sheep appear to be totally resistant under natural conditions. Against that, large outbreaks sometimes occurred in other flocks for no apparent reason. In natural conditions, however, it is more usual for one or two animals in a flock to succumb. In 1936 French scientists first reported that they had transmitted scrapie to a healthy sheep by injecting tissue from the spinal cord of an infected animal into the eye of a healthy animal. The time from injection to apparent sickness was eighteen months.1 In due course other methods of transmission, such as injection into the brain, were also shown to work, again after a period of many months. Even more puzzling was the scrapie outbreak that occurred in Scotland also in the 1930s in many hundreds of sheep some eighteen months after they had been vaccinated against another sheep disease. The vaccine had been prepared from the brains and other tissues of sheep infected with this other disease (now confirmed as being caused by a virus). It had been treated with formalin, a standard method of inactivating viruses. By then it had been established that scrapie did not involve a bacterium since none could be cultured in the laboratory. At the time, however, most viruses were too small to be detected by the microscopes available. The general assumption was that scrapie was caused by a virus. When electron microscopes became available in the 1950s, however, no scrapie virus could be detected in cultures made from relevant tissues. Equally puzzling, no antibodies to the infection could be detected in the blood of infected animals. Given the strange behaviour of infected animals it was natural to examine their brains under the microscope, and they were found to be profoundly affected. In particular, the parts responsible for balance, arousal and metabolism showed substantial tissue damage. Overall the brain appeared abnormal, and microscopically somewhat like a sponge. Often brains contained plaques, later shown to be composed of polymerized (joined together) protein. Transmission experiments, normally involving the inoculation of tissue from scrapie-infected sheep into the brains of mice,2 were carried out to discover which organs other than the brain can contain infectivity. If the mice succumbed to scrapie as shown by an examination of their brains3 then the tissue injected into them had contained infectivity. The results showed that after the brain the spinal cord is the most affected organ though some other tissues also contain some infectivity. Later when protecting the public from BSE was under consideration these

16

The Politics of BSE

experiments were used as the basis for important decisions on which bovine tissues should be kept out of the human food chain (based on the analogy of BSE with scrapie which seemed reasonable in the absence of data for BSE-infected cattle, since both are ruminants). Finally the detailed results of various experiments led to claims that scrapie could be transmitted from ewe to lamb (though few claimed this was the only naturally occurring method of transmission). The existence of maternal transmission for scrapie (before or after birth) is widely accepted though some respected workers in the field dispute it. The latter claim the outcome of the experiments in question can be better accounted for by variations in inherited genetic susceptibility to infection. Until recently these facts could not be satisfactorily explained according to established theories. Most people assumed a virus must be involved, but this seems to have been more because theory required it than because of the evidence. Those working in the field sensed that there were major discoveries to be made but the subject seemed puzzling – too difficult in fact. The economic impact of scrapie was not major and no link had been established with human health. In line with the overall reduction in government expenditure on agricultural research the effort devoted to scrapie diminished in the period up to 1986. CJD in humans The full name for CJD is Creutzfeldt–Jakob disease. It is named after two German doctors who first categorized CJD in the 1920s. Over the following decades a picture of the disease was gradually pieced together. One reason why the facts took a long time to establish was that CJD was found to be extremely rare. Nevertheless, the closer people looked the more cases they found since some had originally been diagnosed as suffering from some other more common disorder such as stroke. Indeed it was not until the late 1970s that the relevant international authorities included CJD in the official list of diseases. However, even with very careful searching the rate of infection did not go above one case per million per year in a population. Statistics showed that the disease is in the main an affliction of late middle age. Its central features were loss of physical control of the body such as the ability to move limbs voluntarily, often accompanied by involuntary movements, and loss of mental faculties. Typically the brains of those infected, when examined after death, were found to be profoundly affected with loss of neurones and the appearance of ‘holes’ giving a spongy appearance under the microscope. In recent decades what appear to be sub-types of CJD have been identified. They share the main features of CJD in terms of loss of physical control and of mental faculties, but differ in the detail in which these features present themselves and sometimes demonstrate others in addition. In one, patients go blind though their eyes appear unaffected (in such cases the part of the brain dealing with sight is grossly affected). In another, patients lose the ability to sleep. In a minority of cases sufferers were found to have affected relatives, sometimes dozens of them over many generations, though for most CJD patients this was not

Science and Research 17

the case. Examination failed to identify any common thread of diet or lifestyle or exposure to danger or medical history that might account for who became infected (other than membership of the few families who seemed to be particularly affected). Kuru Kuru is the name given by an ethnic group in New Guinea4 to a mysterious disease that struck them in the twentieth century reaching its height in the 1950s. The main symptoms were a progressive loss of motor control (that is the ability to move one’s body as one wishes and not to move it as one does not wish) followed by dementia and death. The brains of those affected when examined after death were found to be severely affected with loss of neurones and a general spongy appearance. Often the brains contained plaques. When it came to the attention of the (Australian) authorities in the 1950s the disease was found mainly in women, young men and children of both sexes. Initially it was very rare in older men. Relatives and those who had been brought up together often succumbed even when they had moved away from their original homes many years before. Only the one ethnic group was affected. The numbers affected increased steadily as the 1950s advanced. Kuru became the major cause of death in women to the extent that the sex ratio among the ethnic group became severely distorted. One of the most important advances in understanding in this area occurred in 1959 when an American vet called Hadlow, a researcher into scrapie, wrote a letter to the Lancet pointing out the similarities between kuru and scrapie. Given the way I have presented the facts above this probably seems a less brilliant insight than it was. This is because I have made no mention of the many other brain diseases of humans and animals which demonstrate some of the features of scrapie and/or kuru and made the picture much more confusing than the one I have painted. It must also be borne in mind that human and animal diseases are generally investigated by different sets of professionals who do not often communicate. Nor was there any particular reason to link kuru and scrapie. There are few sheep in New Guinea and they are not known to suffer from scrapie. Hadlow recognized that his suggestion could be tested experimentally. If kuru was closely related to scrapie then probably it, too, would prove transmissible. Obviously experiments could not be conducted on humans, likely to be the most susceptible to transmission. Mankind’s closest relative is the chimpanzee so the best test possible would be to inject brain tissue from kuru sufferers into the brains of chimpanzees. The scrapie analogy suggested, however, that it might be months or years before the animals succumbed (if they did).5 Organizing such an experiment is a large task and it was 1962 before chimpanzees were injected with kuru-infected brain. They became ill twenty months later and deteriorated for a further six months. Their brains were found to be severely affected in the same ‘spongy’ way as kuru sufferers, though the detail, for example which part of the brain was most affected, was different. However, it was clear that kuru had been transmitted to the chimpanzees. Hadlow’s insight had

18

The Politics of BSE

been correct. The experiment was reported in Nature in 1966 and one of the scientists concerned shared the Nobel Prize for Medicine in 1972. Some of the workers who examined the brains of the chimpanzees infected with kuru commented that they looked similar to brains they had previously examined of humans suffering from CJD. This suggested an obvious further experiment and by 1968 it had been reported that CJD, too, could be transmitted to chimpanzees though again with an incubation period measured in years. CJD, kuru and scrapie had been shown to be closely related diseases. These discoveries showed that infection might involve a lengthy incubation period so that any precipitating events had probably occurred long before – possibly many years before. Together with other evidence this consideration allowed the kuru mystery to be solved. The other evidence was that by the 1960s the age of the youngest child succumbing to kuru seemed to increase annually. This was especially true in those regions in closest contact with ‘Western’ influences. However, at the same time the number of adult men succumbing increased. The answer lay in cannibalism which was practised by the ethnic group concerned as a way of marking respect for the dead. Bodies were dismembered and cooked by women and the internal organs eaten by them and by children. Men ate only the flesh. Cannibalism was banned by the Australian authorities who gradually penetrated even the remotest regions, and by the end of the 1950s the practice appears to have ceased. Piecing together all the evidence the best account appears to be as follows. Kuru appeared in the 1920s as the result of the consumption of one individual who had died of CJD. (Remember most cases of CJD occur sporadically, that is they have no apparent cause.) By the Second World War it had spread to a number of villages, and it continued to spread after the war. A single incident was sufficient to cause disease, possibly decades later. The incubation period varied between four years (based on the youngest who succumbed at that age) to several decades (based on the experience of those who had moved from villages where kuru was common to villages where it was unknown and succumbed there decades after moving). Differing infection rates among men and women were accounted for by the different roles at the cannibalistic feasts and the different organs consumed, so that males only normally became infected while children. The epidemic was halted and kuru has died out because of the suppression of cannibalism by the authorities in the 1950s. In effect kuru represented CJD transmitted orally.6 A link between CJD and scrapie? CJD and scrapie having been shown to be similar types of disease the question was posed as to whether the link was very close indeed. Could CJD be caused by scrapie? However, on careful examination of medical and veterinary records no causal link could be found. CJD occurred worldwide at comparable frequencies (if allowance were made for different intensities of searching) and appeared to be unrelated to the presence of scrapie. Indeed CJD was found in countries where scrapie was unknown.

Science and Research 19

Acquired CJD Kuru was unfortunately not the only example of CJD being spread by human activity. Various medical practices have also contributed to the dissemination of the disease in the last fifty years. These include treatment with growth hormone or gonadotrophin derived from human pituitaries to induce growth and to combat female infertility respectively; transplantation of the cornea; the use in brain surgery of instruments or electrodes used previously on other people; and the use of dura mater (a natural covering of human brains) in operations. Fortunately none of these examples has led to major epidemics, but worldwide over a hundred people have died from human growth hormone related CJD. These facts demonstrate how persistent the agent causing the disease can be. For example the instruments and electrodes implicated in causing CJD had been sterilized to normal surgical standards – that is, what would normally be regarded as a very high standard. This was not sufficient to prevent the transmission of CJD when they had previously been used on someone later shown to be suffering from the disease, though it was certainly sufficient to kill any known bacterium or virus. Experience also showed that the incubation period was dependent on the method of transmission. In the case of contamination via brain surgery or corneal transplant – that is injection directly into the brain – the period was two years or less. In the case of injections of growth hormone outside the brain the period is at least eight years and often longer. Related diseases Finally we need to mention two other animal diseases which are recognized as falling within the same family of diseases as CJD, kuru and scrapie, that is within the group of transmissible spongiform encephalopathies (TSEs). One is a disease of mink known as TME, severe outbreaks of which occur occasionally in mink farms. TME has similar features to other TSEs. It might or might not be relevant that farmed mink are typically fed animal waste such as the carcasses of animals that have died. Apparently7 in one experiment healthy mink fed on scrapie-infected sheep did not succumb to the disease but did so if the scrapie infected material were rubbed into abrasions in their skin. Another TSE was first found in mule deer and elk in wildlife parks in the US states of Colorado and Wyoming. This has now spread outside the parks and is found in deer and elk in several states and in a more limited way in Canada (and in South Korea which imported animals from Canada). The prion theory Let us recall the principal facts that need to be accounted for by any theory purporting to explain TSEs. Using CJD as the main illustration they include: (a) most cases do not appear to have an environmental or genetic cause, they occur ‘sporadically’; (b) CJD occurs at a low incidence in all human populations;

20

The Politics of BSE

(c) nevertheless some cases of CJD ‘run in the family’ and are likely to be genetically based; (d) it can be transmitted most effectively by injection of infected material into the brain, but sometimes by other means, for example, orally; (e) transmission can occur whether the material comes from a sporadic case, from a familial case, or from one that was itself the result of transmission; (f) infection with a TSE does not generate antibodies in the host; and (g) the infectious agent is impervious to treatment that would kill all known bacteria and viruses. Before the prion theory was put forward these facts could not be accounted for. That a disease could arise spontaneously and yet be transmissible was only one seeming incongruity. The essence of the prion8 theory put forward by Prusiner in 19829 is that the transmissible agent in TSEs is radically different from other infectious particles and probably consists wholly of protein. This was a highly radical suggestion in terms of existing biological theories, and it was by no means generally accepted at the time. Since 1982 the theory has been developed further and we do not have time to follow every twist. It is important to remember, however, that until the 1990s most scientists regarded the prion theory with deep suspicion. Though it was ingenious the evidence to support it was flimsy. The state of knowledge when BSE emerged in 1986 was as set out above. As will become apparent from the account which follows of the prion theory as it has been developed over the last twenty years, it now explains quite well many of the features of TSEs, which is why most workers regard it as the best theory yet advanced. This is not to say that further discoveries may not require it to be modified or even rejected. That is the ultimate fate of all scientific theories.

The current theory A simplified version of the current theory goes like this, again using humans and CJD for purposes of illustration. One of the tens of thousands of human genes is found on chromosome 2010 and is called the PrP gene. Its function is unknown though it is presumably significant since very similar genes are found in a large number of animals. Like other genes it brings about the production11 of a protein in this case called PrP. This is found in normal healthy humans. Like most proteins it can be destroyed fairly easily by chemical action.12 As is the case for other proteins it is believed PrP is constantly being made and destroyed in healthy people. Normal PrP is also found in those suffering from CJD. However, in the latter cases a different version of the same protein13 is also found especially in the brains of sufferers, which is much more sinister. This sinister version is virtually impossible to destroy by methods which normally destroy proteins. The reason is that the sinister version (known as PrPSc14) has a different geometrical shape15 which serves to protect it from agents which destroy most proteins including normal PrP (known as PrPC).

Science and Research 21

The theory is that very occasionally for some unknown reason PrPC converts itself into PrPSc. Unlike PrPC the body cannot destroy PrPSc once it is made. Moreover, by some unknown mechanism PrPSc can catalyse (help) the transformation of PrPC into PrPSc. Thus once PrPSc is present in a person the amount of it steadily increases. CJD sufferers have large amounts of PrPSc in their brains. The accumulation of PrPSc in a brain is eventually incompatible with its normal functioning; the person concerned has contracted CJD. In recent years it has become possible to unravel the detailed composition of the genes of any given individual. Where CJD runs in families those affected are found to have an abnormality (mutation) in one of their PrP genes. Presumably the mutation makes the production of PrPSc more likely. Several such mutations have now been detected and each has a characteristic incubation period before those possessing it succumb to CJD. No known environmental action can prevent the person concerned from developing CJD. The detailed conformation of the PrP gene has other important effects. I will give one of many possible examples. At one place16 on the human PrP gene there are two alternative versions17 that can be present. Since everyone has two copies of the PrP gene inherited from their father and mother respectively, there are three different possible presentations for any person. They can have the same copy of either of the versions or one of each version – as it were two heads, two tails or a head and a tail. Yet of more than a hundred persons who have so far succumbed to vCJD believed to result from exposure to BSE all have the same presentation. Since this presentation is shared by only 38 per cent of the UK population this is not chance. Whether the other 62 per cent of the population are not susceptible to vCJD or might contract it later after a longer incubation period is one of the important unknowns. The future Significant discoveries about TSEs continue to be made at a rapid pace. Scientifically the area is a ‘sexy’ one; it has already resulted in two Nobel Prizes and, having met some of the main workers in the field, I am confident that there exists in some quarters a strong determination to increase the number. Areas where major discoveries may be made include the development of reliable early tests for the disease in animals and man and of a treatment for CJD in man. Another might involve the relationship between TSEs and other brain diseases. Notes 1 Initially this time lag led to the connection between the two events being doubted. As we shall see, lengthy incubation periods are typical of the diseases we are considering. 2 In the early 1960s mice were shown to be susceptible to scrapie if so injected, but only after an incubation period of several months, that is a significant time in relation to the life-cycle of mice. 3 As would be expected the mice would be killed and examined if they appeared to show signs of infection, but left if they appeared healthy. Eventually if none of the mice injected with some particular tissue appeared unhealthy and if after a long time (for such experiments) their brains appeared normal then it was concluded that the organ from which the tissue had been prepared did not contain infectivity in sheep. Such experiments are very laborious and tedious and need the best care and method if error is to be avoided.

22

The Politics of BSE

4 The ‘Fore’ people. 5 In fact workers on kuru had already tried some transmission experiments but these had been discontinued when the animals did not succumb after a few weeks, apparently demonstrating that a virus was not responsible. 6 The possibility of non-oral transmission at the feasts cannot be discounted. For example, infective material might have entered the bodies of those participating via sores or cuts on the skin. 7 I take this from Ridley and Baker, p. 36. Their book, Fatal Protein, Oxford University Press, 1998, is the best source for those who wish to know more of the science of TSEs than there is space to include here. 8 Derived from proteinaceous infectious particle. Why ‘prion’ rather than ‘proin’ is just one of life’s mysteries. 9 For which he, too, received the Nobel Prize. 10 Setting aside the sex chromosomes every individual has two copies of each chromosome, one from their mother and one from their father. Hence they have two versions of each gene which may or may not be identical. 11 I say ‘brings about’ because the precise process of protein production is a complicated one. It is true, however, that each gene causes a specific protein to be produced. 12 In the case of living entities such chemicals are called ‘enzymes’. 13 By the ‘same’ I mean that both versions of the protein have the same chemical formula. 14 The ‘Sc’ stands for ‘scrapie’. 15 It is common for there to be compounds which share a chemical formula but have different geometrical shapes and different properties. Different versions of sugars with the same formula have vastly different sweetnesses. 16 Known as ‘codon 129’. 17 Producing methionine or valine in the PrP molecule.

3 Slaughterhouses

Public attitudes Most people think about slaughterhouses as little as possible. Though only a very small percentage of us are vegetarians there is something about the organized killing of large animals which causes us to recoil.1 A consequence of this state of mind is that few, if any, deliberately seek to visit a slaughterhouse to see what goes on. In some ways this is a pity since standards would undoubtedly be helped by a measure of public scrutiny. Another is that more sensitive souls do not, by and large, work in slaughterhouses. There is plenty of evidence suggesting that the attitude towards authority among slaughterhouse workers is often what might be called robust. In one UK pig slaughterhouse until recently visits by senior management used to be greeted by a synchronized banging of (very sharp) knives on tables. Management there did not interfere with the line unnecessarily. This does not suggest an atmosphere where it is easy to enforce 100 per cent compliance with detailed rules. Unfortunately some discussion of slaughterhouse activities and standards is necessary for a proper understanding of the BSE saga. This is partly because the low standards in many undertakings and unsatisfactory enforcement of the rules by local authorities were two of the most significant difficulties the government faced in controlling the BSE epidemic. When the enforcement problem was solved in 1995 by the establishment of a new national body, the Meat Hygiene Service, it was possible greatly to improve the protection of the public.

The state of the UK slaughterhouse sector in the 1980s/early 1990s Towards the end of the 1980s the UK slaughterhouse sector faced a wide range of practical and political problems. They included: (a) low profitability hence a lack of funds for investment; (b) low standards of hygiene; 23

24

The Politics of BSE

(c) a confused system of control, MAFF had responsibility for licensing some (and by the early 1990s all) slaughterhouses and setting the rules while local authorities were responsible for enforcing them; (d) poor enforcement by many local authorities; (e) differing standards, those applying in plants licensed to export outside the UK were required to be higher than in others; (f) a requirement that all slaughterhouses should over time be upgraded to the standards of those licensed for export for which upgrade the operators concerned often had neither the necessary funds nor will; (g) resentment by Environmental Health Officers (EHOs) and Meat Inspectors and their unions that following the requirements of EU law some of the functions they had traditionally exercised in slaughterhouses in the UK had been taken over by qualified vets and this process was planned to go further; and (h) political and media opposition to attempts to improve standards which were characterized as either unnecessary in technical terms being really based on the wish of ‘bureaucrats’ to enhance their powers, and/or unreasonable impositions by EU fiat. The ‘excessive’ requirements of EU law on meat hygiene constituted a stick constantly wielded by eurosceptics in their battles with government. Thus the eurosceptic case depended on EU law in this area being ‘excessive’ and, unsurprisingly, they found little difficulty in persuading themselves this was in fact the case despite the expert view being solidly to the contrary. Let us consider these points more fully. The slaughterhouse sector in the UK, especially in England, was surprisingly undeveloped. Most plants were small with a poor structural layout which both made it difficult to sustain high standards of hygiene and to achieve economies of scale. Though there were exceptions in economic terms the sector was something like grocery before the advent of supermarkets. There was also excess capacity. For all these reasons profitability was low. On hygiene there are two related but different considerations. There is first the physical structure of a plant. This relates to such matters as the amount of space available and the materials used. To give one example, slaughtered cattle have to be hung up by a hind leg for organs to be removed. If the height of the hooks from which the carcass is suspended is insufficient it will touch the floor and inevitably become contaminated. Plants showing such deficiencies were required to invest in new overhead lines. Licensing of plants by MAFF was based on their having satisfactory structures. Plants licensed for export had to meet EU requirements in full, while lower standards, sometimes much lower, were initially accepted for other plants. It was known, however, that all plants would have to meet the higher standards eventually. Low profitability meant that many plants were unlikely to be able to find the necessary funds for the necessary investment. Second, ‘hygiene standards’ can also refer to the way in which cattle are processed from live animal to meat – for example whether the utensils used are cleaned properly. Obviously it is easier to act hygienically if the plant structure is a good one but this is not guaranteed. As to low standards of hygiene (in both

Slaughterhouses 25

senses) being widespread there is abundant evidence. In 1985 an official report, the Preston Report, referred to: problems include slack methods of dressing carcasses, careless spraying of carcasses with water, infrequent sterilisation of knives and washing of hands, and inadequate cleaning of the slaughter hall and equipment. In 1990 another MAFF report referred to: stomachs frequently dropped on floor during evisceration… external doors left open (entry of flies, etc.)… trays of meat in contact with floor… no cleaning or sterilising of knives, no washing of hands or aprons, faecal contamination of carcasses. Nevertheless, all the political pressure was to the effect that slaughterhouse operators were being subjected to unreasonable demands. Thus Nicholas Soames, then Parliamentary Secretary at MAFF, received a very hostile reception from his own backbenchers in a Parliamentary adjournment debate in October 1992. This was no doubt why later in the month the Minister, John Gummer, quoted to the House of Commons Agriculture Committee some of the official reports he had recently seen: Slaughter hall floor heavily soiled with blood, gut contents… cleaning brush heavily contaminated with blood and fat being used to wash carcasses… missing window pane in roof – birds, flies entering… effluent discharging across floor under dressed carcasses. And so on. All qualified observers seem to have agreed that standards in many plants were well below acceptable levels. These qualified observers included the European Commission. However, it was not an EU plot; all qualified UK observers held the same view. The only exception lay in the UK body politic most members of which believed, against all the evidence, that UK standards were sufficiently high and that other member states did not apply the rules. MAFF Ministers were constantly pressed by their Parliamentary colleagues to adopt a lenient approach to the rules. Often the belief behind this request, stated or unstated, was that the rules were unnecessarily onerous and bureaucratic. The existence of low hygiene standards was partly a function of poor plant structure but also of unacceptable attitudes among plant management and poor enforcement by local authorities. That local authorities varied widely in their approach to enforcement had been realized since at least the Preston Report. Some were good. Others gave little attention to the matter. In some cases inspectors appear to have become far too close to those they were meant to be inspecting. In others there appears to have been outright intimidation. All this was bad enough, but matters were made worse by the resentment among EHOs and meat inspectors at what they perceived as the reduction in their status implied by EU rules. Outside the UK responsibility for the enforcement of

26

The Politics of BSE

slaughterhouse rules had always been allocated to those who had undergone a veterinary training. EU regulations had been drawn up on that basis. Where EU single market rules were applied in full EHOs/meat inspectors could only work under the supervision of a vet. That was already the position in export plants by the early 1990s and would have to be the case in all plants eventually. It was argued by some that the vets who enforced the rules in slaughterhouses elsewhere in the EU were not of the same calibre as UK vets and that EHOs/meat inspectors were their real equivalents. There appeared to be something in this in that a sizeable proportion of foreign vets did not seem to be the types who would have gained the equivalent of three or four ‘A’ grades at ‘A’-level as virtually all UK vets qualifying in recent decades had done. However, years earlier the UK had sought to argue in Brussels that EHOs/meat inspectors should be accepted as meeting the requirements of inspectors for the purposes of meat hygiene legislation. By the late 1980s this argument had effectively been lost. Many slaughterhouses, especially small ones, needed to invest to be able to meet EU structural standards. Those trading on very low margins – a substantial proportion – found this difficult. Though a period of grace was usually granted to make the necessary changes it was known that eventually those not meeting the requirements would not be licensed and hence would be forced to close. Operators placed in this position tended to criticize the EU rules, the immediate, obvious cause of their difficulties. The need to comply with EU rules may sometimes have been the final straw forcing the closure of some slaughterhouses but the problems of the sector went far deeper. They were overcapacity, chronic low profitability and lack of investment. But it was the ‘unreasonable’ requirements of EU law that got publicity, even though in my experience the private opinion of most UK experts was that something very like the EU rules should have been adopted by the UK long since. Within government the drive to improve standards of meat hygiene appeared to run directly counter to the political current which from 1992 was given focus in the deregulation initiative. Almost all representations MAFF received on the subject argued either for less onerous rules and/or more ‘sympathetic’ enforcement. The general premise was clear. The move towards higher standards was unnecessary and reflected undesirable interference by the EU and the influence of over-regulatory civil servants in MAFF. This attitude went right to the top. The Prime Minister, John Major wrote to the Minister (Gummer) on 30 November 1992: The regulatory burden we are imposing on business frustrates enterprise, innovation and growth. Regulations result in lost jobs, reduced international competitiveness and higher public expenditure. We must change all this. In case Gummer had not got the message he went on: We… need to look at the new rules on meat hygiene which have caused alarm to local business, including butchers and village shops selling meat. Do we go too far in bowing to EC pressure on such things?

Slaughterhouses 27

In other words, those at the top of government believed the propaganda against their own administration’s policies. That was the background against which MAFF were trying to drive up standards so that the public could be better protected and the UK could meet its EU obligations.

The decision to establish a national meat hygiene service A precipitating factor in the decision by MAFF to try once and for all to break out of the ghastly state of affairs described above was the imminent advent of the European Single Market. This required the abolition of veterinary checks on exports from one member state to another. Accordingly all members had to have confidence in the standards operated elsewhere. In a single market any product can end up anywhere so in practice all plants had to be brought up to an acceptable level. Also, member states were required to exercise control over slaughterhouse standards and the system operated in the UK did not really provide for this. The EU Commission considered that both the standards in many UK slaughterhouses and the UK enforcement system itself were not compatible with EU rules. MAFF was therefore faced with an industry with low standards, poor and inconsistent enforcement by local authorities and the imminent coming into force of rules (those of the Single Market) which the current system would not be able to deliver properly. Infraction proceedings in the European Court were inevitable eventually unless there were a change of direction. One likely consequence would be a finding that the UK was in breach of its obligations which could well have serious implications for UK meat exports worth many hundreds of millions of pounds annually. After considering a report on the possibilities for the future commissioned by MAFF and DoH, John Gummer decided to take the plunge. On 18 July 1991 he wrote to the DoH Secretary of State (William Waldegrave) advocating a new national, dedicated, enforcement service for meat hygiene to replace the local authority system. This was, he suggested, the only way to improve standards, ensure consistent enforcement and meet the UK’s obligations under the Single Market. Waldegrave replied two months later that he was ‘content’. In other words, DoH would not oppose the concept but would not help much if it ran into opposition. That was exactly what happened. Gummer put his proposal to the Prime Minister on 4 November 1991. John Major asked for the views of the Treasury which were negative as, one suspects, Major, who had recently been Chief Secretary and Chancellor, had known would be the case. It is also pertinent that while financial considerations are relevant to all policies, the Treasury would have had no expertise in the factors Gummer had cited as justifications for his proposal – low slaughterhouse standards, inconsistent enforcement and the failure of the existing system to meet the UK’s obligations under the EU Single Market and meat-hygiene legislation. On the last criterion the Cabinet Office’s European Secretariat, the obvious persons from whom to seek a second opinion, would no doubt have confirmed MAFF’s assessment. But they were not asked.

28

The Politics of BSE

After the inevitable inter-departmental wrangling, Major asked the Machinery of Government Division in the Cabinet Office to take matters forward. One does not need to be a conspiracy theorist to detect another attempt to stifle the idea. However, Gummer’s persistence in matters he regards as important is often underestimated. In this case his support for the proposal will have been reinforced by the fact that it would help the UK to meet EU obligations. Eventually Major agreed and Gummer announced the intention to create the new body on 9 March 1992. Only the veterinary profession expressed itself in favour. Opposition from EHOs and local authorities was only to be expected, but opposition was widespread including among the government’s own supporters in the House of Commons. The creation of a new centralized enforcement body simply did not fit the political mood of the day especially in the Conservative Party. The hostile debates in Parliament referred to above took place just after the announcement on the MHS. Given the hostility towards the embryo MHS among MPs it was not surprising that when Gillian Shephard replaced Gummer in May 1993 she immediately decided to review the decision to create it. Fortunately she approached this, despite the political pressures, by putting an assessment of the public interest at the forefront of her considerations. She read accounts of the appalling standards achieved in some plants, came to the view that local authorities were unwilling or unable to do anything about it, and took on board the UK’s obligations under the Single Market. As a consequence she accepted the official advice to maintain Gummer’s policy. I was relieved. While a national service was proving very difficult to get off the ground I knew that if we did nothing matters would eventually get even worse.

The putting in place of the MHS Nevertheless political opposition to the new body continued right up to its creation. At Cabinet level John Redwood, who had been appointed Secretary of State for Wales in 1993, expressed complete opposition despite the Prime Minister’s decision made only a few months before. This was serious since certain of the provisions needed to establish the MHS needed to be included in a Parliamentary Bill coming forward (ironically enough called the Deregulation Bill) and Redwood’s agreement or at least acquiescence was needed for this. I advised Mrs Shephard not to give an inch, judging that Redwood would not be satisfied with anything which would leave in place a service capable of achieving the improvements we needed. When Redwood proved obdurate I suggested we should in effect ignore him and agree the necessary modalities with the Treasury. After all it was we, MAFF, who were trying to take forward agreed government policy. However, the Chief Secretary, Michael Portillo, also raised objections similar to Redwood’s. We were obviously facing a eurosceptic phalanx in the cabinet itself. I reluctantly concluded that I would have to recommend to Mrs Shephard that she should appeal to the Prime Minister to clear the logjam which I had held back from doing earlier judging him (Major) to be of doubtful reliability on this

Slaughterhouses 29

subject. Before I did so, however, Ian Lang, the Secretary of State for Scotland intervened in our support, one of the few occasions a helpful intervention came from that quarter. Redwood and Portillo backed down. These exchanges had wasted months during which it had not been possible to take the MHS project forward. Clearly it would not have been prudent to commit substantial sums of public money to a project which was opposed in the Cabinet itself. At much the same time we had to cope with a ‘deregulation scrutiny’ of meat hygiene suggested by the Cabinet Office. These scrutinies were conducted by individual officials for a special section of the Cabinet Office (for which they formally worked for the period in question) to see whether red tape could be reduced in the area in question. At the time they had a high political profile. It was clear that many expected major changes to be recommended in a meat-hygiene scrutiny, which would probably include not going ahead with a National Service. Most probably that was the main reason for having one. However, I was able to put forward a MAFF candidate for the task of ‘scrutineer’ who could be relied upon both to impress at interview and to take an objective view. Even so I was a little surprised when she was given the job. Probably she was so much better than the other candidates no way could be found to avoid appointing her. In due course the Scrutiny Report made a number of recommendations but, crucially, agreed a National Service was needed. At last we could get ahead. The vital need in setting up a new organization is to find a good Chief Executive. Unfortunately the Treasury, typically for the period, insisted on a salary for the MHS Chief Executive which seemed low. The Selection Panel, which included me, could only find an adequate candidate and recommended a serving civil servant as the best available. Mrs Shephard, sensibly, refused to accept anyone other than a candidate who appeared truly outstanding. So we advertised again at a higher salary and this time found someone we could enthusiastically recommend. Shortly after I put forward the recommendation to Ministers I bumped into Nicholas Soames, the MAFF junior Minister with responsibility for meat hygiene. The conversation went like this: NS: RP: NS: RP:

‘Hear you’ve put forward a new man for Chief Executive of the MHS’. ‘Yes, name of Johnston McNeil’. ‘Excellent name. Sounds just the sort of tough type we need. A Scot?’ ‘Comes from Northern Ireland in fact; but you’re right about the impression he gives’. NS: ‘Capital’. Neither Mrs Shephard nor Soames asked me any further questions about the recommendation and McNeil was duly appointed. Soames’s intuition was pithily put but proved sound. Shrinking violets would not have succeeded in welding together the disparate groups which formed the MHS, some with inadequate approaches to their work, into the successful organization the MHS became.

30

The Politics of BSE

However, even though we had appointed a Chief Executive designate we were not there yet. Commercial and political opposition to the new body remained strong and a ‘payment strike’ was threatened by one group of small slaughterhouses who opposed in particular the imposition of veterinary supervision. The clamour was such that when William Waldegrave succeeded Mrs Shephard as Minister in July 1994 he, too, queried the decision to set up the new body. Ministers were uncomfortably aware that indignation at the ‘excessive’ requirements being placed on slaughterhouses was widespread among people they would usually count as their friends and not unnaturally wanted to investigate whether there was any way out of an awkward situation. However, Waldegrave, like Mrs Shephard, eventually concluded that the reasons for going ahead were stronger than those favouring delay. He, too, put the public interest before political expediency. The establishment of the MHS was beneficial in many ways. In particular, as the BSE Inquiry later concluded, it allowed the enforcement of the BSE controls to be greatly improved. The Inquiry’s Report states: The establishment of the MHS had a beneficial impact on the implementation of both the human and animal SBO ban. It is unfortunate that this was so long delayed. (Vol. 1 para 690) [The CVO] was correct to stress the structural problems prior to 1995 of enforcing Regulations in slaughterhouses. The MHS was not introduced as a response to the problems of BSE. Its introduction was, nevertheless, of the greatest significance in addressing the dangers that BSE posed to the human and animal food chains. (Vol. 1 para 484) On the last point I would only comment that driving up standards in slaughterhouses was always one of the principal reasons put forward for a national service. While the problems of BSE were admittedly not explicitly quoted as a justification for the MHS, an improvement in the enforcement of the rules in slaughterhouses was exactly the sort of result anticipated by those who supported the MHS.

Assessing the reasons for support for and opposition to the MHS I have mentioned the opposition of some well-known figures to the MHS, but this was merely the tip of a large iceberg. Negative representations were made by numerous Conservative members of Parliament. The Opposition, who claimed to be more sensitive to issues of food safety than the government, gave no support. Many others, especially those opposed to the EU, chipped in – all negatively. Local authorities and the representatives of EHOs and meat inspectors – vested interests which as events showed were incapable of administering an effective system – claimed a new body was unnecessary. ‘Deregulation’ and ‘excessive bureaucracy’ were cited as justifications for opposing the MHS by people who gave little sign of having thought about the iniquities of those phenomena in other fields. The DoH

Slaughterhouses 31

gave no support. Consumer associations were too busy launching campaigns that would gain them publicity to support a proposal that might be of immediate practical advantage to consumers. For their part the media were fully aboard the fashionable bandwagon. There were plenty of articles about the plight of small slaughterhouses put in difficulty by bureaucracy and the EU. I have not found one from the relevant period that examined the opposite proposition – that the fundamental problem lay in low UK standards and poor UK enforcement; and that a national enforcement service might be a way of dealing with this. Those who opposed the creation of the MHS might well have succeeded in causing the government to abandon the project at least for a period. As it was they delayed the establishment of the organization. As a result the severity of the BSE epidemic was heightened and its duration lengthened. Were those who opposed the MHS culpable? The answer, I suggest, is both ‘no’ and ‘yes’. To take the ‘no’ elements first, there is every reason to question departmental proposals especially if they involve the establishment of a new bureaucracy. Likewise EU legislation ought to be examined and, if appropriate, challenged. Valid questions include does the legislation actually require the action government claims it does and are the requirements justified? In some cases it would be reasonable to suggest government ought to propose in Brussels that the legislation should be changed, though one must be realistic as to whether such an objective has some chance of success. But those operating in the political world also have a responsibility to examine a case made especially if the matter is one of public safety. MAFF presented plenty of evidence that over a prolonged period the local authority system had not delivered satisfactory hygiene standards in slaughterhouses. They had pointed out that if matters were left to drift substantial and valuable UK meat exports would eventually be compromised. Most of those who opposed the creation of the MHS did not seriously address these questions because they did not wish to do so. In some cases this was because it was inconvenient for their political position if the facts were as MAFF claimed so they simply assumed that the MAFF claims were unjustified without seeking any evidence to support that conclusion. They simply asserted their position comforted by the fact that others were asserting the same thing. Those who opposed the creation of the MHS without properly addressing the evidence that MAFF had put forward that such a body was necessary to protect the public and without having an alternative proposal to meet this objective were in my view culpable. What about those who supported the establishment of the new body? John Gummer originally put the proposal forward though he must have known that it would be unpopular with his colleagues and more widely. He sustained that line even though the Prime Minister made it clear he was unenthusiastic and despite Treasury and much other political opposition. Gillian Shephard could have quietly reversed the policy when she became Minister knowing that this would have obtained her immediate plaudits from a wide range of commentators. William Waldegrave could have done the same. MAFF officials could have proposed a reversal of tack, let it be quietly known to the Treasury and Cabinet Office that

32

The Politics of BSE

they had done so and reap career benefits since they would be deemed to have shown ‘judgement’. All the above continued to support the establishment of the MHS because they believed it was the correct course of action given the established facts. They were right. A little praise seems in order. Note 1 Interestingly we do not have the same aversion to the killing of rats and mice even though they are by most biological measures at least as advanced creatures as, say, cattle or horses, and therefore presumably as deserving of our sympathy. The truth is our response is instinctive and not wholly rational.

4 A Chronicle of Events until 20 March 1996

A summary of the chronology of events precedes the Introduction to the book.

The period up to early 1988 The beginning The grim saga began, later analysis suggests, possibly in south-west England in the 1970s or, conceivably, even earlier. We know this because we now know that the incubation period for BSE in cattle averages just under five years and the first case later identified as BSE was seen (or more accurately its brain was examined) by veterinary pathologists at MAFF’s Central Veterinary Laboratory (CVL) in 1985. This cow had shown the symptoms, notably excitability and loss of control of limb movement, now recognized as indicative of BSE. Examination of the brain of this animal showed a condition which was compatible not only with an SE but also with other possible diagnoses and its significance was not immediately appreciated. The diagnosis of BSE was made later when tissues were reexamined after the existence of the new disease had become accepted. Similarly when the written records were examined cases were found of animals – dairy cows – which had gone down before 1985 often on the same farms as animals which were later diagnosed as having BSE with symptoms which, with the benefit of hindsight, looked suspiciously similar. A very few further cases were sent to CVL towards the end of 1986. On examination by the pathologists the brains showed characteristics similar to but not identical to scrapie in sheep. On 19 December 1986 the Head of the Pathology Section sent the Laboratory Director a note commenting on the brains of the animals examined: … the lesions observed have similarities to spongiform encephalopathies of other species and in particular scrapie of sheep. In the same note the author mentioned two major concerns if indeed this turned out to be ‘bovine scrapie’, namely the implications for the export trade and possibly human health. 33

34

The Politics of BSE

Though its relevance was not appreciated until later, it is significant that in the summer of 1986 CVL had diagnosed a spongiform encephalopathy in the brain of a nyala (a bovine species) which had become sick at a small English zoo. This was the first known example of an SE in a bovine species. Over the next few months it became clear that the 1986 cases were not isolated. Gradually more cases came to light in herds in southern England. Initially the records were not kept as systematically as they were later but the BSE Inquiry went into the evidence comprehensively and concluded that by the end of January 1987 four cases had been confirmed by brain examination in two herds. By the end of May there were six confirmed cases and 13 suspects (that is cases awaiting brain examination) in four herds. By the end of June there were nine confirmed cases in seven herds. By early 1987 the Chief Veterinary Officer (CVO) and the equivalent administrator had been informed of the position. It is necessary now, over fifteen years later when over a hundred people have died and nearly two hundred thousand animals have been slaughtered at a cost of billions of pounds as a consequence of BSE to remind ourselves that there was absolutely no reason why any of this could have been appreciated in the early days. New animal diseases emerge quite regularly without their having such dramatic effects. Nevertheless as the existence of the disease became firmly established in the first half of 1987 two questions naturally arose; first, who should be informed and when, and second what measures to take in response (if any). Examining events fifteen years later the BSE Inquiry concluded some things ought to have moved faster. This may be right but it is worth remembering that the expectation that the public will be informed rapidly of just about everything has developed enormously over recent decades. I invite anyone who doubts that proposition to study the history of nuclear power in the early postwar period. Even fifteen or twenty years ago the ‘principle of freedom of information’ which the Inquiry rightly regards as a present standard was less fully accepted than it is now. It is also necessary to have in mind the position of the scientists involved in what appears to be a new discovery when it is made. They have two main preoccupations which might be summarized as, first, the desire not to look foolish which, experience shows, can happen if announcements are made before all angles are thoroughly checked, and, second, the desire to take a proper share of the credit. These are very important matters for someone who makes a career as a scientist. A mistake on a serious matter will significantly lower their reputation while the opportunity to make a name in the (scientific) history books may only come once. These considerations lead to the wish to keep matters private until results are published or at least until a paper has been submitted to a relevant journal (though many journals take a dim view if the results they expect to publish are publicly revealed beforehand). There are two further considerations, which will always be present in the mind of anyone with policy responsibilities when a significant new development occurs. The first is that it is desirable to be able to answer at the time of the announcement the questions to which it is likely to give rise. While the reply ‘don’t know yet’ may

A Chronicle of Events until 20 March 1996 35

be perfectly reasonable objectively it is unlikely to attract favourable comment. The second is that if some new ‘fact’ turns out subsequently to be wrong any adverse consequences of premature announcement (for example a decision by a foreign government to ban imports of something as a response) will be blamed on those responsible for the announcement. Those who are eager to criticize any delay in announcing something will not be standing up if things go wrong to explain that the odd error is a price worth paying for complete transparency. A specific factor which the written record suggests influenced the senior vets (the CVO and the Director of the CVL) when BSE emerged was the possibility that an announcement that ‘bovine scrapie’ had been discovered in the UK would lead to restrictions on UK exports of cattle and (less probably) beef. This was a perfectly reasonable concern that could justify hesitating over making an announcement for as long as there was any real likelihood that comparing the new disease to scrapie might prove misleading. The BSE Inquiry went into this in great detail and find that the CVO and Director of the CVL unjustifiably operated a policy of restricting information flows within the SVS, to others in the veterinary profession, to other research groups and more widely for a period of some six months at the beginning of 1987. When information was released it was to limited groups only and subject to a requirement that direct comparison with scrapie be not made. While the Inquiry accord less weight to the reasons for limiting information flows set out above than some might regard as reasonable the delay in giving the full facts, including the pathologists’ views on the resemblance to scrapie, went on for far too long. I found the decisions to restrict information flow in the first half of 1987 surprising in one respect. This is that the CVO did not inform Ministers or the Permanent Secretary about the new disease. Even at the time the keeping of information within a very small circle was controversial within the SVS and the natural course for a civil servant in such circumstances is to seek cover. If Ministers or the Permanent Secretary had been informed about BSE in early 1987 the responsibility for disseminating information would have been passed upwards. The criticism eventually made of the CVO by the Inquiry would not have been possible. All this shows that vets, perhaps like other professionals, do not think like civil servants and are reluctant to involve others in decisions they regard as falling within their remit even when formally those others stand higher in the hierarchy. The principal British journal for veterinary matters which can be expected to reach the great bulk of the profession in the UK and a significant proportion abroad is the Veterinary Record. The first communication was published there by SVS staff on 11 July 1987. This referred to a ‘previously unreported slowly progressive neurological disorder of adult cattle… in England’. However the original draft which had referred to an encephalopathy was amended; the published version stated that the nature of the disorder was ‘undetermined’. Ministers and the Permanent Secretary were informed of the disease on 5 June 1987 when a submission was sent to the Parliamentary Secretary (Mr Donald Thompson) though it did not reach him until 15 June after the General Election. Other Ministers were informed by a paper sent forward on 7 July. Eventually an

36

The Politics of BSE

article giving a full description of the disease noting its similarity to scrapie was submitted to the Record on 17 August and published on 31 October 1987. After August lapses in communication about BSE were in the main unintentional though as we shall see there was a problem with informing DoH. Hence by summer 1987 the existence of a new disease in cattle apparently very similar to scrapie in sheep had been established. The disease was probably a TSE though it was not formally (and still provisionally) classified as such until January 1988 when fibrils characteristic of some TSEs were identified in the brains of infected animals. This diagnosis was strengthened in September 1988 when transmission (as in the ‘T’ of ‘TSE’) of BSE to mice was achieved at the NPU by injecting infected tissue from cattle brains into mice brains. The Director of CVL asked the Head of Epidemiology, John Wilesmith, to investigate the origin of this scrapie-like disease. The need was to identify some common factor which could explain the outbreak. Possible explanations included contaminated vaccines, the newish and widespread use of organophosphates, and genetic factors. However, by the end of 1987 attention was focusing on contaminated feed since commercial concentrates had been fed to all the known cases. Meat and bone meal (MBM) appeared the most likely culprit even though it was known this had been incorporated in animal feed for a long time before BSE had appeared. Wilesmith identified a number of changes that had occurred in the material being sent for rendering and in the rendering process itself in the late 1970s and early 1980s. The size of the UK sheep flock had increased and the incidence of scrapie might also have increased; changes in rendering processes, for example the reduction in the use of solvents, might also be significant. While no one factor seemed the key cumulatively they could perhaps have been sufficient to cause some animals to become infected. In any event the theory that infection was caused by MBM was strengthened when at the same zoo that a nyala had succumbed to a TSE in 1986 a gemsbok also succumbed in June 1987 and it was found that MBM from south-west England was included in the antelope feed used there. On 26 February 1988 Wilesmith concluded that the evidence strongly suggested that the epidemic was caused by ‘the introduction of an infectious agent via commercial cattle feedstuffs’.1 By then there had been articles in a number of papers about the new disease. For example on 29 December 1987 an article in The Times referred to a new ‘mystery disease’ and speculated whether it might be ‘transferable to humans’.

1988: first policy responses Consideration of a slaughter/compensation scheme and of a ruminant feed ban Now that it was beginning to seem that MBM that had somehow become infectious had been the immediate cause of the epidemic it was possible to consider possible policy responses.

A Chronicle of Events until 20 March 1996 37

At this point it is necessary to stress one factor common to all TSEs, namely their lengthy incubation periods. In 1988 this period was not known for BSE but by analogy with other TSEs was expected to be a matter of years. This is important because, in the absence of a reliable test for infected live individuals (still the case for BSE), the success or otherwise of policies adopted to eliminate the disease will not become apparent for a period at least as long as the incubation period. Only after this time will the absence of newly infected individuals constitute evidence for the success of the policy. Of course the partial failure of a policy may become apparent earlier as animals succumb after a period less than the average incubation period. But the extent of success or failure can only be judged when the proportion of animals succumbing has been established – that is after more than the average incubation period has passed. In diseases with long incubation periods, like BSE, this puts a premium on getting the policy detail right first time round. By early January 1988 officials had concluded two policy responses were needed. These were first that the disease should be made ‘notifiable’, that is that it be made a legal requirement to report suspected cases to the authorities (MAFF) and second that a slaughter and compensation scheme be established. The slaughter of infected animals was a common method of coping with animal health problems (such as foot and mouth disease) while it would also provide a degree of protection in case the disease had implications for human health. A research project had been set up designed to test whether BSE was transmissible to marmosets, which would give evidence (though not proof) on whether BSE posed a danger to humans, but because of the likely incubation period results were not expected quickly. In line with expectations at this period thought was given to whether the costs of a slaughter scheme should be recovered from the industry for which there were contemporary precedents. However, officials decided that this would not be appropriate since a major justification for the proposed scheme was the protection of the public. In putting forward a submission on 24 February 1988 recommending that a publicly funded slaughter and compensation scheme be established, the Permanent Secretary, Sir Michael Franklin, advised the Minister that he did not see how this could be avoided unless the CMO agreed that such a scheme was not necessary to protect public health. On 29 February the Minister, John MacGregor, gave his initial views. MacGregor was unenthusiastic about the recommendation for publicly funded compensation worrying about possible implications for the campaign to eradicate rhizomania, a disease of sugar beet and hence of interest to farmers in his Norfolk constituency, for which no compensation was provided. At this stage he appears not to have focused on the potential risk to public health from BSE mentioned in the submission. Humans were known to be susceptible to TSEs, while in contrast it could be stated with confidence that rhizomania posed no threat to humans. MacGregor did agree that Franklin should consult the CMO as proposed. However, before learning of MacGregor’s views he (Franklin) had anticipated writing on the basis that MAFF intended to introduce a slaughter and compensation scheme unless the CMO advised this was not necessary to protect the public. In the light of MacGregor’s attitude he could not do so. Instead he wrote on 3 March

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The Politics of BSE

in more general terms asking the CMO’s view on ‘the possible human health implications’. The CMO had apparently not previously taken on board the existence of BSE, though there had been by this date a fair amount of comment in the newspapers. At that time DoH had no veterinary expertise so the articles in the Veterinary Record would probably have passed them by. Some relatively informal and low-level contacts with MAFF on BSE had taken place, the significance of which had been exaggerated in the papers that had gone forward within MAFF. As a consequence MAFF administrators appear to have assumed DoH were in the picture to a greater extent than was the case. Years later the BSE Inquiry got rather onto their high horse about MAFF’s ‘failure’ for some nine months from mid-1987 formally to alert DoH to the potential risk to human health from BSE. This is unjustified. It would not have been apparent to those concerned how DoH as a Department would be affected – what could they do? – nor how they could help given the limited information available. Subsequent developments show such an attitude was a reasonable one save in one respect. Informing DoH somewhat earlier would have helped in giving the CMO rather more time to think about the matter. Even so given the existence of human TSEs the CMO should probably when he received MAFF’s letter of 3 March have replied that sick animals ought be kept out of the human food chain. That is clearly the view of the Inquiry though they stop short of criticizing the CMO for not doing so. The Southwood Committee, established in response to the CMO’s recommendation, is discussed in more detail below. It quickly recommended that to protect the public the carcasses of infected animals should be destroyed as MAFF had proposed and Southwood wrote to Franklin on 21 June 1988 to this effect. In the meantime MacGregor continued to express doubts about publicly funded compensation. This had one useful result in that the possibility of industry funding of a compensation scheme was examined. The beef industry was resolutely opposed. Had this not been done the Treasury would probably have insisted it be examined later when their authority to proceed with a scheme was sought. In the light of the Southwood Committee’s recommendation MAFF officials advised, correctly, that the negotiating position had changed. Government had to implement a slaughter/compensation scheme and it was now not possible realistically to argue that such a scheme should be industry funded. MacGregor continued to worry about the cost and eventually after Treasury agreement was obtained a scheme paying compensation at a rate of 50 per cent of average market values was established. It came into force on 8 August 1988; notification had come into force earlier on 21 June. The above account shows that compulsory slaughter/compensation came into effect nearly six months later than it might have done due to a series of events which were in retrospect unfortunate. In early 1988 MAFF officials decided such a policy was necessary both to protect the public from any risk (though this was considered unlikely) and to get on top of an animal-health disease in a traditional way. This was a view which all, arguably, ought to have shared on the evidence

A Chronicle of Events until 20 March 1996 39

by then available. However, the Minister (MacGregor) expressed doubts when the recommendation was put to him, although he accepted the CMO should be consulted. MacGregor’s doubts caused the issue to be put to the CMO in less definite terms than MAFF officials had anticipated. In particular the CMO was not told that MAFF officials had advised slaughter/compensation was necessary to protect human health. Also MAFF had not previously formally informed DoH about BSE so the CMO was unprepared. Even so he ought probably to have recommended infected animals should be kept out of the food chain. After all if MAFF officials could work out that this was necessary to protect public health why could the CMO not do so? However, he took the less exposed option of suggesting the advice of an expert committee be sought. Only when that committee had been established and recommended that clinically infected animals be kept out of the human food chain was action put in hand. This six-months delay is of some significance since (though it was not appreciated at the time) the number of cases was increasing very rapidly. In the absence of a compensation scheme more infected animals may have gone for human consumption than would otherwise have been the case. The other obvious need was, if possible, to cut the disease off at source. We saw above that the head MAFF epidemiologist (Wilesmith) had concluded by February 1988 that the infectious agent was found in commercial feedstuffs and that changes had been made in rendering processes in the late 1970s and early 1980s which could plausibly account for MBM becoming infectious from this time. Discussion on a confidential basis with the renderers, and the absence of any viable alternative explanation, led to the firming up of the MBM hypothesis over the following weeks. On 3 May Wilesmith confirmed his earlier view and advised that a ban be instituted on the inclusion of MBM in cattle and sheep feedstuffs. One conclusion he reached was to have important consequences though it was not relevant to the ban on MBM. This was that: The… picture is typical of an extended common source epidemic in which the incidence increases sharply over a short period of time and then maintains at a constant incidence. In line with the conclusions on feed on 6 May the CVO advised Ministers that attempts should be made to persuade the feed industry voluntarily to withdraw MBM from ruminant feedstuffs. Officials may have suggested a voluntary scheme in the light of MacGregor’s reservations about compensation. Certainly a compulsory and legally enforceable scheme was much to be preferred. In any event MacGregor quickly decided, at a meeting on 18 May 1988, that a compulsory ban was necessary. MAFF vets also decided quickly and correctly thereafter that, although suspicion at that stage was directed at sheep remains because of BSE’s resemblance to scrapie and the absence of any previous history of a bovine TSE, the most logical form for the ban would be for it to cover the inclusion of all ruminant derived material in feed for ruminants. This would address the possible problem of BSE being recycled via bovine remains.

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The Politics of BSE

This was a wise decision since experience subsequently showed that it was essential that cattle remains be included within the ban since they were probably the main source of infection. Otherwise the measure decided upon might be described as minimalist. Though it was recognized that some feed already prepared and about to be prepared would contain infectivity, no special steps were taken to deal with it for example via a feed-recall scheme (which would of course have led to further demands for compensation). At the time it was assumed that any infectivity would be washed through the system without any major effect. Similarly it was not considered necessary to introduce any new, special precautions for the manufacture of ruminant feed for the future. Manufacturers already had to ensure antibiotics, included in some feeds but banned from others, could only be detected where they were permitted. Presumably it was considered that precautions equivalent to those needed for antibiotics would suffice. It was, of course very much in the interests of manufacturers that their products were not suspected of containing infectivity so it was reasonable to assume they would work to keep it to a minimum. This approach made an implicit assumption which appears not to have been fully articulated at the time though as we shall see some indications supported it. The assumption was that very small quantities of infectivity would not suffice to bring about infection. If this were not true then the measures adopted would not suffice. In the event subsequent developments showed that the amounts of infectivity which had to be consumed to cause infection was less than most had assumed. The Order instituting the ban was signed on 14 June 1988 and came into force on 14 July. It proved very successful up to a point. Professor Roger Morris, a distinguished veterinary epidemiologist from New Zealand, told the BSE Inquiry that the ban had been ‘spectacularly successful’. He calculated that the risk of a cow contracting BSE had increased by a factor of 25 times between 1985 and 1987 and would, but for the feed ban, have increased by a factor of 40 times between 1985 and 1988. Instead the ban produced an immediate reduction in risk of 80 per cent and this figure increased in the following years. Yet the ban was far from being completely successful. As we shall see many thousands of animals born after the ban eventually succumbed to BSE. We will consider the reasons for this later. Taking stock: late 1988 By the second half of 1988 two major measures had been put in place to contain the spread of the disease; the slaughter and compensation scheme requiring the destruction of the carcasses of animals showing clinical signs of disease, and the ban on the inclusion of ruminant protein in ruminant feed. The former also provided a significant degree of protection for the human population should BSE prove to be a risk to humans. At the scientific level the disease had been identified as a TSE closely related or identical to scrapie; the cause of the epidemic, contaminated feed, had been identified though the original trigger remained speculative. Unfortunately the current best estimates of the number of infected animals not yet showing symptoms greatly underestimated the scale of the epidemic but this could not have been known at the time.

A Chronicle of Events until 20 March 1996 41

1988 onwards; independent scientific advice to government; the Southwood Committee, the Tyrrell Committee and SEAC The establishment of the Southwood Committee As we have seen, the CMO suggested that the views of an expert committee should be sought when he was asked by MAFF for his opinion on the merits of a slaughter and compensation scheme for clinically infected animals. He proposed that Sir Richard Southwood FRS, Professor of Zoology at Oxford University, should be the Chairman. Southwood, the CMO and the MAFF Permanent Secretary agreed on three additional members, Professor Anthony Epstein FRS, recently retired head of the Department of Pathology at Bristol University, Sir John Walton, a clinical neurologist soon to be Warden of Green College, Oxford, and Dr William Martin, a vet and recently retired Director of the Moredun research institute. All four members were, therefore, distinguished though none was expert in TSEs. It was suggested by MAFF that Dr Richard Kimberlin, who was such an expert, should be included but Southwood objected apparently because this might involve the committee in the fierce controversy over the nature of TSE agents. The establishment of the working party was announced by MAFF on 21 April 1988 though the detailed membership was not finally settled for another month. MAFF and DoH finally agreed a very wide remit for the committee: To advise on the implications of Bovine Spongiform Encephalopathy and matters relating thereto. The committee, which it had been agreed should have joint secretaries from MAFF and DoH, held its first meeting on 20 June 1988. After the meeting Southwood wrote at once to the MAFF Permanent Secretary with four immediate recommendations of which the most important was that the carcasses of infective animals should be destroyed – in effect endorsing the slaughter and compensation scheme MAFF officials had recommended in February but which had been held up by MacGregor’s reservations and the CMO’s caution. Another important recommendation was that an expert working party should be established to advise on research needs. The committee also asked the secretariat to investigate the use of bovine products in biological products such as vaccines, about which they expressed unease. On the interim recommendations the MAFF Permanent Secretary wrote to Southwood on 20 July confirming that the recommendation to slaughter and destroy infective animals had been accepted and a slaughter and compensation scheme would be introduced. He added that the CMO and he also agreed on the need to set up an advisory body on research. The second meeting was held on 10 November 1988 and Dr Kimberlin was invited to attend part of it though in the event he was present throughout. Kimberlin’s attendance followed a letter from the MAFF Permanent Secretary to Southwood strongly advocating he be consulted by the committee. The evidence

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The Politics of BSE

given to the BSE Inquiry by members of the committee on the one hand and by Kimberlin on the other appear to show that there was some tension between the committee and Kimberlin at the meeting over ten years earlier. The cause is not immediately apparent from the record but it may be that Kimberlin (who had had to travel from Edinburgh for an unpaid meeting of a committee of which he was not a member) thought that insufficient scope was given for him to contribute, while the committee perhaps thought that he had been rather foisted on them by MAFF and resented the fact. Following this meeting the committee made two recommendations, first that the ruminant feed ban (due to expire at the end of the year though nobody expected this to happen) should be extended indefinitely and, second, that milk from BSE suspects should be destroyed. Both were accepted. After the first and second meetings Southwood himself and the secretariat had sought to encourage those with responsibilities for human and veterinary medicines and occupational health and safety actively to consider the possible risks of BSE. Their efforts were not best judged and did not lead to much useful action. The committee was also considering whether some protection should be introduced in relation to human consumption of ‘ox brain’ which might be sold as or incorporated in food. This discussion represents the committee wrestling with the problem of whether there was some protection that could be provided for the human population from the threat, which they clearly regarded as very small, of infection from apparently healthy animals which were incubating the disease. The committee appears to have been hampered by an understandable lack of expertise about what could be done to eliminate potentially infective tissues in slaughterhouses. However, they did not attempt to investigate this in detail. Eventually the only recommendation they made that would protect the public from subclinically infected animals was the baby-food recommendation described below. The committee held two further meetings on 16 December and on 3 February 1989, at the latter agreeing the final text of the Report and signing the letter to Ministers. The principal extra advice in the Report not covered by the earlier interim recommendations was that: … manufacturers of baby food should avoid the use of ruminant offal and thymus. The committee subsequently clarified that they had not intended ‘offal’ to include liver and kidney but only brain, spinal cord and lymphoid tissue. The Report said that the committee had considered the potential for transmission of BSE to occur through the use of bovine products in medicines, including human medicines. It noted that in this connection Southwood had been in contact with the Chairmen of the relevant advisory committees. In similar vein they recommended that the Health and Safety Executive should consider issuing guidance to occupational groups likely to be exposed to the BSE agent. Hence the principal recommendations made by the Southwood Committee were (i) that clinically infected animals should be destroyed; (ii) that an advisory

A Chronicle of Events until 20 March 1996 43

body on BSE research needed should be established; (iii) that the ruminant feed ban should be extended indefinitely; (iv) that milk from animals showing clinical symptoms should be destroyed; (v) that ruminant offal should be excluded from baby food; and (vi) that further action against possible risks to workers and from the inclusion of bovine products in medicines should be considered by the Health and Safety Executive and the relevant advisory committees. All these recommendations were taken up. Even with hindsight all seem sensible, though there is a question over whether given the knowledge at the time more recommendations were needed. However, the Report also had other important consequences going beyond its recommendations. These include the effects of its comments on risk and its conclusions on the origins and likely course of the disease. It is worth examining these points here because for reasons that will be explained they had an impact for many years. The Report was drafted by several hands including the joint secretaries, which is quite usual for Reports of this kind. Significant sections were also drafted by Wilesmith, and again there is nothing inherently odd about that. Drafting reports is a time-consuming business, and it is natural that a committee of this kind will want help in drafting. They were four busy people and it must be borne in mind that they were unpaid. The important point is that the committee should revise the draft and accept full responsibility for the final version. This they did. After thanking the secretariat and others for their assistance Southwood stated in his letter sending the Report to Ministers: The Report remains our own. The Report was clear that in the committee’s judgement the risk to human health was probably very small. It was also apparent that this was based on analogies with scrapie about which data had been assembled for centuries. No link between scrapie and the incidence of CJD had ever been shown. Thus the Report states (para 5.3.5): … the risk of transmission of BSE to humans appears remote. Again it states (para 9.2): … it is… most unlikely that BSE will have any implications for human health. However, clear warnings were sounded. Paragraph 9.2 continued: Nevertheless if our assessments of these likelihoods are incorrect the implications would be extremely serious. Though it was known humans could contract TSEs, which was obviously relevant, the main evidence on which to base an assessment of the threat to human health

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posed by BSE was the analogy with scrapie. This was the case whether BSE was considered to be a manifestation of scrapie in cattle or a new disease of cattle. Given their assessment of the level of risk outlined above, it was not easy for the committee to decide whether to recommend the introduction of controls to protect human health. In the event the baby-food recommendation was the only one they put forward. Making the baby-food recommendation, the only one which could protect humans from infected cattle not yet showing clinical symptoms, looked odd. If babies should be protected what about everyone else? There was some faint evidence that calves (hence babies?) might be more susceptible than adult cattle but it was not a strong prop on which to base the baby-food recommendation. In any event many parents do not feed babies on commercial baby food (they use mixers to prepare a mash from their own food instead) so the recommendation would not even have protected them completely. Whether the middle-aged gentlemen on the committee were aware of this fact is not clear. However, the committee had to reach a decision on what to recommend knowing that the evidence needed for them to come to an authoritative view did not exist and would not be available for years. As it was the committee did a reasonable job on this aspect. Any other committee of comparable standing that might have been appointed would probably have shared their view that BSE was ‘most unlikely’ to pose a risk to humans. Nevertheless they gave a clear warning that this conclusion was not certain and that protective measures were worth considering. However, they might have done better if, instead of making a detailed recommendation (the one on baby food), they had stated simply that because it could not be proved for years that BSE had no implications for human health, meanwhile it would be desirable if potentially infective tissues were kept out of the human (especially baby) food chain so far as possible. The point was that what could be done depended not only on the specification of potentially infective tissues, a biological question on which the committee were competent to assess the evidence, but also on detailed slaughterhouse practices on which the committee could not be expected to be expert. This would have left others to assess what could be done at different levels of cost. As it was the committee appear not to have appreciated that something like the specified offal ban (discussed below) was a possibility. There was one curious episode just before the Report was finalized. Southwood had concluded that feeding animal waste to herbivores was inherently undesirable. His reasoning was that herbivores would not have evolved defences against infections which might be acquired in this way (because natural selection had not had an opportunity to act to provide such defences) and hence new pathways could be opened to the infection of animals and, via them, humans. Southwood apparently hoped to include a recommendation against the recycling of animal waste in the Report, though whether he originally considered animal waste should be banned from pig and poultry feed is not entirely clear since they are not herbivores. His method of achieving this was to hold the idea back until the last minute and hope to finalize the drafting with the DoH secretary only, thereby excluding any MAFF protests.

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Southwood’s basic concerns were valid ones, which deserved to be carefully considered. The development of BSE appeared to have shown that feeding ruminant protein to ruminants was a ‘recipe for disaster’ in the later words of the BSE Inquiry even though it had been going on for decades without apparent ill-effect. Southwood identified a basic scientific explanation for the occurrence of BSE before anybody else and saw that it raised important questions about agricultural practice. However, Southwood’s method of going about matters was naïve and unwise. MAFF were unlikely to allow themselves to be excluded from the debate by such crude tactics; they were understandably concerned about the consequences of prohibiting a use of animal waste which provided an economic route for disposing of hundreds of thousands of tonnes of unpleasant and potentially dangerous material each year. MAFF pressure resulted in the recommendations on this point in the Report being watered down so that they were compatible with the ruminant feed ban. No doubt MAFF were irritated by what appeared to them to be the sneaky way Southwood had gone about things. Southwood would have done better to raise his fundamental concerns openly and to include in the Report a suggestion that they warranted examination in detail. As it was he appeared to want to slip proposals into the Report without being prepared to see them openly discussed, and then to back off when challenged. One of the principal legacies of the Southwood Report was its conclusion that BSE posed only a remote risk to humans. This continued to be quoted for many years by Ministers and officials as the best guide available. The BSE Inquiry were unhappy at this. For example they state: Unhappily, the Southwood Report was treated by many…in MAFF and… DoH… as if it contained definitive conclusions based on an evaluation of adequate data by expert scientists in relation to the extent both of the risk and of the precautionary measures necessary to counter that risk. (Vol. 4, para 1.1) This is to miss the point in spectacular style. The issue is an important one which we will follow as matters develop so it is worth setting out my position here. The Inquiry’s description, quoted above, is a travesty. There is, admittedly, no view so foolish that nobody has held it, so I cannot claim with certainty that nobody treated Southwood’s views in the way described. I can say that I never met anybody who did so. It was well-appreciated by all that Southwood had had to work with very little data and that his views were as a result necessarily tentative at the time of his Report. The real point is that as more and more data became available over the years, Southwood’s conclusions on risk were not discarded or amended to any significant extent by the government’s scientific advisers. Instead they were implicitly and sometimes explicitly endorsed. They were implicitly endorsed by the decision of the advisory committee not to issue an amended assessment. They did not, for example, state following any of the developments of the years after 1989 that the likelihood of transmissibility to humans could no longer be described as ‘remote’. Note it would not have been necessary for them to say transmissibility was likely. They could have said it

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The Politics of BSE

was still improbable but not as unlikely as it had appeared earlier. If they had been concerned at public reaction they could first have sent private letters to Ministers. Indeed on such a fundamental point one must go further. If the government’s scientific advisers considered that the well-known Southwood conclusions on risk had been overtaken it was their manifest duty explicitly to draw this to Ministers’ attention. They did not do so before their well-documented reconsideration starting at the very end of 1995 which in itself constitutes strong evidence that they never clearly reached any such conclusion. In the absence of new advice it is obvious that existing advice remains valid. Southwood’s advice was not replaced for the good reason its successor committee believed it to be the best assessment of the risk posed. This is proved by the fact that in 1994 (by then known as SEAC) the advisory committee explicitly endorsed Southwood’s view that the risk to man from BSE was remote: Our conclusion therefore is that, as the Southwood Working Party determined, taking all the available evidence together, the risk to man from BSE is remote. The gratuitous reference to Southwood scarcely suggests reservations about his advice. Similar statements were made well into 1995 by leading members of SEAC including the Chairman and Deputy Chairman and the CMO. Those in MAFF and DoH were not, therefore, living in cloud cuckoo land, disregarding a changed scientific view. In quoting Southwood’s assessment up to the end of 1995 they were following the advice of their own expert committee, which had both implicitly and explicitly reinforced it. The BSE Inquiry’s strictures are unjustified. Instead it is they, as we will see below in chapter seven, who have misread the evidence and in effect substituted their view of what ought to have been the position for what took place. Whether the views expressed in the Southwood Report on the unlikelihood of BSE proving to be a danger to man should have been amended by SEAC later in the light of new evidence as it arose is an important point. Whatever our answer the Southwood Committee cannot, of course, be held responsible. They can only be held responsible for the advice they gave when they gave it. Finally, the Report contained predictions about the future course of the disease, which in the event proved optimistic. The BSE Inquiry discovered that this section had been drafted by Wilesmith and it is apparent they took a disapproving view of this. However, presumably the committee were convinced by his account of how the disease had arisen. Most people were at the time (and many of his deductions, notably that transmission had occurred via infected feed, are still regarded as essentially correct). In the event his predictions on the future course of the disease, accepted in full in the Report but not ascribed to him, proved highly optimistic because he had not allowed for the extent to which cases coming forward represented a recycling of earlier cases of BSE in cattle which had gone undetected. The Tyrrell Committee At its first meeting the Southwood Committee had recommended that an expert committee should be established to advise on research into TSEs, notably BSE.

A Chronicle of Events until 20 March 1996 47

After some typical sparring between MAFF and DoH it was agreed that the committee should consist of two medics suggested by the CMO, two vets suggested by MAFF and one other. The Chairman decided upon was Dr David Tyrrell FRS, a virologist and Director of the Medical Research Council’s (MRC’s) Common Cold Unit. Other members were Dr William Watson, director of the CVL, Professor John Bourne, another vet and Director of the Institute of Animal Health, Dr Robert Will, a neurologist and Dr Kimberlin. The establishment of the committee was announced on 17 February 1989. Its remit was the one described above with the addition that any new work recommended should be prioritized. On 10 June after three meetings the Committee presented an ‘interim’ report to the government; each piece of new work recommended was allocated one, two or three stars in ascending order of importance. The Committee had deliberately worked with speed so there would be minimal delay in getting projects underway. The recommendations covered a wide range of experiments into BSE and CJD with particular emphasis on the epidemiology of BSE and its transmission and related genetics. However, one aspect which the Tyrrell Committee’s Report did not cover and could not have covered was finance; and experiments cannot be done without the money to pay for them. The bulk of the work recommended fell to be financed by MAFF. There was also a political dimension. The Minister (John Gummer) took the view that it was essential for the government to be able to say that all the new work prioritized at two or three stars would be undertaken. Until he was in a position to announce this he did not want to publish the Report. Accordingly the source of the required sums had to be identified in each of the several years ahead. The rules of government accounting make this more difficult than might be expected though there is not space here to explain in detail why. For example while in theory some money might have been found from elsewhere in the MAFF budget such a course would be risky since underspends in particular areas are prone to be reclaimed by the Treasury at no notice. In practice the money needed to be found from the funds earmarked for research. Although only some £2 million per year was at stake, and this would be dwarfed by later expenditure, this was not easy to find. The need to find this sum was only the start of an ever-growing problem. Looking forward in time it is no coincidence that throughout the 1990s MAFF non-veterinary laboratories and some Research Council institutes outside the livestock area which traditionally did a lot of work for MAFF experienced financial difficulties including closure. The reason was the same in both cases; MAFF funds were being drained away in ever-increasing amounts by work on BSE. Eventually the necessary funds were found for all the work to which the Tyrrell Committee had allocated two or three stars and an announcement made accordingly but not before 9 January 1990. At the same time the Report was published – over six months after it had been delivered. This was awkward and the delay understandably irritated Tyrrell. On the narrow issue no great harm was done by the delay since work was put in hand as soon as possible. Nevertheless it would have been better to publish the Report earlier which would have allowed others

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outside the world of MAFF, DoH and the Research Councils to put forward any bright ideas they may have had about what was proposed or how the work might be done. The establishment of SEAC Following the Report of the Tyrrell Committee in June 1989 it was recognized in both MAFF and DoH that government would continue to have need of independent, expert advice on TSEs. This would need to cover research and, it came to be recognized, wider issues including matters of policy. The establishment of the new committee, the Spongiform Encephalopathy Advisory Committee (SEAC), was announced by John Gummer on 3 April 1990. Its remit was a wide one: To advise the Ministry of Agriculture, Fisheries and Food and the Department of Health on matters relating to spongiform encephalopathies. The membership was initially very similar to the preceding committee. Dr Tyrrell continued as Chairman and Drs Will, Watson and Kimberlin as members. Professor Bourne was replaced by Professor Fred Brown, a virologist formerly of the Animal Virus Research Institute at Pirbright. Later in 1990 the membership was enlarged to include Professor Ingrid Allen, a neuropathologist, Professor Richard Barlow, a veterinary pathologist and Mr David Pepper, a veterinarian in private practice. Thereafter the membership remained unchanged until 1995 except for the appointment of Dr William Hueston, a veterinary epidemiologist from the USA in 1994. SEAC thus consisted of distinguished individuals from the medical, veterinary and research fields. Together with its predecessors, the Southwood and Tyrrell committees, it has been the main source of advice to government on BSE to the present day. Because of the positions and reputations of its members and the fact that most were seen to be outside government, it had prestige and was viewed as independent. Because it had prestige and a reputation for independence Ministers found it valuable to cite its advice in defence of their policies – which were in any case often based on SEAC recommendations. Ministers quickly recognized that they could not act against SEAC advice. To be more precise, they recognized that they could not take fewer precautions than SEAC had recommended. Taking more precautions than SEAC recommended needed careful justification but was sometimes desirable and possible. Also relevant is the highly adversarial nature of UK party politics, especially where the Opposition senses it is on a good wicket such as was the case in the area of food safety in the 1980s and 1990s. Ministers and MAFF more generally were routinely denounced for complacency and/or putting the public at risk unnecessarily. Such denunciations were supported by many in the media. The merit of individuals or of specific proposals had little effect on this state of affairs. Given the uncertainties over BSE it was apparent that virtually anything Ministers might decide could be attacked in a way which a substantial proportion of the public would find alarming. The temptation to score in this way was irresistible to

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politicians and commentators alike. To minimize this standing problem there was every incentive for Ministers both to be guided by SEAC and to justify measures on the basis that they were based on SEAC advice. In this way they hoped to put SEAC between them and criticism. There was a disadvantage to this process in that it came very close to delegating government decisions to a specialist committee which, while it was eminent in some areas, did not know everything. We saw above how the Southwood Committee may have made suboptimal recommendations on protecting human health from BSE because they were insufficiently versed in slaughterhouse techniques. However, given the realities at the time it is difficult to see how this dependence on SEAC on matters of policy could have been avoided. Overall, whether or not it is accepted that the reliance on SEAC on policy matters to the extent it occurred was inevitable, that is what happened. This pre-eminent position of SEAC and its predecessors on policy issues within government was established at a very early stage. In April 1990 DoH objected to MAFF advising farmers not to breed from animals which were the offspring of cows that had succumbed to BSE mainly on the grounds that Southwood had not recommended such action. (The thinking behind the MAFF idea was to prevent inadvertent spreading of BSE should it be maternally transmissible and/or should certain animals be genetically susceptible to infection.) The matter was referred to SEAC at DoH insistence. The outcome was that MAFF felt unable to issue their intended advice which, as the BSE Inquiry recognized later, would have been sensible and fell more within MAFF’s area of competence than SEAC’s. The establishment of the CJD surveillance unit (CJDSU) As discussed above, though the Southwood Committee considered it highly unlikely that BSE would prove to be a human health hazard they did not rule out the possibility. They recognized that, since there was no test to identify those individuals who were developing TSEs, there was a case for carefully monitoring relevant illnesses in the human population. Their Report states: It is a reasonable assumption that were BSE to be transmitted to humans, the clinical disorder would closely resemble CJD… Identification of any such cases as unusual or atypical would not be easy… The CMO could consider whether… neurologists, neurophysiologists and neuropathologists…should be made aware… of BSE so that they can report any atypical cases or changing patterns in the incidence of the disease. Consideration of this recommendation and the concerns that lay behind it led to Will presenting a paper to the Tyrrell Committee. Will had much experience of working on CJD including the first systematic surveillance of the incidence of the disease in the UK in the late 1970s/early 1980s. His advice was accepted and as a consequence the Tyrrell Report recommended the monitoring of all cases of CJD in the UK for the following two decades. DoH accepted this recommendation and CJDSU started on 1 May 1990 based in Edinburgh where Will was working.

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The Unit considered all cases of suspected CJD (including the diagnosis) and developed a detailed procedure for investigating the genetics and environment for each case. In 1996 it was the Unit’s discovery that in the cases of CJD in young people the brains of those affected showed unusual features that was largely responsible for SEAC’s initial conclusion that the cases were probably the result of exposure to BSE.

1989: the decision to impose the human SBO ban The BSE saga has a number of unhappy aspects. As this account shows there were occasions when things went wrong essentially because of bad luck, and others when wrong decisions were taken or matters moved too slowly. There was, however, one occasion when matters went very much right perhaps with the help of a bit of good luck. This occurred in 1989 when the Southwood advice (which fell short of a recommendation) that bovine offal should be kept out of baby food was transformed by MAFF, against mild opposition from DoH, into a requirement which excluded almost all the tissues which we now know to be potentially infective from the human food chain. This measure added to the protection afforded to human health by the slaughter and compensation scheme. Obviously the biggest risk to human health is posed by animals that are clinically ill since there is much evidence that the concentration of infectivity increases rapidly in the disease’s final stages. In his evidence to the BSE Inquiry Southwood went so far as to suggest that it might be that all cases of vCJD were infected before this measure was adopted. This might be true though there is no proof of it as yet. A more cautious claim would be that it is unlikely that anyone has become infected since the imposition in 1989 of the human SBO ban. This imposed a requirement to exclude from the human food chain certain tissues from all bovines. The tissues concerned were those believed then (by analogy with scrapie but reasonably accurately as subsequent work has shown) to carry the highest doses of infectivity in infected animals. (The measure is known as the Specified Bovine Offal Ban or ‘SBO ban’ for short.) This is because the SBO ban offered a large measure of protection against infection via the consumption (for example of food or medicines using bovine material) of material from animals infected with the disease but not yet showing clinical symptoms, that is ‘subclinically infected’ animals. Though such animals would normally contain a smaller amount of the infectious agent than would animals showing clinical symptoms there were many more of them. The Southwood Report was well-received both nationally and internationally. The committee had been composed of eminent individuals and their Report was also the main prop on which government relied to explain to the public that they were being properly protected. It was, therefore, difficult for government to go beyond its recommendations since to do so could seem to imply lack of confidence in its conclusions. It might also cause trouble with the wider scientific community. The former reason lay behind the lack of enthusiasm DoH showed for the SBO ban

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in the wider form in which it was eventually introduced. MAFF were also affected by the same considerations. This makes it all the more remarkable that it was adopted as quickly as it was. Yet doubts were quickly raised as to whether the Southwood recommendations to protect human health went far enough. There was no straightforward decision that led from Southwood to the SBO ban, rather a number of factors which, cumulatively, led in that direction. First, at a very early stage two senior officials in MAFF (but none in DoH) questioned why if babies were to be protected as Southwood had recommended bigger children and adults were not. Second, concerns that the risk posed by BSE might be greater than Southwood had assumed began to be voiced both in the press and by the Opposition in Parliament. Third, through the good offices of Pedigree Petfoods, a leading manufacturer which had retained Kimberlin to advise them on BSE, the latter’s detailed views became known. He had been working on TSEs for decades, and it was therefore pertinent that his recommendations for petfood went beyond Southwood’s recommendations for human food, that is he was more cautious and recommended that more tissues be excluded. Kimberlin’s explanations, backed up by detailed knowledge of the scientific literature, appears to have brought about a change of view in the CVO, who was himself influential in MAFF. Fourth, the Parliamentary Secretary, Sir Donald Thompson (as he became) queried whether more ought not to be done than Southwood had recommended. Thompson was the sort of MP who rarely attains political office let alone senior office. However, on BSE Thompson sensed a need where others did not. Over a period of two or three months the climate of opinion changed. Among those who came down in favour of a more cautious regime than that advocated by Southwood were the Chairman of the British Veterinary Association (a body for veterinary practitioners akin to the British Medical Association for doctors), the Chairman of the Meat and Livestock Commission (MLC), a Director of the largest UK renderer and the Women’s Farming Union. By late May 1989 it appears that MacGregor had decided that a ban excluding certain offals from all human food should be introduced. His reasons appear to have been a mixture of the presentational, that is seeking to reassure and respond to political pressure, and the objective, that is seeking to deal with concerns that clinically infected animals might be going for human consumption despite the slaughter scheme and that subclinically infected animals might pose a danger; and that as suggested by Thompson and others in principle a more precautionary approach was preferable. He seems to have given the first (presentational) considerations the most weight. Ministers and officials were still worried, however, about how to justify publicly a departure from Southwood’s recommendations. That was why DoH were unenthusiastic about extra measures. This was a perfectly understandable concern. Government is always keen to operate coherent policies and if in this case it went further than Southwood then how could it explain why it had done so or, indeed, why it had not gone further? What was clear was that if government decided to do anything that appeared incompatible with Southwood’s recommendation he would have to be told and

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that it would be awkward if he did not support the action proposed. For his part Southwood could scarcely alter his recommendation in the absence of new scientific evidence. These awkwardnesses were solved by making use of something that had become apparent as officials had examined how effectively to implement the baby food recommendation. This was that such a measure would be very difficult to control if the banned material could be used in other human foods. The solution identified was to emphasize that a wider ban in respect of all human food was the most easily enforceable way to implement a ban in respect of baby food. This had credence since it would then become possible to specify that the banned material had to be removed at the slaughterhouse and made subject to special arrangements for its disposal. This would make for much easier controls than if the materials in question could be used in adult but not baby food. Stressing the control aspects of the decision to provide for a wider ban than Southwood had recommended got over the difficulty of going beyond his recommendation while keeping him onside. He made no claim to be an expert on enforcement and readily agreed with the ban when it was explained this was the easiest way to give effect to his recommendation. The official presentation made in a Parliamentary reply on 13 June 1989 by MacGregor did not mention concerns that clinically infected animals might be reaching the human food chain. This would have been a difficult thing to acknowledge openly though it was widely known that this was a concern. It did however point out that the SBO ban in the form adopted would deal with any risk posed by subclinically infected animals. Thus the measure, which with hindsight we can see was more or less in the form needed to protect the public, was adopted early on despite the fact that a committee of distinguished scientists had not recommended it and the Department whose only remit was to protect public health was mildly hostile to it. In most walks of life those who took the decision in MAFF would now be covered with praise for having brought about such a feat. Generals are normally praised for victories even if everything does not go smoothly on the way. However, this has not been the case here. The truth appears to be that all association with BSE impinges negatively on those concerned even where, as here, matters have gone surprisingly well. We should not diminish this achievement – the introduction of the human SBO ban – by thinking that the decision was inevitable because of public pressure. On matters of food safety there is a vociferous lobby which almost always argues for greater restrictions which always have an economic cost. Ministers and officials get used to the clamour; they also note such pressure often has little scientific backing. On BSE there was no ‘right’ answer. The natural course would have been to take the best scientific advice and implement it and to brush aside complaints. When the course ahead is hazy following professional advice is the least risky option. Nevertheless, it is clear that even if MAFF had not acted when they did an SBO ban in broadly the same form would have been adopted eventually as further information came to light over the coming months and years. However, if the baby-food proposal had been put in place in the form advised by Southwood there

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would have been a reluctance to change it subsequently. It might have been many months and perhaps years before a full SBO ban was adopted. This would have been a serious matter since it subsequently became apparent that the number of subclinically infected animals going for slaughter was increasing very rapidly by the end of 1989. Hence the action taken was important in bringing about a major reduction in the amount of infectious material reaching the human food chain. The drawing up of the SBO order After the announcement on 13 June 1989 that a human SBO ban would be put in place it was still necessary to decide on the precise contents of the necessary Order. Though the principle was clear – exclude tissues likely to contain high doses of infectivity from the human food chain – and Kimberlin’s summaries of earlier work were useful guides, a large number of detailed, micro decisions still needed to be made. Bovines have four stomachs with slightly different natures. What about tripe made from bovine stomachs? Similarly what about rennet also made from (different) bovine stomachs (and used in cheese manufacture)? Other important questions included how to deal with bovine heads (which contain the most potentially infective tissue, the brain, but also include substantial quantities of meat in the cheeks and the tongue); what to do about MRM produced from the spinal column, which contains the spinal cord, another potentially highly infective tissue; and what to do about calves which ought to pose much less of a risk since the ruminant feed ban had been in force for some time and in any case even if they had consumed contaminated feed the agent would not have had time to reach the brain and other nervous tissues. In the absence of new evidence, which even if experiments had been started immediately could not have been obtained for several years, the answers to most such questions were a matter of judgement. In fact decisions were informed by no less than ten reports from the head of the Pathology Department at the CVL on the detailed anatomy and physiology of the tissues under consideration and the consequent likelihood (based on the scrapie model) of their containing infectivity in an infected animal. It was regarded as highly probable from the start that brain, spinal cord, thymus, spleen, tonsils and intestines from adult animals would come within the ban. Following extensive discussions within MAFF, between MAFF and DoH, and public consultation the Order was made under the Food Act on 8 November and came into force on 13 November 1989. This defined the ban as applying to the bovine tissues listed in the previous paragraph. The four bovine stomachs, certain fat (mesenteric) and calves under six months of age were exempted from the ban. No extra controls were imposed on MRM. The production of sausage casings (made from intestines) fell within the ban. Even with the benefit of hindsight this list appears reasonably accurate. However, it appears that the position of MRM made from spinal column (which in turn contains the spinal cord) was not considered with the same care as the other issues. My suspicion is that the nature of the manufacturing process for MRM was not widely understood. However, it is unlikely the process could have been

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banned in 1989 on the evidence then available. Even in the very different circumstances of 1995 manufacturers were prepared to challenge a ban via judicial review when government imposed one having taken account of evidence which did not exist in 1989. The Regulations required the necessary action to separate the banned tissues (Specified Bovine Offals (SBOs)) to be taken at the slaughterhouse. They thus fell to be enforced by the District Council tier of local government, which was responsible for the enforcement of meat-hygiene legislation. In autumn 1989 MAFF attempted to call a meeting to discuss the implications of the proposals with the relevant representative organizations (Association of District Councils, Association of Metropolitan Authorities and Association of London Authorities) but this proved impossible since the organizations could not make themselves available. Eventually a meeting went ahead on 18 October without them though the Institute of Environmental Health Officers (IEHO) attended. MAFF wrote afterwards to the organizations unable to attend. Later, the BSE Inquiry pointed out that local authorities were never told (by MAFF) that it was essential that the entirety of the spinal cord should be removed from carcasses. This is correct though it is not apparent this should have been necessary or that it would have had a useful effect. The Regulations were clear complete removal was required. Enforcing authorities were invited to contact MAFF if they had queries. Writing to enforcement authorities emphasizing that legislation ought to be enforced properly is unlikely to be received enthusiastically by those authorities or to lead to useful action. Writing to emphasise that parts of new legislation should be enforced properly (for example that concerning removal of spinal cord) is only too likely to be interpreted as implying that other parts of the legislation are less important and hence are a lower priority in enforcement terms. That, too, is likely to lead to problems. Enforcing authorities have to be trusted to act efficiently – or they should be replaced as eventually happened in this case. Problems posed by the human SBO ban The detailed form of the human SBO ban produced one unanticipated problem. It introduced controls on the treatment and movement of bovine heads because brains were known to contain large amounts of the infective agent especially in animals that were showing, or were near showing, clinical symptoms of disease. However, heads that had had brains removed were not subject to these controls. Unsurprisingly heads which were not subject to controls came to have a higher value. This obviously provided an incentive to remove brains from skulls at an early stage of processing and in fact the proportion of cases where this happened, though it remained fairly low, increased somewhat. This appeared and was undesirable. If the brain was removed under normal butchery conditions there would inevitably be some risk of contamination of the surroundings and some of the methods used (in a few cases splitting the skull with an axe!) were highly undesirable. This risk could be avoided if brains remained within the skull until after all head meat had been harvested. Afterwards the skull could go for rendering which was a process which did not risk contamination.

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The IEHO was quick to appreciate that, given the stated objectives of the SBO ban, removing brains from skulls before processing was completed was inherently undesirable and that the incentive to act in this way provided by the Regulations should be eliminated. The instincts of MAFF Ministers were similar. MAFF officials were initially more concerned to defend the integrity of the protective system just put in place, no doubt fearing that tinkering with it could cause a loss of confidence in the rules. However, in this case confidence was more likely to be shaken by the retention of rules, which inadvertently provided an incentive to act in a way which increased risk. The Minister (Gummer) asked SEAC to advise. At their meeting on 13 June 1990 they took the sensible view that removing the brain before all head meat had been harvested ought not to be permitted. On 14 June MAFF issued guidance to this effect. A little later the House of Commons Agriculture Committee recommended that this guidance should be given statutory effect. On 21 November 1990 the government accepted this recommendation, though legislation was only put in place on 12 March 1992.

Late 1989 to early 1990: pressure for an animal SBO ban Initial pressure for a ban The human SBO ban thus went further than Southwood had recommended. Subsequent events were to show that it was not completely watertight but nevertheless together with the slaughter and compensation scheme adopted earlier it provided a high degree of protection to the human population. However, as so often in the BSE saga, attention then immediately turned to another aspect. This was the continued feeding of SBOs to animals other than humans and ruminants. (The human SBO ban excluded SBOs from human food while the ruminant feed ban excluded all ruminant protein including SBO from ruminant feed.) Very soon after the human SBO ban was adopted a number of organizations pressed for SBOs to be excluded also from other food including pet food and food for other farm animals, notably pig and poultry food. Even before the human SBO ban was adopted the major pet-food companies, Pedigree Petfoods and Spillers, had taken steps to eliminate bovine material of the type later characterized as SBO from their products. There is a lesson here. Major manufacturers especially of goods sold directly to consumers have a strong interest in protecting long-term public confidence in their brands, and this provides an incentive for cautious and responsible behaviour. Thus three days after the government had announced its decision to introduce the human SBO ban, that is on 16 June 1989, the Pet Food Manufacturers’ Association, the umbrella body representing companies producing some 95 per cent of manufactured pet food, announced a voluntary code of practice under which SBOs would be excluded from pet food. Their reasoning, as explained in an internal note, was the need to avoid adverse publicity. The Association explicitly noted that the code was not based on scientific evidence. Animal-feed manufacturers felt similarly. Soon their main representative body the United Kingdom Agricultural Supply Trade Association (UKASTA) had decided

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in favour of a voluntary measure whereby member companies were recommended to exclude SBO from animal feed. Some renderers also wondered if the complete exclusion of SBOs from all feed chains would not be wise. Others to express unease included the Consumers’ Association and the Chairman of the MLC. MAFF were initially opposed to this pressure. What lay behind the pressure for an animal SBO ban and why did MAFF oppose it? The pressure to take action had two strands. The one which appears to have featured less prominently in the thinking of those concerned was the risk of transmission of BSE to other animals, notably pigs and poultry. This would be alarming partly because it would represent BSE jumping a species barrier, but mainly because it would have represented an extra risk to the human population from the consumption of products containing pig and poultry meat. The main drive behind the pressure for an animal SBO ban was, however, not this concern but worries of a presentational kind. The public were seen to be uneasy about BSE. There was therefore from the perspective of the commercial interests involved advantage in distancing their products, such as pet food and animal feed, from such concerns. As we have seen those concerned were normally clear that their actions were not based on science. At this stage most thought along the lines of the Southwood Report – that the risk to humans was remote. MAFF consistently opposed this thinking to the extent of putting a degree of pressure of their own on UKASTA to amend their position and withdraw the recommendation not to use SBOs in animal feed. It is illuminating to consider why they took such a strong line. The relevant considerations are not fully set out in the Report of the BSE Inquiry. This reflects the Inquiry’s procedures which relied primarily on evidence from individuals. While this approach has a number of advantages each individual witness was obviously primarily concerned to explain and justify his or her own actions. In the cases of those rare individuals where this may not have been their own instinct they would have received firm advice to this effect from their lawyer who will also have recommended against commenting on issues with which they were not personally involved. As a consequence what might be called institutional concerns can be overlooked. One such institutional concern would have been the need to base policy on best scientific advice if there was to be any hope of deciding where to draw the line on protective measures and explaining and sustaining that line in discussion. It is always a disadvantage for governments to be pushed from pillar to post. That is one reason why from the government’s perspective it was desirable that the Southwood Committee and its successor, the Tyrell Committee, should include eminent individuals – to give their recommendations weight. It was true that the science on BSE and TSEs more generally was known to be highly uncertain as Southwood had made clear, but that made it all the more important to take and keep best advice on where the line should be drawn. Though I have not found an explicit statement to this effect in the evidence to the Inquiry, at this time (1989/early1990) MAFF officials probably regarded the pressure for an animal SBO ban as demonstrating the wisdom of keeping to the scientific advice. The human

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SBO ban had gone beyond that recommended by Southwood. This had not induced confidence but on the contrary appeared to have resulted in pressure to go yet further and adopt another measure not scientifically recommended. Where would this end? One moral which probably suggested itself to the officials responsible is likely to have been that going beyond Southwood in respect of the human SBO ban had made it more difficult to resist this further pressure. That indicated the wisdom of sticking to the authoritative advice. Another institutional concern would have been the possible repercussions of the economic effect of extra measures on the different sectors of the beef industry. This was not because MAFF officials had an exaggerated concern for the welfare of producers to the detriment of food safety as is sometimes claimed. The point was that an animal SBO ban would destroy the value of a product (SBO) so that total returns to the beef food chain (farmers, slaughterhouses, renderers, retailers) would be reduced. Both economic theory and experience suggested most of the effect would be felt by farmers and slaughterhouses. This was regrettable in itself and clearly such action should only be taken if necessary. But that would be unlikely to be the end of the story. A deterioration in the profitability of farms and slaughterhouses would be likely to lead to pressure for compensation, especially if that deterioration had been brought about by government action and action moreover which could not, on the evidence available, be claimed to be essential to protect the public. Farmers in particular had many champions especially on the government (Conservative) backbenches in the House of Commons. Experience showed that such pressure for compensation could not always be resisted successfully. If Ministers wanted to make concessions to such pressure that would inevitably put the Department in difficulty. The Treasury would certainly object and refuse to find new money on the grounds that it was for industry to meet such costs. If the pressure for compensation grew strong enough they might relent to the extent that they agreed to the subsidy if the Department found the money. Since MAFF was badly strapped for cash this would pose difficulties. Taking money from elsewhere in the budget would be bound to give rise sooner or later, probably sooner, to complaints from those affected. It is these two classes of concerns, both points of substance, which will have underlay much of MAFF’s resistance to the animal SBO ban over this period. The resistance to the concept in MAFF as revealed in the pages of the Report of the BSE Inquiry looks odd unless account is taken of these factors not really covered there. With the benefit of hindsight we can, however, see that there were better arguments in favour of stricter controls on SBOs than were advanced at the time. The arguments put forward for an animal SBO ban other than presentational ones related to the danger of transmission of BSE to pigs and poultry. On that MAFF pointed out that pigs had been fed much higher concentrations of MBM than cattle for many years without a single case of an SE ever having been discovered (or indeed induced) in a pig while the likelihood of transmission to poultry was even more remote. These arguments have stood the test of time. To this day no case of an SE has been caused in pigs by oral ingestion, and SEs are still unknown in poultry. MAFF’s

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opposition to the case for an SBO ban as it was presented was, therefore, sound. However, what their arguments did not deal with was the disadvantage of allowing widespread movement of SBOs including in feed mills where ruminant feed was produced. In these circumstances the possibility of accidental (or indeed deliberate) contamination of ruminant feed with SBO must always have been present especially since no test was available able to show the presence of ruminant protein in samples. An animal SBO ban would help with this problem.

Other developments in 1990 Thus pressure for an extension of the controls to include a ban on the feeding of SBO to animals other than ruminants grew during the first half of 1990. At the same time a number of other significant developments were of political importance and kept BSE in the news. These included: (a) The transmission of BSE to mice fed on infected cow brain. (b) The adoption of new EU rules stated to have as their basis the need to protect consumers in other member states from BSE which required exports of UK cattle and beef to satisfy certain conditions. (c) The removal of beef from school dinners by some UK local authorities. (d) The discovery of an SE in cats. (e) The incident in which John Gummer fed a beefburger to his daughter. (f) The enquiry into BSE conducted by the House of Commons Agriculture Committee. (g) Comments were made on the safety of beef both by those in official positions such as Ministers, the CMO and SEAC and critics of the ‘official line’. Each of these developments, discussed individually below, received extensive publicity. The seemingly inexorable drip of bad news, with previous incidents being recalled each time something new happened, served to sensitize the public to BSE in a very major way. The transmission of BSE to mice fed on cow brain On 1 February 1990 MAFF announced the results of some of the experiments set up following the Southwood Report. The less significant which attracted little interest was that BSE could be transmitted by injection of infected material into the brains of living cattle. The more significant, which did attract considerable attention, was that mice fed on infected cattle brain went down with the disease. The point picked up by the press was that this represented a jump across the species barrier and thus, they suggested, could have implications for human health. While to a layman this seems a reasonable view, it has to be said that the government’s scientific advisers did not demonstrate any great concern at the result of this experiment. Perhaps they viewed the conditions, feeding raw brain to a tiny animal, as so extreme that conclusions could not really be drawn. If so their caution received some support from the pig experiment discussed below.

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The establishment of EU rules on UK exports of beef and cattle At the end of 1989 Germany imposed a unilateral ban on the import of beef and cattle from the UK; other EU member states including France and Italy followed suit. The economic core of the EU project is of course free and unrestricted trade between member states. As is natural the EU Commission is fully seized of the importance of free intra-EU trade and deeply suspicious of any claims that special circumstances justify departing from the principle. In particular they are instinctively opposed to national measures which interfere with trade flows. In their view either the measures should be removed or they should be replaced by EU measures. It is worth stressing that for the Commission the principle that trade should be regulated by EU rules is more important than the precise details of what those rules should be. In 1990 qualified vets and the public took different views of BSE, not only in the UK but throughout the EU. Thus the EU Scientific Veterinary Committee (ScVC) concluded on 8 January 1990 that: Meat derived from animals in countries in which BSE is widespread is not considered to be a significant danger to public health. As a precautionary measure every attempt should be made to prevent the inclusion of large quantities of lymphatic and nervous tissue from products intended for human consumption. Nevertheless the national bans mentioned above were brought into force reflecting the fact that Ministers had felt obliged to respond to the concerns of consumers who were anxious whatever the views of the professionals. It is, therefore, significant that ScVC’s view at their meeting on 6 June 1990 was: … meat derived from bovine animals in countries in which BSE occurs is not considered to be a danger to public health. Nevertheless, as a precautionary measure, every attempt must be made… to remove obvious nervous and lymphatic tissues… These tissues, where removed, must not be put into products for human consumption. Given that some members of the committee will have felt constrained by the action taken by their national authorities this is a remarkably mild recommendation no doubt reflecting the professional views of members that the concerns of laypeople were probably unjustified. This meeting was held directly before a meeting of the Council of Ministers starting on 6 June. The latter was the first occasion we have considered in which I played a part. I was the senior official present as I was at virtually all meetings of the Agriculture Council at this period, that being one of the tasks of the post I then held which was mainly concerned with EU policies on agricultural production and trade. As was and is not unusual the meeting went on well into the small hours. I remember being very concerned because until the very end, despite the scientific view quoted above, it appeared quite likely that the outcome might not allow the export trade in UK beef to continue. Though at that stage the Commission were

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helpful to the UK reflecting the view of their veterinary advisory committee the Germans in particular were reluctant to lift their national ban. Given the alarmed state of UK public opinion I suspected that if the outcome of the meeting did not allow exports to resume to all other member states the resulting furore in the UK might force the Minister to resign. A civil servant’s first responsibility is to protect his or her Minister; from the personal perspective it was also the case that being the lead official at a meeting following which the Minister was forced to resign would be unlikely to be career-enhancing! When I discussed this occasion many years later with John Gummer I learnt that he had had similar thoughts about his position. At the time, however, we both kept stiff upper lips. In the event matters resolved themselves less dramatically. In the small hours the position of some delegations crumbled. This is not unusual for the Council of Ministers; by, say, 4 a.m. of the second day only those who really care hang on. On BSE at this time only the UK really cared for the reasons given above. Hence the outcome was more favourable for the UK than had seemed possible a few hours earlier. However, the reality of negotiation in the Council of Ministers is that the final ‘compromise’ is almost always put forward by the Commission and reflects bits of what every delegation has said. For legal reasons the outcome in this case was set out in a Commission ‘Decision’, a Decision being an EU legal instrument. The Decision required the UK to certify that boneless beef exported to other member states was ‘fresh meat from which… obvious nervous and lymphatic tissue has been removed’. This reflected the advice of the Scientific Advisory Committee. Bone-in beef had to be from holdings on which BSE had not been confirmed in the previous two years. In practice this Decision allowed trade to resume while the national bans were lifted. From the immediate practical point of view the outcome was therefore a success for the UK and was by and large reported as such. However, from some perspectives it was less satisfactory. It proved impossible to find a legally satisfactory definition of ‘obvious nervous and lymphatic tissue’. If such tissue had to be removed to protect the public ought it to be treated as SBO? Since the trimming concerned would typically take place in butchers’ shops this would have required an extension of the exacting controls on SBO to the thousands of premises involved with major implications for them and for the control authorities, that is for local authorities. Further, removing ‘obvious’ tissue still left much of it attached to the muscle: that part would eventually be consumed as beef. It would be absurd to treat the same tissue as both SBO and as prime beef. Yet treating the tissue removed as SBO would have precisely this effect. The truth was that the reason the decision on nervous and lymphatic tissue was difficult to apply was that it was a fudge without any scientific merit. Either lymphatic tissue was a danger or it was not; removing some of it imposed a cost without achieving anything. Eventually this part of the Decision was implemented in the UK via MAFF guidance which simply repeated the words of the Decision. The other part of the Decision on bone-in beef also lacked scientific rationale. It reflected the kind of measures adopted to control infectious diseases. But even at this stage it was known that BSE was not infectious – that is animals did not catch

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it from contact with infected animals. New cases frequently occurred in herds that had never had a case before and had never been in contact with infected animals. The measures reflected what vets in other member states were used to and not the known facts. It gave the appearance of action and imposed costs while not doing anything useful. There was a further difficulty on bone-in beef. The UK lacked a computerized cattle-tracking system although a manual record of movements between holdings was supposed to accompany each bovine. However, there were doubts whether the practical application of the system was sufficiently robust for the new rule to be applied effectively in all cases given the incentives to cheat. No doubt the vast majority of vets who certified that meat going for export came from animals which met the specified criteria did their best but with the best will in the world the scope for honest error was significant while not everyone could be relied on to be honest. Again, therefore, the UK was faced with applying a protective measure which was both of little scientific merit and difficult to enforce. Thus there was scope for rows and bad publicity when instances were discovered when the rules had not been adhered to even though any such breaches were likely to have no implications for human health. Such rows (and bad publicity) erupted now and again over the next few years. The banning of beef from school dinners by local authorities In April 1990 Humberside County Council became the first UK local authority to respond to the public’s worries about BSE by removing beef from their school lunches. Over the coming months and years with each upsurge in concern similar action was taken by other authorities. This was news at both local and national level. Sometimes such action was taken by authorities in rural areas to the anger of local farmers. The ensuing rows became in themselves good copy which helped to keep BSE in people’s minds. Discovery of an SE in a cat John Gummer was informed on 9 May 1990 that it was likely that a cat first examined in the Bristol University Veterinary School had succumbed to an SE. Questions that immediately arose included whether the discovery resulted from the cat’s exposure to BSE probably via food or merely reflected the greatly enhanced sensitivity of vets to SEs since BSE had emerged. Cats might previously have developed an SE occasionally without it being identified. After all the rate of CJD in man was about one in a million and at that level a disease in cats might well have been missed. It was known that previously it had been found possible to infect cats experimentally with CJD by intra-cerebral injection. Significantly it had not proved possible to infect cats with scrapie either by this method or orally. SEAC were hurriedly convened to consider the implications of the cat on 17 May. Faced with the uncertainties outlined above they concluded that it would be premature for them to form a definite view. In short they did not recommend any immediate action. Over the coming months dozens of further cases of feline

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SE were identified, and at one point it seemed possible that the number of cases would reach epidemic proportions. However, this did not happen and relatively quickly the number of cases dropped away sharply. Gradually it came to be generally accepted that the cause of the disease was almost certainly consumption of meat infected with BSE. John Gummer, Cordelia Gummer and a beefburger On 16 May 1990 an incident occurred – ‘Gummer’s daughter and the hamburger’ – which became one of the defining moments in the BSE saga. It seemed that whenever BSE hit the news it was recalled and John Gummer denounced though it was rarely made explicit for what, precisely, he was being denounced. When in September 2000 the newspapers were speculating with relish on who would be revealed to be the main ‘guilty parties’ in the forthcoming publication of the Report of the BSE Inquiry most assumed that Gummer would be one of them largely because of this incident. What happened was that while public concern on BSE was at one of its periodic highs following the discovery of an SE in a cat, Gummer was challenged by the media present at an agricultural show to show his confidence in his own pronouncements that beef was safe by feeding a beefburger to his small daughter who was present. Probably the situation was given added piquancy by Gummer’s (justified) reputation for being very much family-orientated. No doubt envisaging the likely critical headlines if he refused to comply and also genuinely believing beef was safe Gummer agreed, only for the young Miss Gummer to burn her mouth on the said burger. Her spitting it out made good television. How so many people persuaded themselves that this occurrence would justify a formal criticism of Gummer was never clear (the Inquiry rightly dismissed it in a couple of paragraphs). However, the incident is interesting from a psychological perspective. The public were understandably worried about BSE, and as a consequence anyone who was strongly identified with the subject, as Gummer already was before the incident which itself served to reinforce that perception, was likely to have directed at them intense bursts of hostility much more vehement than could be justified by any reasonable view of their actions. Douglas Hogg suffered similarly at a later date. These prominent individuals became proxies on whom the public felt justified in venting their fury, which in turn reflected their fear and frustration. The Enquiry conducted by the House of Commons Agriculture Committee The committee decided to undertake an investigation into BSE on 16 May 1990. It received evidence in June and July and published its Report on 10 July. The Report was well-written, ranging over the major scientific issues. In general it supported government actions though inevitably it suggested it had taken too long to put some measures in place – unnecessary delay is always an allegation that those without executive authority find it easy to make. Being couched in moderate terms and being broadly supportive of the government the Report did not make many waves. Nevertheless it contained some

A Chronicle of Events until 20 March 1996 63

important passages. For example it explicitly noted that SBO would have been eaten by consumers before the human SBO ban came into force. This was not, however, taken up by the media so that the point made in the following paragraph remains important. The Committee also recommended that an enquiry be set up into animal feeding stuffs. This was accepted by government. Comments on the safety of beef In response to the alarm generated by the coverage of all the developments set out above and the pessimistic statements made by some commentators of whom Professor Richard Lacey received the most publicity, MAFF and DoH sought to reassure the public. They emphasized two points; first that there was no evidence that BSE was transmissible to man, which was of course true at the time, and second that they were confident beef was safe, which, given the first point and the protective measures taken, was also reasonable. However, such claims only covered the contemporary position. If, unexpectedly, BSE was in due course shown to be transmissible to humans the position before the human SBO ban was adopted in November 1989 would have been different – and dangerous. Commentators did not seem to grasp this point, however, and given public sensitivity it was understandable that those who did appreciate it did not volunteer the fact. To do so might have been seized on by the media and if that led to a ‘scare’ the person concerned could well have been criticized – hounded is probably not too strong a word. Nevertheless the fact that the reassurances given might have been construed by the unsophisticated to amount to a claim that nobody had ever been exposed to danger, though unjustified, had the potential to cause trouble if in the event it were shown later that BSE did pose a threat to man. The statements made at this time set important precedents examined later (and often criticized) by the BSE Inquiry. It is worth examining some of them. In particular, while concern about SE in a cat was at its height the CMO issued a statement on 15 May 1990 which included the phrase: British beef can be safely eaten by everyone, both adults and children. In a TV interview on 16 May the CMO said: There is no risk associated with eating British beef. In neither case did the CMO make any reference to the fact that this assurance depended on the proper enforcement of the BSE controls, notably the slaughter and destruction of clinically infected animals and the human SBO ban. On one view (taken, for example, by the BSE Inquiry) it is particularly incumbent on the CMO, who is known to have a freedom of expression not open to other officials or indeed Ministers, to be particularly careful that his statements are not merely accurate but do not lend themselves to misinterpretation. On that view the CMO’s statement quoted above is unsatisfactory. The Inquiry point out that by omitting all caveats it would tend to mislead the public; they do not go on, as they might

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have done, to note that by its categorical tone the statement might have misled officials also. Understandably the CMO was keen that his statement should be endorsed by SEAC, and SEAC agreed to do so at an emergency meeting on 17 May 1990. Their attitude is set out in the minutes of that meeting: In describing the risk as no greater than those of everyday life, this was not to imply that they were in any way comparable, say, to smoking. BSE was of a much lower order of magnitude. But…it would not be justified to state categorically there was no risk to humans. SEAC set out their views in a letter to the CMO dated 24 July 1990. They said: … we believe there is no justification for not eating British beef. In the annex to the same document they stated: … our own opinion based on our assessment of the available scientific evidence is that the BSE risk… is so slight it can be ignored. It is also helpful to note one other statement in the letter: Oral transmission of some spongiform encephalopathies undoubtedly occurs – although very large doses are needed because the oral route is very much less efficient than, say, intracerebral inoculation. Those who claimed later that large doses were needed to infect orally were therefore only quoting the government’s own scientific advisers. We can ignore later obfuscations introduced by SEAC seeking to justify themselves to the BSE Inquiry by which time it was known that a ‘small’ dose was sufficient. They went on about the difference between the amount of infective material and the titre (concentration) of infectivity in that material and claimed they referred to the latter only. This may even be true. However, the normal meaning of a ‘dose’ of something be it a medicine or whatever, let us call it an ‘agent’, reflects both the amount (volume or weight) of the material containing the agent and the concentration of the agent in the material. ‘Dose’ is one multiplied by the other. If we are given a medicine and told it has double the normal concentration of the agent we would expect to take half the usual volume (or weight). SEAC’s 1990 view, quoted above, was that a lot of agent was required to achieve BSE infection by the oral route. The reference to a ‘large dose’ was presumably meant to suggest that more agent was required than qualified observers might otherwise have thought.

Late 1990: new evidence leads to an animal SBO ban The developments described above all served to heighten public concern over BSE. By the summer of 1990 the position was that there was widespread pressure for a

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statutory animal SBO ban, while some organizations were informally operating one. In part this reluctance of some to use SBOs reflected concern at the possible risks posed by feeding SBOs to non-ruminants, but even more it reflected attempts by those with commercial interests at stake to think of something which might soothe public opinion even if this entailed accepting additional costs without a good scientific justification. Meanwhile MAFF continued to oppose taking any further protective measures not clearly justified by the science or (what amounted to the same thing) recommended by SEAC. All this was altered by the discovery that BSE could be transmitted to pigs. This was achieved only under the fiercest conditions, that is by subjecting the pig to simultaneous intracerebral, intravenous and intraperitoneal inoculation – that is to injection of infected brain into the brain, the blood stream and the abdominal cavity. This result became available to government on about 20 August 1990. Given the extreme conditions of the experiment it was not self-evident that in itself the result justified taking further protective measures, and indeed officials in MAFF and DoH queried whether this would be justified. However, SEAC advised at their meeting on 19 September that: … pigs should no longer be fed with protein derived from bovine tissues which might contain the BSE agent, i.e… specified bovine offals … It would make sense to extend this prohibition to feed for all species. As far as human health is concerned…we do not believe that…any further action needs to be taken. That settled matters. In the jumpy state of public opinion there was no question of not introducing the protective measures that SEAC had recommended, and the animal SBO ban had become inevitable. The precise way in which it was introduced did not follow normal procedures which, as we shall see later, was unfortunate. The normal procedure is to announce an intention to legislate and to circulate details of what is proposed to all with an interest who then have an opportunity to comment not only on its desirability in principle but, crucially, also on the detail; often the draft legislation is circulated or at least shown to those with major concerns and, crucially, those with expertise are given the opportunity to draw attention to any weaknesses in what is envisaged. In this case it was thought that public opinion was too febrile for this to be possible. Instead it was decided to keep the SEAC recommendation confidential for a short period and rapidly to draw up the secondary legislation necessary to put it into effect. In this way it would be possible to adopt the response to the SEAC recommendation virtually at the same time as it was announced. It was hoped that this would serve to reassure the public. Accordingly the results of the experiment, SEAC’s recommendation and the government’s intention to legislate were announced on 24 September 1990, while the legislation was introduced immediately thereafter on 25 September.

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The difficulties of the animal SBO ban Experience over the next few years showed, unfortunately, that of all the measures adopted by government during the BSE saga the animal SBO ban in its original form was the least satisfactory. We will come back to the reasons for this later, but a contributing factor was the decision to draft in secret and to implement without consulting either those with an economic interest or those charged with enforcement. This approach would have been acceptable albeit not desirable if those concerned in MAFF had made a good job of drawing up the draft Order. Unfortunately they did not do so and the lack of consultation meant that their proposals were not subject to any informed scrutiny. There is a lesson here, namely that consultation on such matters is desirable and should only be forgone in wholly exceptional circumstances. Whether the state of public opinion in autumn 1990 justified forgoing consultation is a matter of judgement. If we judge by results it was not a success. For the present we need only note that the basic system adopted was to continue to treat SBO in the same way as ‘unfit meat’, that is meat that had been condemned by slaughterhouse inspectors as being unsuitable for human consumption or meat from knackeries or hunt kennels all of which was excluded from the human food chain. SBO had, for example, to be stained with the same distinctive dye as unfit meat. The system had been adopted to implement the human SBO ban since the rules for unfit meat were well known and specifically designed to keep material out of the human food chain.

Taking stock: the protective measures in place from Autumn 1990 Thus a full array of protective measures was in place from September 1990. The slaughter and compensation scheme protected the public from clinically ill animals, while the requirement to remove SBOs from all bovines served to do so in respect of subclinically infected animals. So far as animal health was concerned ruminants were protected by the ban on feeding them with ruminant protein. Other animals were protected by the ban on feeding them with ruminant SBO, that is by the animal SBO ban; the latter measure acted as an additional protection for ruminants since even if they were inadvertently fed ruminant protein it ought not, after September 1990, to have contained infective material. This was a comprehensive (and costly) set of measures which had a substantial degree of success. While with the benefit of hindsight we can see that none of them were 100% effective we can also see that the measures to protect human health were the more successful.

A relatively quiet period: late 1990 to 1994 After the adoption of the animal SBO ban in September 1990, the BSE story entered a relatively quiet period. A comprehensive system of controls had been put in place which it appeared ought in due course to eliminate the disease

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(though because of the incubation period it was appreciated that this would take several years) while protecting the public from any unexpected risk. The size of the epidemic becomes apparent However, it was clear from the latter half of 1990 that the epidemic would be much greater than had been initially expected. The number of cases rose sharply until the beginning of 1993 when it reached a peak. As Figure 4.1 shows (on a monthly basis), confirmed cases per week rose from about 150 at the beginning of January 1989 to 320 in January 1990 to 420 to 800 in January 1992 and to 860 in January 1993; thereafter numbers gradually fell. Of course this increase in cases proved nothing about the effectiveness of the measures taken. By the end of 1990 it was known that the average incubation period of the disease was nearly five years so the effects of any measure would not be noticed for several years (see also Figure 4.2). Over the four years or so following the adoption of the animal SBO ban policy was adapted as the results of various experiments set up years before and as evidence of the effects of the protective measures taken became available. These are described shortly. One unwitting experiment was not, however, referred to very often. This was the effect on people of hundreds, perhaps thousands, of clinically infected animals which probably went into the human food chain before the slaughter and compensation scheme was adopted in 1988 (and in many cases before the disease had even been properly recognized). Significant quantities of infectious material may also have reached consumers from subclinically infected animals before the human SBO ban was adopted in November 1989. The point was not overlooked. When I became Permanent Secretary in February 1993 the CVO told me he was uneasy on the former score in particular. Matters were, however, being monitored. The CJDSU had been set up to check for any evidence suggesting that BSE was having an effect on human health. There was simply nothing anyone could do to alter what might have happened as a result of this exposure before 1988/89. The dose of infected material required to infect cattle with BSE by the oral route All the evidence is that until well into 1994 it was more or less universally assumed that a relatively large dose of infectivity would be required to infect cattle via the oral route. (An earlier experiment at the Neuropathogenesis Unit (NPU)2 in 1990 which showed that half a gram of infected brain could transmit BSE to a sheep was not properly brought to the attention of those active in the area such as SEAC and MAFF and was not discovered by them until the end of 1994.) This was clearly the overwhelming view in MAFF as is shown by numerous internal notes written at the time supported by the recollections of most of those involved; the evidence is that DoH shared this view, as indeed did SEAC as we have already seen. Naturally the various sections of the beef industry took their cue from the relevant departments. This widespread assumption about the dose required to cause infection was probably more significant than it might appear at first sight. For example it may account for current attitudes towards enforcement

0

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Source: DEFRA: Monthly BSE statistics (Data valid to end of March 2005. Produced July 2005), © DEFRA (2004).

Figure 4.1 BSE cases in Great Britain confirmed by passive surveillance, by month and year of clinical onset

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Source: DEFRA: Monthly BSE statistics (Data valid to 1 June 2005 The inset shows 1996 to 2000 on larger scale as the cases for later years do not show on the scale used in the larger) © DEFRA (2005).

Figure 4.2 Confirmed cases of BSE in Great Britain with known dates of birth, by month of birth

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particularly of the feed ban. Clearly if a large dose of infectivity is required to cause infection minor cross-contamination in mills probably does not matter much; accordingly there would be no justification in insisting the industry should adopt expensive extra precautionary measures. Why was this view on dose, later shown to be misguided, held? The Report of the BSE Inquiry is not helpful in this respect. Perhaps those concerned did not want to discuss the reasons that had led them to support a wrong view. However, in discussion with those involved over the years I have identified two reasons which are, at least superficially, plausible. One was the belief that BSE was either the same as or very closely related to scrapie and hence would behave similarly. Since scrapie had existed for centuries, perhaps longer, it seemed to follow, given that the scrapie agent would almost certainly have been present in feed at some concentration since MBM had first been incorporated in ruminant feed decades before, that the sudden occurrence of an epidemic in cattle must be caused by an increase in the amount of infective agent present. As we have seen, changes in rendering procedures which occurred when the epidemic started gave a plausible explanation as to how this might have arisen. Note that in this view significantly reducing the amount of infectivity in feed would suffice to stop animals becoming infected. The second reason reflected the need to account for a puzzling phenomenon, namely the number of instances where only one animal in a herd succumbed to the disease. This is quite unlike the pattern for other diseases. A plausible explanation seemed to be that a critical dose was needed to cause infection and that feedstuffs normally contained concentrations of infectivity at a level below the critical one so that only the odd animal which by chance ate unusually large amounts became infected. These explanations do not feature in the Report of the BSE Inquiry by when they were known to have been disproven. By then the consensus view was different and there were attempts by some to claim that they had never accepted that a large dose was needed to cause infection. It is, therefore, instructive to consider the details of the ‘attack rate’ experiment started at the CVL by MAFF in January 1992 essentially to determine the dose required to transmit BSE to cattle orally. Calves were fed homogenized brain from BSE cases in doses of 1 gram (g), 10g, 100g or 300g. It was appreciated that as in the case of all other experiments on BSE the results would not be known for years. The structure of this experiment gives a clear indication of the expectations of those who set it up. This is because any scientific experiment set up to assess sensitivity will seek to include within it concentrations which give both positive and negative results. In this way the experiment will yield the most information because the dose necessary to give a positive result will be narrowed down to a range. If all the concentrations tested give the same result all we can conclude afterwards is that the critical level is above or below a given figure which is much less informative. Accordingly we can deduce that the expectation, or at least the best guess, of those who set up the experiment was that a critical dose would be well above 1g and well below 300g. This was highly significant because later when

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it became apparent that 1g was sufficient to cause infection in all normal cases it came to be appreciated that the assumptions that had underlain attitudes towards enforcement were unjustified. The details of the experiment were also significant for another reason. The existence and details of the attack rate experiment were widely shared within the scientific community. There is no record that it was criticized on the grounds that the doses tested would yield less information than was possible for the same effort – or in other words that the doses tested should be smaller. This does not prove that there might not have been those who had suspicions that this might prove to be the case. It does, however, show that if anyone did have such doubts they were insufficiently confident to voice doubts publicly (or indeed privately) and hence run the risk of being proved wrong. Claims by some after the real position had been established that they had never accepted the ‘high-dose’ theory should be judged with this fact in mind. Why those at the NPU who knew of the earlier work with sheep did not comment is not clear. The emergence of infected animals born after the feed ban (BABs) The major development between late 1990 and the end of 1994 was the advent of BABs and the attempt to account for them. Eventually serious conclusions had to be drawn to the effect that there had been a degree of failure to comply with the rules in some slaughterhouses, rendering plants and feedmills, both accidental and deliberate; that the local authority enforcement system was even less effective than had been thought; and that the rules themselves were inadequate in some respects especially taking account of the results of the attack-rate experiment described in the previous section which became known towards the end of 1994. However, this is to jump ahead and it was some time before these conclusions were drawn. The first BAB was reported on 22 March 1991, though this case was complicated by the fact that its dam had died of BSE raising the possibility that it represented a case of maternal transmission. However, by 15 November five cases had been confirmed and by 14 February 1992 16 cases. By 11 June the figure had risen to 69. This unwelcome development led those concerned to reflect more closely on the constituents of feed following the feed ban. They noted that at the time of the feed ban there had been no attempt to withdraw feed that might be contaminated from the feed chain. They also began to appreciate that contaminated feed or feed ingredients (some farmers make up their own feed) might linger on farms for quite a time especially if purchases were not used up in the order of purchase, which might well occur if new purchases were placed on top of existing stock. Those of us with experience of regular purchases of yoghurt stored in the family refrigerator will appreciate the possibility that a particular item might linger for a long time if stock is not properly reorganized after each purchase. The conclusion was accordingly drawn, quite reasonably, that there could have been a considerable carry-over of infected feed after the ban came into force that would be expected to cause many cases of BSE. Even more importantly, it came to be appreciated as the number of cases rose sharply in the period 1990/92 that the

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rate at which animals were being infected in 1988 when the ban was imposed had been rising sharply. Thus the delay of a month between the making of the Order and bringing it into force had been more significant than had been thought at the time. By June 1992 MAFF vets were advising Ministers that carry-over of infected feed could be expected to lead to a three-month lag in the effect of the ban. By September, given the relentless increase in the number of BABs being confirmed they were speculating that the period might be six months. By 10 November 1992 the number of BABs had risen to 353, 16 of them born in 1989 and that day the CVO met UKASTA, the main representative body for the animal feed industry. The latter gave him in confidence the results of a survey of their members. This showed that some feed containing ruminant protein had probably been manufactured right up to the date of the ban and some sold as late as October 1988. The ban on sale was meant to have come into force on 18 July. It had also been expected that manufacturers would cease using ruminant feed in ruminant protein directly the Order were made; the responsible ones did so but, apparently some did not. This information, regrettable as it was, lent credence to the carry-over theory. SEAC considered the question of BABs at their meeting on 22 April 1993. By then there were 1,791 BABs of which 108 had been born in 1989. The carry-over of infected feed was still considered to be the most likely explanation of the phenomenon though other explanations, such as maternal and horizontal transmission could not be ruled out. By 7 October 1993 when SEAC again considered the matter the number of BABs had risen to 4,010 of which 614 had been born in 1989 and 4 in 1990 (Figure 4.2, p.69). Despite the problem of BABs it was established that the number of cases was very much less than would have been the case had the course of the epidemic up to the imposition of the feed ban in July 1988 continued unchanged. A MAFF epidemiologist published a paper in the Veterinary Record on 12 March 1994 showing the extent to which the epidemic had declined despite the advent of BABs. By then cross-contamination in feedmills was suspected to have contributed to the BABs phenomenon. She wrote: The accidental inclusion of meat-and-bone meal in cattle feedstuffs or contamination with ingredients used in pig and poultry rations is also possible. This last point reflected consideration by MAFF epidemiologists of the geographical spread of cases with a disproportionate number being found in the Eastern counties of England where pig and poultry production is concentrated for economic reasons (because these are the counties with the greatest cereal production which comprises much of the feed of both pigs and poultry). In other words, cross-contamination in feed mills had contributed to the BABs phenomenon. By August 1994 four BABs had been identified, born in 1991. This was worrying and significant because it meant that infection had not been cut off by the adoption of the animal SBO ban. Thus, despite that ban and the feed ban some SBOs were finding their way not only into feed, which ought not to have been

A Chronicle of Events until 20 March 1996 73

possible (provided the definition of SBOs included all the infective parts of the bovine carcass), but into ruminant feed. The protective system put in place over the period 1988/90 had succeeded in reducing the number of cases to a major extent but it had not been fully effective. Major improvements in it were needed. We deal with the action taken below. Enforcement and monitoring in slaughterhouses, rendering plants and feed mills in the period up to early 1995 Before looking at the changes made to the protective system essentially in response to the continued confirmation of BABs, it is useful to look at the enforcement of the original controls. Essentially these required SBO to be kept separate from other bovine material and destroyed, ruminant protein to be kept separate from other protein and feed for ruminants to be kept separate from feed for other animals. An important practical consideration was that SBOs, which contained the intestines, were bulky and messy. They could not be dumped or burnt; they had to be processed first into a more manageable form and in practice this meant treated in rendering plants. Thus care was needed in slaughterhouses, in rendering plants and in feedmills (and on farms) and in the transport of material between all such premises of all material from slaughtered bovines. The first responsibility for ensuring the rules were adhered to lay with the operators concerned. It was obviously in the interests of operators throughout the beef sector to be scrupulous in following the rules, especially those concerned with a highly sensitive matter like BSE, since all of them (the operators) could be affected by the public reputation of the sector. Moreover, given the number of operators, the small size of many of them and how scattered they were geographically there were limits to what outside enforcement could achieve with the resources available. Given the self-interest of operators in sustaining the reputation of the sector relying to some extent on self-regulation did not appear unreasonable. This was the general view. The Report of the Lamming Committee (set up to investigate animal feedingstuffs following a recommendation of the House of Commons Agriculture Committee in their report on BSE) stated on 16 July 1992: … the ruminant protein ban and the specified offals ban are to a considerable extent dependent of self-regulation by the industry. The Lamming Report stated that in their view ‘the controls are working’. Unfortunately it gradually became clear that this judgement was an exaggeration in two respects. First it emerged that some animals could become infected much more easily than had been assumed. Secondly and sadly, it became apparent over time that whatever the long-term interests of operators in sustaining the reputation of the beef sector, the rules had been ignored by some slaughterhouses and probably some rendering plants and feedmills also. Thus probably some BABs reflected the unwitting results of actions that those concerned would reasonably have regarded as responsible in the light of the information they had been given; others certainly arose as a result of deliberate and/or careless infringement of the

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rules. Unwitting contamination was at bottom a consequence of the widespread view that a large dose of infective material would be needed to cause infection. Deliberate flouting of the rules owed more to the unscrupulous nature of some operators and the financial strains to which they were subject. MAFF were uneasily aware that the success of their BSE policy was dependent on satisfactory enforcement and from the beginning operated checks of their own on what was happening on the ground. However, they operated under a number of handicaps in attempting to do so. Such activity was not part of their normal work; accordingly they were not financed or staffed to undertake it. While some such work can always be absorbed they could not spend too much time on the task without neglecting other work. Further, responsibility for enforcing the BSE controls fell to local authorities and MAFF had no formal enforcement powers in slaughterhouses, rendering plants or feedmills. The legislation did not even give MAFF powers to monitor local authorities as some authorities were quick to point out. In slaughterhouses MAFF did not have powers of entry but instead had to rely on the good offices of local authorities to secure entry. Since it was apparent to all that such inspections were directed at finding out whether the same local authorities were performing their duties properly it ought to cause no surprise that MAFF vets found only a small proportion of the widespread abuse that became apparent only after 1 April 1995. On that date the Meat Hygiene Service was established as a part of MAFF and from then on SVS checking only had to rely on another part of MAFF for cooperation. Both levels of local authorities were involved in enforcing the rules on BSE. So far as slaughterhouses were concerned dissatisfaction with enforcement by (District) Councils was one of the factors that had led government to conclude that a national system was required. Nevertheless, speaking broadly, policing of the controls to protect human health in slaughterhouses was the only area where some real attempt was (mostly) made to enforce the rules. In that part of slaughterhouses where activities did not impact on human health, notably the gut room where SBO was stored, enforcement appears to have been close to non-existent; enforcement elsewhere in the chain was patchy at best. MAFF’s attempts to monitor enforcement outside slaughterhouses was handicapped both by their absence of formal powers and by the absence of a test that could detect ruminant protein and differentiate it from other protein. Work to develop such a test started in a MAFF laboratory in 1988. By 1994 though still not perfect it was sufficiently reliable to be used in feedmills and MAFF, by then sufficiently alarmed largely to sweep aside doubts about the legal position which had inhibited them earlier, started testing samples. There is evidence that the mere fact that such tests were taking place led some feedmills to tighten up their procedures. It was also important that practices in rendering plants did not risk contaminating material which would ultimately go for animal feed with ruminant SBO, though of course renderers could do little if the material delivered to them was already contaminated or was simply incorrectly labelled. There is evidence that both occurred. However, following concerns expressed in 1991 at procedures in

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some plants MAFF issued a code of practice on 7 August 1992 stressing the need to keep SBO separate from other material and suggesting how this could be achieved. Transmission of BSE to marmosets On 14 February 1992, MAFF and DoH were advised that BSE had been transmitted to marmosets by inoculation of infective brain material into the brain. The significance of this was that marmosets are primates and hence more closely related to man than cattle, mice or any other non-primate species. However, in the same experiment scrapie had also been transmitted in the same way to marmosets so it was not clear whether the results represented something to worry about or not. SEAC concluded that in the light of previous experiments the result was ‘not surprising’. SEAC’s 1994 Report on the present state of knowledge and research In September 1994, SEAC produced a Report on the present state of knowledge. This was a useful document but attracted no media coverage. Later the BSE Inquiry claimed that it demonstrated a significant change in SEAC’s perception of the risk posed by BSE. I refute this claim in more detail in Chapter 7. For the present it is sufficient to note that there is no evidence that the Report had any effect on the attitude of any of those working on BSE in DoH or in MAFF, though I for one studied it carefully at the time. If SEAC had intended to indicate they had revised their perception of risk then they were signally unsuccessful. CJD in farmers In August 1992, Will, the Director of the CJDSU, reported that he had identified a probable case of CJD in a farmer who had had a case of BSE on his farm. SEAC considered the matter on 15 October. Will reported the case in the Lancet on 6 March 1993. He wrote there that the case: … is most likely to have been a chance finding and a causal link with BSE is at most conjectural. Despite this, inevitably the case excited much media interest. ‘Mad cow link to death of farmer’ was a typical headline in one tabloid. As a consequence of the media fuss the new CMO made a statement on the safety of beef on the same lines as his predecessor had done (p. 63). Again the BSE Inquiry later criticized him for not including sufficient caveats in it. Matters became more serious in July 1993 when it became known that Will had confirmed a second case in a farmer who had had a case of BSE in his herd. SEAC concluded on 20 July 1993 that ‘no conclusions could be drawn from the available statistical information’. The DoH issued a statement intended to be reassuring, and in October SEAC decided that if a third case of CJD in a farmer appeared it would need to hold a meeting immediately. As we shall see, a third and a fourth case of BSE in a farmer appeared in due course but before then attention focused on a different case.

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The case of Vicky Rimmer Public concern reached new levels of intensity when it became known in January 1994 that a 16-year-old girl was suspected of having contracted CJD. It is highly unusual for anyone so young to contract CJD and the implications seemed very worrying. Some were quite clear on the lessons to be drawn. Stephen Dealler was quoted in Today as stating ‘It is an inescapable conclusion that BSE has got into our food chain’. In The Times Richard Lacey was quoted as saying ‘… this is the first case of BSE infecting a member of the human race by this method’. (The method was eating processed beef.) The case struck a cord with the public, understandably given the appalling state to which a teenager had been reduced. However, to this day it has not been shown that it had any relation to BSE. This may come as a surprise to many given that it was cases of CJD in young people that eventually led to the conclusion that BSE had probably infected humans. Nevertheless, though Vicky Rimmer is another example of CJD in a young person her case may well have no connection to BSE. The point is that in the cases of CJD in young people which led to the conclusion that they had been infected with BSE the brains of those concerned demonstrated certain specific and otherwise unusual patterns when they were examined after death; such cases came to be described as new-variant CJD or vCJD for short. Vicky Rimmer is not included within this class. If, therefore, she was infected by BSE, which is possible, she is a member of a different class of which other cases have not yet been found. Alternatively, her case may have had nothing to do with BSE and she may simply have been dreadfully unlucky. BSE agent found in the distal ileum of calves On 17 June 1994 it was reported that a MAFF experiment had shown that BSE could be detected (via injection of material into mice) in the distal ileum (small intestine) of calves fed a large (100g) dose of homogenized infected cattle brain at four months of age. This was potentially significant since calves under six months of age were exempted from the BSE controls. On the other hand, 100g of infected brain is an awful lot of infectivity and enquiries revealed that that part of a calf’s carcass is not used for human consumption. On 25 June SEAC considered the matter and clearly thought the risks, if any, to be minute, though they did note one option was to include calves’ intestines within the definition of SBO. They concluded that: … the theoretical risk of infection of man via food derived from infected calves is miniscule if it exists at all. There is a theoretical risk and Government could respond by a limited SBO ban for calves to exclude the intestines. The CMO, however, was by now becoming alarmed about BSE and quickly concluded that extending the SBO ban to include calves’ intestines and thymus (another potential risk by analogy with the scrapie model) was the correct response. Judging by the evidence given later to the BSE Inquiry there appears to

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have been some disagreement about this at working level between DoH and MAFF; this would not be surprising given SEAC’s views. If this was the case it never surfaced at top level. The Minister (Gillian Shephard) quickly made it clear that she would be guided by the CMO and there was no dissent. The relevant Order was made and came into force on 2 November 1994. Result of attack-rate experiment The official results of this experiment were not put forward until February 1995. However, the Attack Rate Study was being conducted at a MAFF site and by the second half of 1994 it was becoming known to Ministers and officials that the animals succumbing to the disease included some which had received the minimum dose of one gram. One gram was a much lower dose than most had considered would be required. The information coming forward from the vets that one gram was sufficient became stronger as the months passed, presumably as more animals challenged with only one gram succumbed to the disease. This information on dose was of considerable significance since it suggested greater care was needed throughout the animal feedchain than had been hitherto assumed by all if contamination were to be avoided. Report of CJD surveillance unit An appropriate end to this section is provided by quoting from the third Report of the CJDSU published on 7 October 1994: We see no evidence… of an emerging CJD epidemic. We…. remain satisfied with the adequacy of current controls to protect public health in regard to CJD.

1994: a reassessment of the success of the animal health controls By the summer of 1994 it had become clear that a substantial proportion of BABs could not be attributed to the carry-over of feed after July 1988 when the feed ban came into force, or even after October 1988 when the sale of ruminant feed which incorporated ruminant protein and hence possibly BSE infectivity had apparently actually stopped. Action needed to be taken to strengthen the animal health controls. The position with which policy-makers were faced was that there was no evidence that infection had been caused other than by infected feed. New cases had therefore probably consumed infected feed. On current theories feed could only be infectious because it contained ruminant protein which after July (or October) 1988 ought not to have been possible. Further, after November 1990 when the animal SBO ban came into force ruminant protein ought not to have contained SBO. Nevertheless, feed could only contain infectivity if despite the rules it contained not only ruminant protein but SBO. Alternatively the current definition of SBO might not include all the organs which could contain infectivity. There was at this stage no evidence for the latter so feed which caused infection had probably included ruminant protein which itself included SBO.

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Each one of the steps in the above argument was at the time rather less certain than I have presented it. It must be remembered that BSE was a new disease and little was certain. For example horizontal (bovine to bovine) or vertical (dam to calf) transmission had always been recognized as possibilities although by this stage it was known that if either occurred it was at a low level. Later, in 1998, it was found that one organ, the dorsal root ganglia, not included within the definition of SBO, could contain infectivity. This shows how in a new field nothing is ever entirely secure. However, even with the benefit of hindsight it is apparent that not treating dorsal root ganglia as SBO did not fully account for the BAB problem. By mid-1994 it was clear that action was needed. The disquieting analysis set out above seemed to imply the rules were not being followed either in slaughterhouses or in rendering plants or in feedmills or in transport between sites or, conceivably, all these possibilities were true. Yet another possibility was that the rules were wrong. Possibly stricter controls were required. This could involve a number of minor changes but two major ones were considered. The first was to concentrate on SBO by requiring it to be processed in specially dedicated rendering plants and keeping it separate from other material until disposal. This approach would have as its aim and method keeping infectious material away from cattle feed. The second was to require ruminant feed to be manufactured in specially dedicated mills, thereby eliminating the possibility of ruminant feed being cross-contaminated with feed for non-ruminants and, hence, perhaps with infectious material despite the animal SBO ban. The two possibilities were not mutually exclusive; it would have been possible to require both. It was apparent that both would prove difficult for the industry, especially small operators (renderers or feed manufacturers) which might well be forced out of business. Consideration of what modifications to the rules would provide the most effective system at least cost proceeded in parallel with the search for what had gone wrong. Three conclusions seemed inescapable. The first was that the animal SBO controls adopted in 1990 were misconceived and unsatisfactory. The system for treating SBO was essentially the same as had been put in place when the human SBO ban had been adopted in 1990. It was based on the long-standing regime for ‘unfit meat’. The latter consisted of material condemned in slaughterhouses or derived from ‘fallen stock’, that is animals which died on farm and were sent to knackers or hunt kennels. Before the adoption of the animal SBO ban this system had been a reasonable one since the only objective then was to keep SBO material out of the human food chain. The unfit meat regime was designed to do just this. However, much meat deemed unfit for human consumption after processing went for animal feed; that was economically and environmentally the best way to dispose of it. The whole system – which involved bins of material travelling round the country labelled ‘unfit for human consumption’ – was inadequate for material which had to be kept out of animal feed. Unless bins were carefully labelled SBO could be confused with other material unfit for human consumption. The same dye was used to stain unfit meat and SBO and this requirement was left unchanged when the animal SBO ban was adopted. Hence even a diligent enforcement officer – of whom there were far too

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few – would have had difficulty in ascertaining whether a particular batch of animal residue in various stages of decay contained unfit meat or SBO. The legislation contained no requirement not to mix SBO with other material. Given the economic incentives it is small wonder that a proportion of SBO (a source high in protein) found its way into animal feed. In short the need fundamentally to amend the SBO regime when the animal SBO ban was adopted had been missed. Secondly, and even allowing for the unsatisfactory nature of the animal SBO ban, it appeared that local-authority enforcement had also been inadequate. The full extent of this failure did not become apparent until after 1 April 1995 when the MHS assumed responsibility for enforcement in slaughterhouses. I describe this below. At this stage it was more a matter of suspecting that failures in enforcement had occurred more frequently than had been detected. Accordingly, the intensity of monitoring by the SVS in slaughterhouses and in feedmills was stepped up at this time despite the legal difficulties and the difficulty in finding veterinary resources. Thirdly the suspicion began to emerge, fed in part by information and/or rumour, that a proportion of operators in slaughterhouses and to a lesser extent in rendering plants and feedmills was prepared to act irresponsibly. MAFF officials decided it would be best to concentrate on controlling the treatment and movement of SBO. With the approval of the Minister (William Waldegrave) the following proposals were circulated to interested parties for comment in August 1994: (a) a suggestion that SBO should be rendered in dedicated lines or in dedicated rendering plants; (b) a requirement to stain SBO with a distinctive dye, that is a different dye than that used for unfit meat; (c) a requirement to handle, store, transport and process SBO separately from non-SBO material; and (d) a requirement that operators keep extra detailed records of the treatment of SBO which had to be kept available for inspection. At this stage (a) was put forward more tentatively than the other proposals, because it was known that several renderers could only operate such a system if they installed expensive new equipment. They might not be able to afford to do so and if not one renderer, Prosper de Mulder, which already operated dedicated lines, might gain a virtual monopoly in treating SBO. Since the Monopolies and Mergers Commission had expressed concern more than once about the dominant position in rendering exercised by this firm, this would be unfortunate. At about this time the first results of the attack-rate experiment began to become known, which provided extra justification for the proposals put out to consultation as did emergence at much the same time of BABs born in 1991, well after the animal SBO ban had been imposed. As expected, the principal difficulty that emerged from the consultation was over the possibility of requiring the use of dedicated rendering facilities for SBO.

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Eventually early in 1995 the CVO decided in the light of all the emerging evidence that it was necessary to make this a requirement even though it might take some time to put into effect. A paper to this effect was put to Ministers on 9 January 1995. This was discussed with the Parliamentary Secretary on 19 January when I am recorded as saying that ‘it was clear we needed to implement the proposals… The difficulty would be in explaining why we had not done so at the outset.’ This last remark proved all too accurate. The proposals were approved and it was decided to go ahead with the introduction of the new staining requirements ahead of the other proposals. An Order was made accordingly with the requirement to use the new dye coming into force on 1 April 1995, the same day as the Meat Hygiene Service (MHS) took over responsibility for meat inspection from local authorities. As we shall see, these two changes were the key to the major improvements in standards it was possible to achieve over the next few months. Standards in feedmills are improved From the second half of 1994, MAFF was engaged in tense discussions with UKASTA. The discussions would have appeared to outsiders as a mysterious dance but what lay behind them was UKASTA’s fear that their members might be pursued in court by farmers for selling them feed contaminated with BSE. UKASTA hoped to get an indemnity or, more realistically, some assurance from MAFF which would help in this respect. To obtain it they suggested that they might be forced to cease using MBM which they knew would be unwelcome to MAFF because of the unpleasant economic and environmental effects. In short, UKASTA’s game plan was to threaten to cease using MBM which they expected to alarm MAFF who would urge them not to take such a damaging step. They would be able to reply that they might not make the change if they were assured that reasonable endeavours on their part to keep MBM out of ruminant feed would meet their legal obligations. If we had been prepared to make such a statement no doubt they reasoned that thereafter any legal liability would lie with government rather than their members. UKASTA’s representations on these lines were made to me. I was sympathetic in general but naturally could not give any assurances implying that the regulations excluding ruminant protein from ruminant feed need not be fully met. The trap was an obvious one. From about this time matters seem to have improved. The information on dose from the attack rate experiment had an effect as did the threat posed by MAFF’s growing use of the ELISA test as it became more reliable. Among actions taken by feedmills were the exclusion of MBM from ruminant mills and the installation of dedicated blow lines for MBM in others.

From 1 April 1995: the establishment of the meat hygiene service transforms the situation The MHS took over responsibility for enforcement in slaughterhouses on 1 April 1995. As a direct result it was discovered that some operators were more or less

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ignoring the rules on the treatment of SBO and that the attitude towards enforcement of a proportion of those charged with providing it was unacceptably lax. As a consequence of what was learned for the first time about the real position on the ground, significant changes were made to the protective system and because of the existence of a single body under departmental control it proved possible, though only at significant cost, to achieve major improvements in enforcement standards. The advent of the MHS represented a major step forward not least in government’s ability to control BSE, and it is a pity it did not come into being earlier. Improved enforcement standards did not come about overnight on 1 April. Except at the top level MHS staff had been taken on from local authorities and they carried on as before. The breakthrough occurred as a result of monitoring by the SVS on the use of the new die for SBO. Now that monitoring was a matter of checking on enforcement by a MAFF body it was a much easier process because the legal constraints disappeared; obviously the department was entitled to monitor itself. It was perhaps also significant that the top management of the MHS were new and hence could not be held personally responsible for existing practices. They were therefore less defensive when deficiencies were found than might otherwise have been the case. In late April 1995, Prosper de Mulder notified the SVS that most SBO arriving at their relevant plant, which processed some two-thirds of the SBO produced in the whole country, was arriving without being stained with the new die. SVS enquiries seemed to confirm this surprising finding though it was not clear whether this was a transitional problem reflecting the introduction of the new die. As one consequence the SVS decided to make an unannounced visit to every slaughterhouse to check on the treatment of SBO during May/June. Follow up action would follow any contraventions found. The summary of this round of visits put together at the beginning of July noted that 14 per cent of slaughterhouses had not fully complied with the rules on separating SBO, and 65 per cent had not complied fully with the rules on staining. Though some of this failure reflected the recent change in the required die there was, the official noted, ‘widespread and flagrant’ infringement of the staining regulations. In some cases no attempt had been made to stain SBO and it was stored in unmarked containers suggesting it would have found its way into animal feed eventually. In some cases management had not even sought to obtain the die without which they could not operate legally. This finding came as a shock since it showed a much worse situation than had been found before when such inspections had had to rely on the goodwill of local authorities. It led to vigorous action by the SVS on this and other matters and to a series of instructions to the MHS which over the next few months was able to transform the situation. Inspectors who had been transferred from local authorities to the MHS came to appreciate that different and higher standards were required across the board not least regarding the BSE controls. Further series of unannounced visits were held and the situation gradually improved; even recalcitrant slaughterhouse operators – a tough lot – came to realize that they would be prosecuted if they did not comply, a sanction almost never invoked under the

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previous regime. All this was reinforced by the Minister (Douglas Hogg). On 9 November 1995 he told slaughterhouse operators that 100 per cent compliance was required, that there would be no more warnings and that deficiencies would result in prosecutions. By 4 January 1996 the failure rate – that is slaughterhouses where lapses had been found – had dropped to 6 per cent and these were of a minor nature. Further improvements in the animal health regime We saw above that the requirement to stain SBO with a specific die was introduced on 1 April 1995 ahead of the other proposed improvements in the animal SBO ban. This had proved a good move since it had revealed the extent of noncompliance in slaughterhouses and the weaknesses in enforcement and allowed steps to be taken to deal with both. These discoveries reinforced the need for the other measures. An Order introducing all the new requirements was signed on 18 July 1995, though the obligation to use dedicated lines for rendering SBO was delayed for six months to give those concerned time to comply. The drive from MAFF and the MHS with consistent, energetic support from the Minister (Douglas Hogg) drove standards upwards throughout 1995 at all stages of the beef chain as is shown by the rate at which animals became infected (see Figure 4.2). Why was enforcement unsatisfactory and why was this not discovered earlier? It was well-known to MAFF that standards in slaughterhouses were dubious and that the local authority enforcement system could not or would not bring about improvement. This was the main justification for the decision to create the MHS. Of course it did not help that there was a vociferous lobby denying that standards in slaughterhouses were low, denying the need to involve vets in enforcement and opposed to the creation of the MHS. Nor did it help that these views were well represented on the Tory backbenches and in the Tory press and, one might add, among some non-MAFF Ministers. This negative chorus was not countered by support for the concept of the MHS from consumer organizations, which one might have thought would interest themselves in proposals to improve meat hygiene and the enforcement of rules on BSE. The extent of the transgressions in the treatment of SBO revealed by SVS monitoring in 1995 came as a surprise. It is instructive to consider why these had not come to light earlier. Enforcement work was underfunded by local authorities and many of those involved in it appear to have been demoralized. The system was due to be replaced which will not have helped. There was among some meat inspectors a resentment at veterinary ‘interference’ along the lines of a standard trade-union demarcation dispute. Rivalries between those charged with enforcing the rules will not have helped the overall enforcement effort. In some cases it seems meat inspectors did not operate as independent entities charged with protecting the public interest, but more as members of plant staff; ‘regulatory capture’ is the technical phrase and

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this was a particular problem for slaughterhouses where the regulators are few and isolated among many of the regulated. A culture of avoiding prosecutions had grown up. In short the system was inadequate for modern purposes and was probably getting worse as the time approached when it would be replaced. Though the shortcomings listed above confirmed the wisdom of the decision to replace local authority enforcement with a national system enforcement may well have deteriorated as the change loomed. One question that arises is whether the SVS ought to have discovered these inadequacies of enforcement earlier. Later the BSE Inquiry made rather a meal of this looking into all aspects in great detail. On this we need to remind ourselves of the limited powers the SVS possessed. They were not the enforcement authority in slaughterhouses or elsewhere; that role fell to District and County Councils respectively. The SVS had not been given any statutory role to monitor the position, and after the Food Safety Act came into force in 1990 they did not even have powers of entry. This meant that the SVS could only monitor matters from a position of weakness. They could only act with the agreement of slaughterhouses – that is those whose activities were being inspected – or, failing that, with the agreement of local-authority inspectors who did have powers of entry but whose efforts at enforcement were also under inspection. Some of the latter would have harboured resentments that their role was due to be taken over by a new part of MAFF (the MHS), and this will not have made cooperation easier. It must also be recalled that at this period the deregulation initiative was at its height. Under this banner a proportion of the press were apt to criticize ‘petty bureaucrats’ who exceeded their powers. Since SVS staff did not have any powers in relation to the animal SBO ban, any attempt on their part to push matters with, say, a recalcitrant slaughterhouse owner would lay them open to just that charge. Given the legal position and government support for ‘deregulation’, a veterinary officer out in the field who suspected that all was not well in a given slaughterhouse and was contemplating how hard to push matters with the management and/or local authority could be forgiven for wondering how much support he would receive from his superiors if a complaint were made that he had exceeded his powers – a complaint likely to be justified by a strict interpretation of the legal position. This thought will not have encouraged courageous action. All these considerations put obstacles in the way of effective monitoring of the situation by the SVS. In particular because of the absence of legal powers it would have been likely that inspection visits by SVS staff would have been agreed with slaughterhouse management beforehand giving plenty of scope for things to be tidied up. Really vigorous and unannounced inspections were unlikely to be made unless staff knew the need for them was fully recognized right at the top and that this task had priority over others. This did not happen until the 1995 developments described above. Given the circumstances it is perhaps not surprising the real situation was not revealed until then. There are some lessons here. One is that it makes a big difference whether those charged with enforcement and/or monitoring of enforcement are possessed of the

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formal powers to fulfil the role assigned to them. It is not satisfactory to expect people to achieve something if they have not been granted the powers to accomplish it. During the period after 1990 SVS management – with periodic encouragement from Ministers – had required the field service to report on whether the BSE controls were being enforced properly and it is now clear that the reports they received were misleadingly optimistic. When in 1994/95 the true position became clear there was some breast beating about all this. Anecdotal evidence, some of it from seemingly reliable sources, had certainly been received from time to time that SBO was being improperly mixed with other material. Reading about how these reports were treated one is left, overall, with the impression that with different personalities in some key positions in the SVS something like the truth might have been established earlier. This is not, however, the main point. The SVS had no formal locus in the control system for slaughterhouse operations (other than in the licensing scheme) as is made clear by the fact that they did not even have powers of entry to check on operations. Relying on exceptional individuals in another service (SVS) to identify deficiencies in the activities of those whose responsibility it was to provide enforcement (District Councils) would have been absurd. Further, with the system of local authority enforcement it is doubtful whether even if the truth about the widespread breaking of the rules had been known it would have been possible to put matters right. More limited deficiencies are found in the human health controls: action is taken on mechanically recovered meat SVS monitoring discovered widespread non-compliance with the rules protecting animal health. In October 1995 it also revealed for the first time a few cases where the human health controls had not been met in that pieces of spinal cord, a part of the carcass which can contain substantial amounts of infectivity in animals harbouring BSE, had not been removed properly yet the health stamp had been applied by the inspector. Subsequent checks showed these were not isolated cases though the level of failure was always low. The first such incident came as a shock to everyone since it was the first time evidence of any failure in the human-health controls had been discovered. (It must be appreciated that the existence of BABs showed only that all was not well with the animal health regime.) The CMO came to see me on 25 October and registered his concern at this development and at the position on BSE more generally; at his request I arranged for him to see the Minister (Douglas Hogg). (After my meeting with the CMO I recommended to Hogg that MAFF should call in the slaughterhouse owners and ‘read the riot act’. Hogg did so personally and this helped to impress on them the necessity of doing better.) Later in his evidence to the BSE Inquiry, the CMO stated that he had always relied on a system of inspections having been put in place by MAFF to ensure the ban was in place and (implicitly) 100 per cent effective. It is not clear whether he was aware that enforcement in slaughterhouses was not a MAFF responsibility until 1 April 1995 and the lapses had only been discovered because of this change in responsibility.

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In any case the finding ought not to have occasioned such surprise. It subsequently emerged that as long ago as 1990 MAFF had submitted a paper to SEAC which stated that it was inevitable that occasionally pieces of spinal cord would not be fully removed from carcasses. A minute’s reflection on the nature of the process involved – sawing down a backbone with a hand held saw sufficiently accurately to allow the spinal cord to be wholly removed afterwards leaving no traces behind – confirms that this must be the case. However, it is true that examples of such failure had not been found before, so it had come to be assumed that they did not happen. Also the results of the attack-rate experiment and the cases of CJD in farmers and young people cast BSE in a more sombre light and reactions to the discoveries on spinal cord probably reflected the fact. The 1990 MAFF paper had been put forward to aid SEAC’s consideration of whether special rules were needed to govern the production of MRM especially from the spinal column. At that 1990 meeting SEAC had concluded that the MRM process could be allowed ‘provided all the rules were properly followed’ – that is provided things happened in the very way MAFF had advised could not be relied upon. It appears that MAFF had assumed their technical advice on the practical position in slaughterhouses had been set aside by SEAC as inconsequential, while the truth was that SEAC had simply overlooked it in the press of a large agenda and limited time. Instead they had substituted their own views on what was possible in slaughterhouses, a subject in which they were not expert. SEAC had subsequently reconsidered MRM but confirmed their previous advice. The findings of spinal cord in 1995 gave reason to reconsider matters. The discovery of sections of spinal cord in carcasses after they ought to have been removed was made public by arranged Parliamentary reply on 22 November together with the steps taken to deal with the problem. In the light of these developments SEAC considered matters on 23 November 1995. By then small amounts of spinal cord had been found in carcasses on 17 occasions. This was the first meeting held under the new Chairman, John Pattison, who must have quickly come to realize what he had let himself in for. Eventually SEAC decided that: … until it was clear that the removal of SBO, particularly spinal cord, was… being undertaken properly in all cases it would be prudent, as a precaution, to suspend the use of vertebrae from cattle aged over six months, in the production of MRM. A measure to this effect was pushed through quickly, though for practical reasons the restriction had to be applied to all cattle. Only a few days were allowed for consultation contrary to standard practice and the measure prohibiting the use of the spinal column in the manufacture of MRM came into force in early December. By now BSE was very much centre-stage and legal and constitutional niceties took second place. Even so the legislation concerned was attacked by way of judicial review. Thus, ironically, the production of MRM from the spinal column was banned just as enforcement of the rules was being tightened up to a major degree. However, the change also had the unintended effect of keeping dorsal root ganglia

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out of MRM which was probably of greater significance since it was not defined as SBO and years later was found to harbour infectivity. Further cases of CJD in farmers: cases of CJD in young people In late 1994 a third dairy farmer died from CJD, which was sufficiently disturbing for SEAC to hold a special meeting to discuss the matter on 13 January 1995. This was recognized as being statistically significant in the technical sense, that is the likelihood of three cases in farmers emerging by chance given the total number of cases was very small indeed, but in the absence of evidence that these cases differed from the normal sporadic type there was little SEAC could do other than to seek further information. The press learned of the third case in September when a suspected fourth case in a beef farmer who had had a case of BSE also came to light. Also, even more ominously, further cases of CJD in young people were discovered. Suspected cases were referred to the CJDSU in May, August and October 1995. By the end of the year there were seven suspect cases in persons aged under fifty years (the normal lower age limit for cases of the disease) in addition to three confirmed cases. I am not clear whether DoH was aware of the number of suspected cases; certainly MAFF was not informed until later when SEAC was discussing the possible link with BSE. On 23 October SEAC issued cautious comments on both phenomena noting that there was no evidence of a link to BSE. One of the leading academic workers on CJD and BSE is Professor John Collinge of St Mary’s Hospital in London. His work interests are reflected in one of his job titles in 1995, ‘Honorary Consultant in Neurology and Molecular Genetics’. He was, in short, just the person to take a keen, expert interest in unexpected or unexplained cases of CJD. By 31 October 1995 he was sufficiently concerned that the cases in young people might have BSE as a cause to put his concerns direct to the CMO at a meeting which it appears he sought. The CMO suggested at about this time that Collinge and others should become members of SEAC. Collinge was obviously well-qualified and following Ministerial approval he became a member in December. The CMO did not, however, pass on to me or anyone else in MAFF Collinge’s fears. There is an interesting point here. At the beginning of the BSE saga in 1986/88 MAFF had taken some time to inform DoH of the discovery of BSE, which was, of course at that stage not expected to have any implications for human health. Later the BSE Inquiry made a lot of this and founded a specific criticism on this ‘failure’. However, they did not even ask Collinge or the CMO why they had not informed MAFF of their fears in 1995. This difference in approach is surprising. In 1986/88 there was nothing DoH could have done to protect the human population; indeed as we have seen all they achieved when they were informed was to delay action necessary to achieve that end. In 1995, by contrast, MAFF was theoretically in a position to take action to protect the public better, for example by pushing up slaughterhouse standards even faster. As it happens the CMO could possibly have justified his position by saying that the doubts raised by Collinge were insufficiently well based in October 1995 and

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in any case SEAC was the government’s formal adviser. However, this is not so obviously a satisfactory reply as to make it unnecessary to ask him the question. The fact that the Inquiry did not put it to him throws an interesting light on their mind set. Reactions, media reporting and official comments Thus developments in 1995 included the finding of CJD in farmers and young people, the discovery of unsatisfactory removal of and handling of SBOs in slaughterhouses and government decisions to tighten the protective rules and enhance enforcement effort. All these attracted intense public interest all too well reflected in the media. Alarming articles appeared in every title. The media sought comments from anyone who might be credible as a commentator or whose remarks might be worth quoting. The stress level for those involved in government was high and, unsurprisingly, some made comments they would later regret. In one widely publicized comment, Sir Bernard Tomlinson, a retired Professor of Pathology, said on 1 December that ‘all offal should be kept from public consumption’ and that he personally would not eat beefburgers. Sir Bernard was justified in being concerned at the trend of events but had no basis for questioning ‘all’ offal which would include some, for example liver, in which infectivity had never been found and where it was implausible to think it might be. The BBC chipped in giving advice to listeners on the dangers of BSE over a ‘helpline’. Inevitably, given their lack of credentials, they got matters wrong. One listener was advised that meat stock cubes such as Oxo were unsafe. Oxo was in fact made from supplies from South America where BSE was unknown; thus a brand was damaged for no good reason. In response to this appalling publicity the MLC embarked on an advertising campaign which contained several exaggerations for which their Director-General was later criticized by the BSE Inquiry.3 On a TV show Stephen Dorrell, then Secretary of State for Health, was trapped into agreeing that there was ‘no conceivable risk from what is now in the food chain’. This, too, was later criticized by the Inquiry. The Inquiry also criticized the CMO for making statements (like his predecessor) that beef was ‘safe to eat’ without making it clear this advice depended on the proper implementation of the SBO controls. The Scottish CMO was also criticized for unwise remarks he made at this time. However, the most interesting point relates to the dog that did not bark. No comments by the Minister of Agriculture (Douglas Hogg), his junior Ministers or MAFF officials made at this time were later criticized by the Inquiry even though the total number of statements made by this group undoubtedly greatly exceeded those made by all others put together. Public comments by the chairman and deputy chairman of SEAC The last few paragraphs may have suggested to some that it was apparent by the end of 1995 that bad news was round the corner. Those who have come to this view may wonder why those involved, like me, could not see this. With hindsight matters may look like that, but at the time opinions, including the opinions of distinguished, independent outsiders, were different. This is

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demonstrated by the terms of an article published in the Independent on 8 December 1995 written by Robert Will, the Deputy Chairman of SEAC and Head of CJDSU and another jointly written by Will and Pattison, the Chairman of SEAC, sent to The Times on the same date and later published by MAFF when The Times said they would only publish it in shortened form. These articles were volunteered; indeed there was no way outsiders like Pattison and Will could be pushed into writing articles against their wishes. While neither article dismissed the potential threat of BSE to humans their tone was reassuring. Will’s article was entitled ‘No significant risk from beef’, and included the following: Transmission by the oral route… is extremely inefficient, requiring large doses of infectivity. The incidence of CJD remains similar in other countries in Europe and also elsewhere, indicating that there is no relative increase in the incidence of CJD that can be attributed to BSE. The occurrence of CJD in four farmers is less easy to explain… However, no means by which BSE could be transmitted through farming has been established and the incidence of CJD in farmers in Europe is similar to the UK. Again, there appears to be no increased relative risk in the UK that can be related to BSE. The occurrence of CJD in teenagers is tragic, but cases of CJD in teenagers have been described previously in other countries where there cannot be a link with BSE. There is also the possibility that cases of CJD in younger patients may previously have been missed because of misdiagnosis… In my opinion there is a risk of over-interpreting small numbers of cases… No link between BSE and CJD has been established… In my view the possibility of such a link remains theoretical… I do not believe it is reasonable to conclude that there is a significant risk from eating beef. The tone of the Pattison/Will article was similar. Since Pattison was Chairman of SEAC (and had been appointed to the Committee that year at the suggestion of the CMO) and Will was the leading expert on CJD in the country, it is not surprising that most of government including MAFF continued to believe that it was unlikely BSE would be found to be transmissible to humans. Pattison and Will would not have written in the terms they did if they had suspected at the time that there was more than a remote risk that this would prove to be the case. These articles also show conclusively that the BSE Inquiry’s suggestion that the official advice on the likelihood of BSE having implications for human health had changed significantly in 1994 is incorrect (see p. 45–6 above). If it had changed nobody had told the Chairman and Deputy Chairman of SEAC – whose advice it was that the Inquiry claimed had been changed.

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With hindsight the surprising fact is that the reputations of Pattison and Will did not suffer when less than a couple of months later they came to very different views. Some, for example Douglas Hogg, who had inevitably had to take SEAC’s advice on the risks were heavily criticized when they announced that that advice had changed, while those whose advice it was that had changed were scarcely criticized at all. There is a lot of luck in politics. Position at the end of 1995 Overall as 1995 drew to a close there was good reason to believe that the system protecting man and animals from BSE had been significantly enhanced over the previous year. The effectiveness of enforcement in slaughterhouses had been improved mainly as a result of the establishment of the MHS. Enforcement in feedmills had been improved helped by the development of the ELISA test and as a result production processes had been altered making contamination of feed less likely. The details of the animal SBO ban had been improved (for example by requiring SBO to be marked with a special die and by prohibiting the mixing of SBO with other material) making enforcement easier. SBO had to be rendered in premises specially designated for that task. The rules on the separation of brains from bovine skulls had been improved. The ban on the use of bovine vertebral columns in the production of MRM had cut off perhaps the most significant potential risk to consumers. Overall I had confidence that matters were now under control. This was not just my view. The BSE Inquiry was able to look back with the benefit of hindsight and, for example, regarding the human SBO ban concluded that: The occasional failure to remove all the spinal cord had been described in MAFF’s paper to SEAC in 1990 as inevitable. Under the structure in place before the MHS took over we believe that it was. After the MHS was in place, by adding resources and monitoring a campaign aimed at ensuring 100 per cent removal of spinal cord, MAFF and the MHS appear to have come close to achieving this goal. (para 685) As regards the new animal SBO ban adopted in 1995 they concluded it was: admirably comprehensive and… simple. (para 459) [and] … by [March 1996] there was at last in place a sound set of Regulations, imposing an effective animal SBO ban which was being properly implemented and monitored. (para 467) Other comments the Inquiry make confirm that they agree that by the beginning of 1996 the protective system was effective as regards the protection of both human and animal health. I labour the point because it is relevant to the next section.

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SEAC concludes that cases of CJD in young people reflect exposure to BSE Ironically, just as these improvements to the protective regime took effect and it began to seem we were completely on top of the problem matters took a serious, adverse turn. On 5 January 1996 SEAC first discussed the possibility that the cases of CJD in young people might be due to exposure to BSE. SEAC made it clear that their position constituted a suspicion rather than a conclusion; and that they would reflect further before coming to a definite view. Factors affecting a government response to a finding of a link between BSE and CJD Nevertheless, this development came as a very nasty jolt to all involved in policy on BSE. There was first of all the ghastly thought that young people might be condemned to a slow death almost as agonizing for relatives as it was for those infected, and that a major epidemic might have started. Second, there was the certainty of a major political crisis if such a link were found, a crisis in which MAFF would be right at the centre. Third, there was also the effect on one’s personal position and the more I thought about matters the more uncomfortable it all seemed. At times of acute crisis, like that which we were entering in January 1996, it is not adequate simply to consider the facts. The political and psychological assumptions of those involved, which in this case would certainly go up as far as the Prime Minister, play a crucial role. I set out below some of the more compelling as they seemed to me at the time. These factors did not only affect what actually happened, they were also relevant to what it was possible to do or achieve. It is normally of little use – indeed it may be positively harmful – to press for something which while it may, viewed dispassionately, be a good thing, stands no chance of being accepted by those who matter. There was, for example, the state of public opinion on BSE. This was extremely jittery based on perceptions both reasonable and unreasonable but, it had to be acknowledged, in substantial part on the impression that the authorities were not on top of matters. A whole series of events had contributed to this view. Controls had been made progressively more stringent for several years. The animal SBO ban had been introduced after being said to be unnecessary. New controls had been introduced for calves in 1994. The production of MRM from cattle vertebrae had been permitted for many years and then banned. It had gradually become clear with BABs born at progressively later dates that the source of infection had not been completely eliminated from animal feed by the measures taken in the period 1988–90. Probably many thought this failing must have implications for the human-health controls also. In any case it had been acknowledged that the human and animal SBO controls had been neither perfectly defined nor perfectly enforced. BSE appeared to have been transmitted to cats, to a range of zoo animals and, under extreme conditions, to pigs. The news of cases of CJD in farmers and in young people was worrying. This was a formidable list of negative developments over a prolonged period all of which had received extensive treatment in the media.

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Public concern was reflected in public debate. This tended to focus on the question of whether ‘beef was safe’. By this enquirers and commentators meant – or thought they meant – safe when the question was asked. On this the authorities were able to be reassuring for the reasons given above. However, the public were not fully reassured, probably sensing that the real question was something different. It was. The real question was whether the position years earlier, particularly before the slaughter/compensation scheme and human SBO ban had been put in place in 1988 and 1989 respectively, had been as free of risk as had been assumed earlier. That was what was now being questioned. Public reaction was likely to be a strong one if it became apparent the question repeatedly asked and answered earlier had not been the crucial one. Again the fact had to be faced that MAFF was not popular with the media or in Whitehall. This reflected dissatisfaction on a range of policies including agriculture where the cost of the CAP was resented, on fish where stocks were in decline and objections made to foreign fishing in ‘our’ waters and on food safety where a vociferous lobby often exaggerated concerns and favoured changing departmental responsibilities. In Whitehall the Treasury regarded the CAP as a waste of money. Having a hostile Treasury is, for a government department, not a good idea. All these problems were used as examples by those who wanted to attack the EU. Those who worked on EU issues (and almost all MAFF issues involved the EU) were in effect blamed by association for its perceived iniquities. The Conservative party included right up to Cabinet level a good number of eurosceptics who disliked the EU. Though some MAFF Ministers had had some success with pointing to good news stories, notably about the rural environment, the overwhelming perception was one of a department involved with intractable problems. This was a fair assessment; what was less fair was the assumption that somehow these problems must have been the fault of those dealing with them. In the context of BSE, the bottom line was that if real trouble arrived there would be no friends in Whitehall or in the media to help. Further, if matters turned ugly those of us who had in 1994/95 put in place the improvements in the protective system for BSE originally set up in 1988/90, and had against strong opposition succeeded in establishing the MHS with all the improvements that had brought about the protection of the public from BSE, were unlikely to be the recipients of praise. We were currently responsible for policy on BSE and any bad news would automatically be blamed on us. Neither the public nor the media would stop to reflect that the known incubation period for TSEs meant that any people who had recently become ill must have been infected during the 1980s (or earlier) when different people had had responsibility for policy on BSE. This might be unjust but unfortunately would, I was sure, be the reality. The Minister, Douglas Hogg, was in his first Cabinet post and, though he came from a long and distinguished Tory line, did not have a strong position in the Cabinet nor in the party. This was not a reflection on his intelligence. If intelligence were the main criterion for top Ministerial posts then incumbents would often be different. However, as matters stood departmental weakness was accompanied by a Minister with a weak political position.

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I reflected on all these and other realities in the period up to 20 March 1996 as I struggled to think of some way of diverting even part of the hammer blow which might be descending onto other shoulders. I found no answer then and cannot find one now. As we shall see, the BSE Inquiry later came up with some half-baked ideas which we will consider in the appropriate place. One practical question that arose was whether further action needed to be taken or planned for the time SEAC came to a definite view on transmissibility. The answer I came to was that further action to protect the public would probably be necessary if only for political and/or presentational reasons but that, objectively, it was not clear that action was essential. This was because the slaughter/compensation scheme and the human SBO ban had been introduced as contingency measures should BSE unexpectedly prove to be transmissible to humans, that is for the precise eventuality we might now be facing. I had every reason to believe that they were working satisfactorily and as the quotations above show this confidence was justified. This meant that it was not imperative that measures be taken immediately to protect the public. All these considerations were relevant to what the reaction in government should be if – and remember initially it was a big if – SEAC concluded that transmissibility to humans had occurred. This reaction would be sharpened by the recognition by all within government (though naturally denied) that the Conservatives were almost certainly heading for defeat at the General Election which had to be held within a year or so. That reaction would be one of dismay and anger. The anger would be directed at those responsible, and the tendency to assume this must be those currently in post would be as strong inside government as it was outside. If transmissibility were found substantial extra public expenditure would certainly be one consequence if only to support the beef market. Extra safety measures might well add an extra cost above that. The figures would be large – probably sufficient to impact on the government’s overall economic strategy. This would be very unwelcome to everyone up to and including the Prime Minister. Overall I concluded that MAFF advice that immediate agreement on substantial extra public expenditure was essential would be distrusted whatever its merits and would not be accepted without external scientific support. There was no advantage in rushing. It would be better to let Ministers collectively come to appreciate that there was no easy way out of the fix in which they found themselves. Human nature being what it is this would take time. Further, the established position throughout government had long been to rely on SEAC to advise on what was necessary to protect the public. Ministers had consistently appealed to SEAC’s authority to justify the measures that had been taken and not taken. This had become the norm. The BSE Inquiry made the reasonable point that government relied too much on SEAC for policy advice when their expertise was in science. However, early 1996 was not the time to seek to persuade everyone in government that this long-standing practice should be changed. Finally, it was necessary to take into account Ministers’ justified fear of leaks. A leak during the period when SEAC was considering the likelihood of transmissibility would have been even more devastating than what actually

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occurred. This is because if challenged Ministers would have been unable to deny that SEAC were considering the matter, but would have been unable to give a definite answer nor able to say what government’s response would be. In short they would be in the worst of all positions – not having a story line. All Ministers, Hogg included, were anxious on this score, justifiably so given the poor record of the Major government on leaks. This had implications for who could be brought within the ‘tent’, that is could be told of what was afoot. This concern over leaks was shown to be well-founded when a couple of days after knowledge of the situation was extended outside the tent of SEAC, MAFF and DoH there was a leak to the press forcing a Parliamentary statement to be brought forward. It will be noticed that some of these considerations could be shared with others both at the time and later. Concern about leaks is a good example since MAFF Ministers were known not to be the main guilty parties. In other cases this would be more difficult. It is not easy to tell your Minister that you doubt whether his colleagues will accept a given proposal from him whatever its merits. Of course many of the attitudes described above had been present long before 1996. Normally, however, they lurked beneath the surface. The difference was that if transmissibility were found to occur after such a long period when it had been stated to be highly improbable then the issue (BSE) would be transformed from a technical issue into one at the centre of the concerns of the most senior Ministers. In the atmosphere of crisis that would reign innate prejudices (assessments to put it politely) would come to the fore. The events in the few weeks leading to the confirmation by SEAC that transmission of BSE to humans had occurred My reflections in the above vein grew stronger over the weeks as the likelihood that transmissibility would be confirmed increased. The first intimation that SEAC might conclude that BSE had been transmitted to humans came at their meeting on 5 January 1996 because four, possibly five, cases of CJD in young people under 30 had been identified, whereas in the previous 20 years there had been none not due to treatment with growth hormones. MAFF top management (but not that of DoH) was told orally of SEAC’s concerns. At the next SEAC meeting on 1 February it was reported that the presentation of the disease in the brains of the young people affected was unusual in that there was extensive plaque formation of a kind not found in normal cases of sporadic CJD. This made it more likely that the cases in young people were a new phenomenon and hence had BSE as prime cause. The MAFF secretary to the committee notified top management of these fears on 6 February though he had to seek clarification of some technical parts of the discussion first from the DoH secretary (this despite his having a PhD in biochemistry). The DoH secretary seems for her part not to have grasped the significance of what was afoot. This altered matters. There was now a real chance that we were close to a catastrophe. We gathered, however, that SEAC were neither definite nor of one view. Very properly they were concerned not to rush but to examine every aspect and potential explanation of this new phenomenon. I was sure that this was right but also that Ministers collectively would want to know what extra protective

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measures they would wish to recommend (if any) if they concluded BSE had transmitted to humans. From this point on Hogg and I had some private, preliminary discussions about what we might need to do if the bad news were confirmed. Meanwhile tension was maintained by the death of a 20-year-old man with what was later diagnosed as vCJD. This tragic incident was widely reported and the media speculated as to the cause. ‘Mad Cow Disease Kills Man’ ran a headline in the Guardian on 15 February. Matters became yet more ominous at the SEAC meetings on 8 and 11 March. The number of cases in young people had increased to a probable nine while it had been determined that none of the cases in question could be accounted for by genetic mutations in the PrP gene. No satisfactory explanation for the different presentation of the brains in these cases had been found. The less-difficult options were being closed off. The probabilities had changed. Unless an unexpected explanation for the emerging facts were found quickly disaster would have arrived. I was informed by the MAFF secretary to SEAC of their thinking on the evening of 8 March and went at once to inform Hogg of the situation. The Chairman of SEAC (Professor Pattison), the CMO and I met on 13 March to consider the way ahead. Pattison said that a visit SEAC had made to a slaughterhouse earlier in the week had reassured them that the human SBO ban could work properly. He asked me for advice on the attitude SEAC should take in giving formal advice to government. According to the record I said that: SEAC should consider what it thought appropriate… 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. Pattison duly reported this advice at SEAC’s next meeting. Reflecting after the meeting I wrote to the CMO and Pattison about why only young people were going down with this form of CJD and wondered why we appeared not yet to have seen a pattern of decreasing time between vCJD cases as one would expect if BSE were the cause. Both acknowledged these were relevant questions (they remain of interest today). I wrote to Hogg and after describing what had happened earlier predicted that: If SEAC… issue statements acknowledging the possibility of BSE/CJD transmission… 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 to a small proportion of its former level. As a consequence Hogg wrote to Pattison asking him to submit SEAC’s advice as soon as possible.

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A special, further meeting of SEAC was called for 16 March. In the few days between meetings Will had contacted other neuropathologists who had confirmed that the presentations of the brains of young people, now confirmed at nine, were of a new type. Taken with the exclusion of special genetic factors this meant that the new variant of CJD (known then as nvCJD, now vCJD) was a distinct entity. The conclusion was inevitable and momentous. SEAC formally advised Ministers that: On current data and in the absence of any credible alternative the most likely explanation at present is that these cases are linked to exposure to BSE before the introduction of the SBO ban in 1989. On the question of further protective measures SEAC was undecided between three possibilities. These were (a) no additional protection except even greater care over the proper application of the SBO ban; (b) requiring the de-boning of older animals over 30 months on the basis that the older the animal the greater the risk if it were harbouring BSE; and (c) excluding animals over 30 months from the food chain. Over the next two days we held numerous meetings both internal and external, the latter involving notably Pattison and the CMO, as we sought to identify the best way forward. It was also necessary to make a public statement soon before the inevitable leak occurred; before then Ministers collectively and the Prime Minister in particular would have to be informed. Hogg decided that he wished to put forward to Ministers collectively a comprehensive set of measures at the same time as he notified them of SEAC’s disagreeable advice on transmissibility and before SEAC had come to a view on what to recommend by way of extra measures (if any). He decided he wished to propose the exclusion of animals over 30 months from the food chain (that is (c) above, the possibility of which had been in the air since before SEAC’s 8 March meeting), the withdrawal of all beef currently on the shelves and a Judicial Enquiry into the official handling of BSE under a High Court Judge. I did not think that such a set of proposals would work in the sense that I could not see them being agreed; I also thought putting forward such a wide-ranging package in a very positive way would take insufficient account of the political and psychological realities set out above. I tried to persuade Hogg to be more modest. I formally notified Hogg that I regarded the withdrawal proposal as disproportionate indicating that I would be unlikely to implement it without a formal ‘Accounting Officer Direction’ from him. (The cost had been tentatively estimated at over £1 billion.) I argued against the proposal for an enquiry. On this I had two concerns. First I was concerned that MAFF was heading into a crisis and the last thing we needed was for those best placed to deal with it to be diverted into dealing with the demands of an enquiry. Second I felt the current administration had been scarred by what they saw as the unreasonable behaviour of the Scott Enquiry into arms for Iraq and would not want to entertain another. Finally I had always argued that it was necessary to await SEAC’s advice before deciding on new protective measures. Up to this point Hogg had agreed with this view. Tony Baldry,

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the MAFF Minister of State, also vigorously supported this line. I doubted whether proposals not recommended by SEAC would command support. I added that there could be legal challenges if we acted before SEAC’s views were known. Hogg was very understanding about these objections. He always accepted that senior officials had the right and responsibility to offer advice even if it conflicted with his own views. This was one reason why, despite the buffeting MAFF received over the coming months, it remained an essentially happy ship under his tenure. Further, in general Hogg accepted most of the advice given. But on this occasion he did not. He insisted on putting forward all three proposals. Ultimately Ministers have the right to prevail and having lost the internal argument I dutifully drafted a note (in fact two notes) for Hogg to send to the Prime Minister. I tried to tone down a couple of the points that I thought might go down least well but to no avail. The only changes Hogg made to the draft were to strengthen these very points. They were dispatched on 18 March. That evening a large meeting of Ministers chaired by the Prime Minister (John Major) considered the situation. Hogg’s proposals got little attention. Instead the Ministers present went back to basics, that is they questioned the underlying science. Some appeared very sceptical without so far as I knew having any qualifications in the subject. No conclusions were reached. Discussions resumed the following morning (19 March) with Pattison, the CMO and the CVO present. It was clear Hogg’s proposals would not be accepted right at the beginning when the Prime Minister emphasized the need to strike a balance between treating the matter seriously and ‘over-reacting’. Later he said that taking ‘drastic’ action in advance of further scientific advice from SEAC would: … make the government look silly and would open it to significant litigation if premature action was taken. The latter point was also emphasized by the Attorney General. Later Hogg told the BSE Inquiry, rightly, that his proposals had been ‘comprehensively’ rejected by his colleagues. The meeting concluded that ‘an early meeting of SEAC [should] be encouraged’ so their definitive advice could be ascertained. This started at 4.00 p.m. with some members in telephone contact. A tenth case of vCJD had been confirmed, and opinion began to harden in support of de-boning older cattle (option (b) from the 16 March meeting). The committee adjourned until the following day without coming to a decision on the advice to proffer. Discussion resumed at 8.00 a.m. on 20 March in the knowledge that SEAC’s conclusion on transmissibility had been leaked to the press, which was naturally full of it. ‘Official: Mad cow can kill you’ ran the headline in the Daily Mirror. The full-blown crisis had started. At 9.30 SEAC produced its advice. This included: The Committee… recommend constant supervision to ensure the complete removal of spinal cord.

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… carcasses from cattle aged over 30 months must be deboned in… plants supervised by the Meat Hygiene Service… The Committee recommend… a prohibition on the use of mammalian meat and bonemeal in feed for all farm animals. The Committee does not consider that these findings lead it to revise its advice on the safety of milk. If the recommendations set out above are carried out the Committee concluded that the risk from eating beef is now likely to be extremely small. The Cabinet met an hour later with Pattison and the CMO attending, and the SEAC recommendations were accepted in full. It was agreed that both Dorrell and Hogg would make Parliamentary statements that afternoon. Pausing in our account for a moment, it will be noticed that my expectations of Ministerial attitudes about the need for SEAC advice had been fully vindicated. Of even greater significance to the handling of the crisis over the coming months was that Hogg’s recommendations had been brushed aside as disproportionate. His political position, not strong to start with, had been weakened. It was also significant that he was a known Europhile. In the Major government all this was sufficient for the disaffected, of whom there seemed to be a lot, to snipe away at his position without thought as to the consequences for the government as a whole. Before the Parliamentary statements the Opposition had to be briefed. At first it was thought Major would brief Blair. When this proved not to be possible it was decided, eventually, that the Cabinet Secretary, Robin Butler, the CMO and I would brief Harriet Harman and Gavin Strang the Health and Agriculture spokespeople early in the afternoon. In the event the location decided upon was one of the peripheral Parliamentary buildings unfamiliar to me and perhaps others. This was probably why Robin Butler arriving a little early decided to wait for us before going to the room. However, the CMO and I had arrived earlier still and subsequently met him, still waiting, on our way out! At the meeting the CMO led off. For some reason, after explaining SEAC’s conclusions on transmissibility he allowed himself to speculate to the effect that notwithstanding official views on the current safety of beef he would not be surprised if some people decided their children or grandchildren should not eat it. Harman seized on this, launched into a tirade more suitable to a quarrel with political opponents than to a factual briefing by civil servants, and swept out. I was taken aback. Harman, the Opposition spokeswoman on health had gone before establishing whether the government would be taking any new measures to protect human health. The CMO and I were left to explain government intentions to Strang who, while he said nothing, was clearly embarrassed by his colleague. This initial impression was confirmed subsequently. Over the following weeks as the crisis developed Harman was consistently shrill to an extent that left most observers doubting her judgement. Strang adopted the critical but responsible

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approach that impresses. In part I suspect this reflected a difference in understanding. Harman gave the impression of not being greatly concerned with facts. There was an obvious political opportunity, she intended to make the most of it and she saw little need to look further. Probably she assumed that errors had been made and those opposite her were ‘obviously’ those who had made them. Strang, a scientist by training, would have realized that the length of the incubation period for BSE would mean that the discovery of transmissibility in 1996 must reflect what had happened many years earlier so those dealing with the matter in 1996 probably bore no responsibility for the situation. Dorrell then Hogg duly made statements that afternoon. That by Dorrell contained an unnecessary hostage which was to prove one of the more serious mistakes in the BSE saga so far as public perceptions were concerned. The CMO had clearly been worrying away about the fact that cases of vCJD were found in young people, and this probably lay behind his remarks at the morning briefing. He had raised the point with Dorrell who included in his statement a phrase which contributed to keeping matters at fever pitch for days afterwards: There is at present no evidence for age sensitivity and the scientific evidence for the risks of developing CJD in those who eat meat in childhood has not changed as a result of the new findings. However, parents will be concerned about the implications for their children, and I have asked the advisory committee to provide specific advice on that issue following its next meeting. (para 829) The first sentence quoted explains why the question in the second half was unnecessary. It also enabled anyone to predict accurately what SEAC advice would be – that there was no reason to believe children were particularly susceptible. In any case if SEAC had had particular concerns about children they would have said so. It was ridiculous to imagine that they could have overlooked the point. A few days later SEAC advised as expected by me and everyone else. However, in the few days after 20 March the existence of this ‘unresolved’ question stoked the crisis. Dorrell and the CMO between them had, like Edwina Currie before them, fanned flames which would in the main engulf others. The public enquiry into actions up to 20 March 1996 All the actions described above were examined by the BSE Inquiry chaired by Lord Phillips (as he subsequently became). I therefore turn next to the establishment, conduct and findings of the Inquiry before returning to the turmoil that followed the announcements by Dorrell and Hogg. Notes 1 We ought to pause here and note that the fact that the disease may be spread by MBM does not prove that MBM is the origin of the disease. Confusion on this point is widespread in many comments on BSE. 2 A research institution outside MAFF. 3 In one of those ironies of fate the Chairman escaped censure – just. Sir Donald Curry has since become the Labour government’s greatly respected official adviser on a whole host of agricultural questions. Official enquiries might be compared to the effect of bombing – prudence beforehand is worthwhile, but disaster is largely a matter of luck.

5 The Establishment and Conduct of the BSE Inquiry

The establishment of the Inquiry The first suggestion that there should be an enquiry into BSE by somebody who had any chance of bringing one about was made by Douglas Hogg. He included the suggestion in one of his two minutes to the Prime Minister of 18 March 1996, which notified him that SEAC had concluded that the disease had probably been transmitted to several young people who had died of a new version of CJD. I had reservations about including in these communications the proposal to set up an enquiry because I suspected that members of the Cabinet, remembering with horror the Scott enquiry into arms to Iraq, would recoil from the suggestion and that this reaction would poison their minds to the other proposals. Also, I was influenced by practical factors. It was apparent that we were heading into a major crisis when MAFF would need to make full use of all its expertise on BSE. The last thing we needed was for those whose contributions would be vital to be preoccupied by an official investigation. Having experienced the demands of the Phillips Inquiry I am sure that we could not have run the crisis and responded to the demands of an enquiry at the same time. Realistically, however, it was never likely that the Conservative government, under the auspices of which the BSE story had developed and which was scarred by the Scott Enquiry, would institute one into BSE. A Labour government, however, might be a different matter. Somewhat to my surprise the Labour manifesto did not promise an enquiry. Formally, therefore, there was no need to make a recommendation to an incoming Labour government on the matter. Nevertheless I did muse on the possibilities. In government if something is inevitable there is a case not merely for lying back and enjoying it, but for gaining the kudos of proposing it. But was it inevitable? From the opposite perspective might there be anything positive in such a process? In this frame of mind – rather inclined to think an enquiry was likely sooner or later – in April 1997 I circulated to my senior colleagues in MAFF a draft of my covering note for the briefing for an incoming Labour Minister, which included a proposal that a judicial enquiry be established into the handling of BSE. Those of my colleagues with any experience of previous enquiries1 were aghast. 99

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Enquiries were, I was told, extremely disagreeable for the departments concerned. Judges, experience showed, found it difficult to understand the nature of government and the pressures of timing and finance under which those involved in it had to work, but which lay quite outside their experience. Their judgements of what ought to be done were therefore utopian. Some judges, released from the constraints of court procedure, had revealed a previously unsuspected eccentricity. The demands made on the host department would be much greater than could be anticipated and prejudice other work, and in practice, no allowance would be made by anyone for this large extra burden. The Treasury would insist that the departments concerned, notably MAFF, met the bill which there was no way of limiting. Events were subsequently to show that there was a lot in these observations. I was impressed by the strength of feeling shown by those with direct experience and did not mention the possibility of an enquiry in the briefing. When he took office, Jack Cunningham did not mention it either. However, after a couple of months he asked for a paper analysing the merits, which he might put to the Prime Minister. I duly provided this using the obvious arguments for and against. At that stage the main argument against, apart from the administrative ones which were never likely to weigh with Ministers, was the possibility that claims or revelations made during its course might make it more difficult to secure the lifting of the EU export ban. Overall, I suggested that the arguments were finely balanced but advised against. However, members of the new government then regarded the BSE saga as having been a scandal to an extent that the facts, as known to me and as subsequently revealed by the Report of the Inquiry, would simply not support. In the main this seemed to stem from the, no doubt healthy, tendency of politicians to believe the worst of their opponents without looking too closely at the facts. Politically an enquiry appeared to present a wonderful opportunity to do down the Tories and my private view was that the temptation would in the end prove irresistible. So it proved, though at first Cunningham sat on my advice for a matter of months with his inclination swinging from one side of the argument to the other. In the end it appears that he agreed privately with Frank Dobson to propose to the Prime Minister that an enquiry be set up. My paper on the pros and cons was put forward virtually unchanged though with the significant omission of the word ‘not’ in the conclusion! Cunningham’s paper was discussed with Tony Blair and Frank Dobson in Downing Street in December. Blair appeared decidedly unenthusiastic about the concept. This may have been a charade but his reservations seemed genuine to me. If an enquiry were to be held he wanted it to be completed much more quickly than previous ones and to be less costly. It was his idea that it must be completed within a year. He stated that he wanted to avoid the excessive legalism of past enquiries and not to go in for blame. Eventually he agreed to the Cunningham/ Dobson proposal on the basis that a time limit of one year would be fixed in the terms of reference and the judge impressed by the importance of this part of his/her remit. It was so fixed, and presumably Robin Butler and Richard Wilson, present and future Cabinet Secretaries, made the Prime Minister’s strong views on

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the point clear to Sir Nicholas Phillips at the briefing when he was appointed. (I was in Brussels and, though invited, could not attend.) However, senior judges are not accustomed to receiving directions even from Prime Ministers. Nor do they have experience of producing results to time (and they do not even have proper budgets let alone need to keep to them). This independence of the judiciary is, of course, one of the aspects of a free society to which we all rightly attach importance. However, one does wonder why Blair, who after all trained as a barrister, assumed that including a time limit in an enquiry’s remit would produce the desired result. Equally one wonders why Phillips accepted the task on the terms suggested. He accepted a specific remit to report within a year, that is by 31 December 1998. If he suspected the timescale would prove unrealistic he should have spoken up at the time. If he did not have such suspicions he was naïve. As we shall see the Inquiry very quickly adopted procedures that were obviously incompatible with the time limit. Instead of the one year originally envisaged, it took two years and nine months for the report to be delivered. It might seem this does not matter. I disagree. First, the longer the process the greater the cost and that means costs to the taxpayer. If it had been known at the start that an enquiry would cost nearly 30 million pounds the decision on whether to go ahead might well have been different. Second, these developments put unnecessary strain on the witnesses to the Inquiry. This was in part because the Inquiry maintained a pretence that the specified timetable would be met long after it was apparent it would not. Thus, pressure was put on witnesses initially to respond to the Inquiry’s requests within unrealistic timescales. The reason given was the need to keep to the specified remit; this pressure on witnesses was justified in part both by the Inquiry and by government departments by the claim that in mitigation the period of uncertainty would be short. This claim was not borne out by events. Worse, when made it was apparent it was not true and was put forward principally to sustain the face of the Inquiry. One senior witness had a mental breakdown caused, it is believed, by the prolonged stress to which he was subject. There is also a third, wider, point. Some of the Inquiry’s conclusions were that in the government response to BSE various things should have been done more quickly. These conclusions may be justified, but it detracts from their force if those making them have failed to meet their own commitments on timing. All this is unsatisfactory. Since the Prime Minister in consultation with the Lord Chancellor chose Phillips to head the Inquiry he has nobody to blame for his wishes not being met except himself and/or Phillips. Probably it was naïve of the Prime Minister to imagine that a senior judge could be directed in the way he envisaged; for a former barrister this is surprising and unfortunate. For his part Phillips ought to have been more robust in his consideration of the remit he was offered before he accepted it; and to have been more ready to admit he could not meet his current deadline when this became apparent which was certainly well before he did so on all three occasions when he asked for an extension. The decision having been taken that Sir Nicholas Phillips (as he then was) should lead the enquiry, it was decided that he should be assisted by two others.

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It was envisaged that one should have scientific expertise and one should be familiar with public administration. I was told to propose the scientific member. This did not prove easy. Someone reasonably eminent was required who could spare the time, which in effect meant someone without a full-time post, who would have a good grasp of the science but had not been involved with advising or commenting on BSE and who had never had close links with MAFF. After some false starts it began to seem that such a person could not be found. However John Pattison, the chairman of SEAC, came up with the idea of Professor FergusonSmith. He fitted the bill nicely being an FRS in a relevant scientific area about to retire. Jack Cunningham was insistent on there being a woman in the team which was one factor behind the choice of Mrs Bridgeman as the other member. We have no knowledge of how large a part the two other members played in deciding on the Inquiry’s findings. The natural assumption would be that the overall lead came from Phillips who determined the general direction and procedure, while Ferguson-Smith led on the science and Mrs Bridgeman on public policy. While this is a reasonable deduction judged by the members’ different experience, it is, however, guesswork. Before the enquiry could start, the official Opposition had to be approached. Rather to my surprise they agreed without raising any difficulty. It has subsequently been suggested to me by a prominent Conservative MP that this was a mistake and that the Opposition should have objected and sustained such objection; and that in such circumstances the government would have found it difficult to go ahead. This is to claim rather a lot. One can see how if the Tories had taken such a position it could have been presented via leaks to the media, as indicative of Tory callousness and irresponsibility. Outright refusal would not in my view have worked. However, it would have been possible to try to attach some conditions to acquiescence. There were a number of possibilities. One would have been to seize on the proposed one-year duration of the enquiry as being particularly important. Probably it would have been possible for the Tories to extract some extra, vague commitment from Blair to the effect that special importance would be attached to this aspect. Though there is no reason to suppose that this would have made any difference to how fast matters progressed, the advantage to the Tories of securing such a commitment would have been that when the timetable was not met it would have given them a grievance. In politics a grievance is very useful. In particular extensive references can be made to it whenever there is nothing else to say. The Tories therefore missed a trick in not seeking to attach conditions to the Inquiry.

The conduct of the Inquiry There are no ready made procedures for enquiries to adopt; they devise their own. That adopted by the BSE Inquiry was to require all who had been involved with the issue to any significant extent to write a full record of their involvement by way of a ‘witness statement’. Thus, unexpectedly, the Inquiry, rather than

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conducting their own search of the papers, placed a large portion of the responsibility of establishing what happened on witnesses. This placed a substantial burden on many people, and inevitably there was much overlap in the accounts of different witnesses. This meant that both witnesses and the Inquiry spent time going over points that had already been covered by others. This made for greater certainty and enabled possible disagreements to be identified, but at a large cost in time and money. The procedure chosen was therefore a costly one for the public purse since the costs of all participants including all witnesses’ lawyers were met by government departments. Inevitably it took a lot of time for all the witnesses to produce their accounts and for the more important of them to be examined at oral hearings. Repetition of the same facts by different witnesses also took up time. In addition it was always obvious that a substantial period would be needed to deal with conflicts of evidence. For all these reasons it rapidly became apparent that there was no possibility of the original timetable being met. From the moment that it was decided to call for witness statements from all concerned the original timetable became unrealistic, though the Inquiry were reluctant to acknowledge the fact. The Inquiry was very much run by lawyers, and Phillips made it clear right from the start that he regarded this as both necessary and appropriate. Probably this was inevitable but the lawyers, including those representing the Inquiry, imported the adversarial approach with which they were familiar. The rows this engendered also added to the time taken. Thus the Prime Minister’s wishes were in practice ignored on all the points on which he had expressed definite views. On the positive side, during the hearings the Inquiry was successful in establishing an atmosphere in which witnesses could put forward their views in as relaxed a way as was possible given the seriousness of the issues. Lord Phillips (as he became) was the courteous but efficient and firm chairman one would expect of a senior judge. The Inquiry’s procedures outside the actual hearings were much less successful. At times things became close to a shambles. The Inquiry appeared not to have anyone who could take control of what became a substantial organization requiring proper logistical skills. If they had such a person they did not make proper use of them. Two series of events were to have adverse effects on the progress of the Inquiry and on its relations with witnesses. One concerned the issuing of a very large number of draft criticisms at the end of the first stage of the hearings. In the event the Inquiry did not cover all the ground before changing tack, but had they continued in the same vein it was clear that it would have taken years longer than the extended period actually taken to deal properly with all of them. This was dispiriting for the witnesses who appeared to see years of effort stretching before them. Some of the criticisms were absurd. I was issued with 17 draft criticisms and some witnesses over a hundred. Many were preposterous. Why, I was asked, at a meeting with the Minister in 1989 (when I had no responsibility for and very little knowledge of BSE) had I not challenged a statement on the subject by the Chief

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Veterinary Officer? My ‘failure’ to do so was the subject of a draft criticism framed in language best described as robust. Criticisms of others were no more sensible and couched in aggressive terms. Faced with this witnesses and their legal advisers responded in kind. However, in due course, probably when the scale of the task necessary to deal properly with all the draft criticisms they had issued became apparent to the Inquiry, most were withdrawn, many before any reply to them had been received. This had the merit, inter alia, of allowing the Inquiry to be concluded while most of those involved were still alive. This episode raised the suspicions of witnesses and their legal advisers as to the criteria that were being applied to justify a criticism. When pressed repeatedly on this point the Inquiry claimed that their criteria had been the same throughout, roughly failure to act as would reasonably be expected of someone in the relevant position. However, this was manifestly not compatible with their actions. If the first draft criticisms had been issued according to these criteria why were so many withdrawn before a reply to them had been received? The second incident concerned the Inquiry’s production of Draft Factual Accounts (DFAs). It was intended that, by describing developments in animal health, public health, scientific knowledge and so on, they would form the basis for the report’s supporting volumes. It was the Inquiry’s responsibility to prepare adequate drafts. If nothing else they should have learned from the embarrassment of the first draft criticisms. Unfortunately the drafts were inadequate and partisan, often implying deficiencies in conduct where none existed. Some DFAs appeared to have been produced by someone with a remit to put the worst possible gloss on witnesses’ actions. Extensive improvements to the drafts were suggested by MAFF’s BSE liaison unit2 with the aim of increasing accuracy and removing tendentious commentary. Eventually over 90 percent of the unit’s suggestions were adopted. Unfortunately even when they had been shown to be seriously deficient the Inquiry refused for a long time to withdraw the DFAs from the internet. They appeared to think that to do so would be to admit error which they would never do as a matter of principle. In acting thus they confused their responsibilities with their amour propre. These two episodes of the draft criticisms and the DFAs poisoned the Inquiry’s relations with many of the more significant witnesses. They appeared to indicate that the Inquiry was determined to be critical whatever the evidence. Admittedly this interpretation seemed at odds with the hearings at which the Inquiry gave the impression of genuinely seeking to get at the truth. But was this just a reflection of the good manners which judges were expected to show? On the evidence witnesses could be forgiven for being apprehensive and taking the pessimistic view. The main result of this suspicion was a series of increasingly acrimonious legal representations to the Inquiry questioning the basis of criticisms. This placed the Inquiry in an awkward spot given their mistake in issuing the first batch of draft criticisms. Since many of them had been based on unreasonable interpretations of the evidence these representations had to be fended off rather than properly answered. As exchanges escalated one witness considered launching a judicial

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review. Many lawyers believed they detected in Phillips’s reactions a recognition that this was a possibility and that he needed to take care to avoid one, if launched, being successful.3 Strong representations continued to be made on the alleged unsatisfactory nature of the Inquiry’s procedures until well into 2000. The scientists who had been involved in advising on BSE were among those who had been concerned at the trend of events. This was understandable. Some were eminent and all had given their time for free and for the public good. They had certainly not expected also to have to devote much time to justifying their actions before a public enquiry, let alone to receive aggressively-worded draft criticisms. A Chairman of SEAC told me that at first he and his colleagues had fully cooperated with the Inquiry being enthusiastically in favour of seeing all the facts exposed. Later, in the light of the treatment they had received, they ‘stopped cooperating’ and ‘confined themselves to answering questions’. Matters were bad enough for the President of the Royal Society, Sir Aaron Klug OM, to write to the Prime Minister complaining about the treatment senior scientists had received and the tone of the draft criticisms. All this went on behind the scenes, although some indication of what was going on did reach the specialist press. For example the British Medical Journal of 27 January 1999 included an article and an editorial questioning whether the Inquiry’s procedures offered sufficient protection for witnesses. There was thus considerable tension between the Inquiry and leading witnesses right up to publication. It is therefore interesting that the Inquiry’s account of their decisions on procedure (Annex I of Vol. I) gives scarcely a hint of the real state of affairs which was much tenser than the Report implies. One moral to be drawn is that the written word, even if literally true, does not always give a full insight into what happened – a fact which the Inquiry’s findings do not sufficiently recognize as we shall see. The irony is that with hindsight it seems probable that this furore was unnecessary. The Inquiry’s Report was cast in moderate terms. Even though it has deficiencies, discussed below, everyone seems to regard it as an honest attempt to come to a balanced view. Had it been known that the report would be couched in such terms I am sure many of the formal exchanges between the Inquiry and witnesses’ lawyers could have been avoided. From the perspective of the witnesses concerned it was the possibility of disproportionate criticism based on the sort of apparently wilful misunderstandings shown by the early draft criticisms and DFAs that drove them and their advisers to question the Inquiry’s procedures. It is possible, of course, that the Inquiry simply changed its mind. On this basis the original draft criticisms and the DFAs correctly represented the Inquiry’s views early on but in response to the evidence they came round to a much less critical view. In that case the fears of witnesses were justified originally and it is difficult to see how the exchanges between the Inquiry and witnesses’ lawyers could have been avoided. I doubt if this was the case. It would require the Inquiry to have rapidly formed an unreasonably critical view at an early stage based mainly on prejudice. A group that would do that would be unlikely radically to change their view later on the

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basis of evidence. The world is divided between those who form their views on the basis of prejudice and those who do so on the basis of evidence. In any case judges, FRSs and senior civil servants would normally, as Oscar Wilde might have said, be expected to be on the side of the evidence. It seems more likely that the Inquiry did not form any very definite views initially. However, their staff were told to identify all possible criticisms. In other words they acted as a prosecuting authority might do before they decide what has a chance of standing up to scrutiny. Drawn up in this comprehensive manner the schedules would have looked daunting to say the least. My suggestion as to how the Inquiry came to issue so many draft criticisms, most of them later withdrawn, is as follows. The Inquiry were probably faced, as explained above, with lengthy schedules of possible draft criticisms. Now scrutiny of Phillips in action suggested to me that his reputation at the bar as someone who, while very capable and always polite, is unlikely to demonstrate zeal unnecessarily, especially if unnoticed, is an accurate one. Faced with the enormous task of going through many hundreds, probably thousands, of draft criticisms and eliminating those that were unconvincing the Inquiry was in a difficult position. The task was unattractive. They were under time pressure. They had already announced that anyone who had a criticism removed would not face the same one again. There would have appeared to be a risk that serious criticisms could be lost by incautious action. One solution was to send out to witnesses the whole list. This avoided the large and unpleasant task of considering the merits of each, and transferred the burden of analysis once again onto the witnesses. And ‘draft’ criticisms did not commit the Inquiry nor, arguably, would it be unfair to send them; unjustified ones could be dropped after responses were received. Only later did it become clear to the Inquiry that this approach did not work. The truth dawned gradually that the task of going through the lengthy lists of draft criticisms themselves and cutting them down radically could not be avoided if progress on any acceptable timetable were to be made. The Inquiry made a big thing of being entirely ‘open’. It even won a prize from the leading pressure group in this area which they record with pride in their Report. This was not sensible on their part. Receiving awards from pressure groups would, I suggest, cause more worldly-wise persons to suspect they are on the wrong tack. Certainly the Inquiry was unusual in placing almost all material in the public domain, including witness statements, records of hearings and virtually all the first hand evidence including that from government files. Given public suspicions and attitudes this was inevitable and sensible. However, there is a risk that such openness will lead to unfairness to individuals as allegations made will tend to be reported as fact especially if consistent with preconceived notions. Thus a claim given in evidence that someone has acted wrongly can receive wide publicity; it can be some time before the person concerned has the opportunity to give their reply. To some extent this is an inevitable drawback of openness, but the Inquiry needed to be especially vigilant that its policy of openness did not lead to unnecessary unfairness. They did not always achieve this, and the incident of the DFAs is one example. While it might reasonably be claimed that giving publicity

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to some unfounded allegations is a necessary price of openness the same defence cannot be made when the unjustified statements in question had been given currency by the Inquiry itself. The procedures devised and followed by the Inquiry were, therefore, defective in significant respects. It is apparent from the BSE Inquiry and others (for example the Scott Inquiry) that judges, even eminent ones, are not necessarily skilled at administrative matters. It would be helpful if procedures for future enquiries could be worked out in detail and formally approved beforehand so that what amounts to a set of instructions can be handed to the judge on taking up appointment. Probably it would be necessary to have alternatives to fit the different needs of different occasions. Such approved procedures might specify, for example, that draft criticisms should not be sent to a witness unless the enquiring body had satisfied themselves personally that there was a good chance they would stand up. The procedures might also state that evidence from all witnesses should, so far as publication is concerned, be treated in an identical fashion. The Inquiry did not do this though I doubt if its members are aware of the fact. Statements that were interesting to the press, that is those that were controversial or critical of someone, tended to be published quicker than the subsequent, from the media perspective rather boring, rebuttal. No doubt the junior staff responsible for putting material on the internet were well-aware of the Inquiry’s policy of openness and instructed to act accordingly. Probably they came to regard openness as requiring them to have special regard to matters in which the media were interested. Why not let them have something in which they would be interested a little earlier than run of the mill statements? After all the media would be unlikely to object. The answer to this hypothetical question is that before conclusions are reached it is unsatisfactory for a Public Enquiry’s procedures to be manipulated to give greater prominence to critical allegations than they might otherwise receive. These procedural deficiencies are important in themselves not least because they added to costs as well as making life more uncomfortable for witnesses than was necessary. However, it is also important to recognize that this critical view on procedure has no necessary implications for substance, that is for the Inquiry’s conclusions. Because someone’s desk is a mess does not mean that they do not produce good work – or so it is convenient for some of us to believe. I now turn, therefore, to the Inquiry’s conclusions. Notes 1 They had spent time in the Department of Trade and Industry, which had experienced several high profile enquiries. 2 A special section devoted to helping the Inquiry and the MAFF witnesses to it. 3 At much the same time a successful judicial review was launched against some actions of the enquiry into ‘Bloody Sunday’.

6 The Findings of the BSE Inquiry

We have seen that the course of the Inquiry did not go entirely smoothly and that the lessons which ought to be learned could be of help with subsequent enquiries. However the most important point about any enquiry is its conclusions. What were they? The BSE Inquiry made a large number of judgements which are scattered throughout the text of the Report, so that even though it is mostly well-written and, so far as the subject allows, clear, it is not easy to establish the whole picture. For this reason I first summarize in this chapter the main findings illustrating the points made by direct quotation from the Report (except where indicated from Vol. I). For ease of reference I have given each such finding a number. I should emphasize that these are my numbers; they will not be found in the Report. In this section where the Report quotes directly from evidence given or from another source I have put the text – a quote within a quote – in italics. I have identified 27 major findings in the Report. Some are closely related to others and I deal with them below in the following order. Section I (findings 1–9) deals with the origin of the disease and science; Section II (finding 10) covers the Southwood Report which is regarded as pivotal by the Inquiry; Section III (findings 11–14) is concerned with the overall nature of the government response, dealing in particular with some frequently suggested weaknesses; Section IV (finding 15) covers the actions of commercial enterprises; Section V (findings 16–25) covers the individual measures government adopted to cope with the disease; Section VI (finding 26) deals with the way risk was explained to the public; and Section VII (finding 27) with the possibility that last-minute contingency planning might have helped contain the scale of the crisis.

Section I: the origin of the disease and the science Finding 1 relates to how the disease arose. The Inquiry is surprisingly definite. They believe BSE was caused by a new mutation in the PrP gene probably in cattle. The first rounds of infection in cattle were missed and the original mutation probably occurred as far back as the early 1970s. The disease was spread mainly by 108

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the consumption by cattle of infected MBM in cattle feed. The cause…is likely to have been a new prion mutation in cattle, or possibly sheep. (para 1122(ii)) We think it…failed to detect several earlier cycles of BSE in the South West of England in the 1970s and early 1980s. (para 1122(ii)) The spread of BSE in cattle… came about from the use of MBM in cattle feed. The MBM… was infective because it had been made by rendering infective offal from cattle suffering from or… incubating the disease. (para 1122(i)) Finding 2 is that the disease could not have been foreseen and its occurrence was nobody’s fault. The practice of feeding MBM in the UK dates back to at least 1926… It is a practice which has also been followed in many other countries. (para 107) When regard is had to the experience of what, by 1981, was over 50 years of recycling of animal protein, we can understand why the risk of a disease such as BSE was one which was not anticipated or addressed by farmers, renderers, feed compounders, animal nutritionists or government. (para 1147) Finding 3 deals with the implications of the lengthy incubation period for the disease. As a consequence it got a hold within the UK cattle population before it was noticed. Similarly, the long incubation period (almost certainly significantly longer for humans than for cattle) meant that the disease could and did infect people before it was even identified. It spread at first unnoticed because most infected cattle were slaughtered before showing clinical signs of the disease. (para 170) It was inevitable that if humans were susceptible to the disease, some would be infected with it before its existence was even suspected. (para 110) The Inquiry discusses the view, widespread since the first MAFF investigations, that the beginning of the disease was linked to the changes in rendering processes in the early 1980s and that these changes resulted from ‘deregulation’. Finding 4 is that they will have nothing of any of this: The conclusion that rendering changes had permitted the BSE agent to survive unscathed, whereas previously it had been inactivated, is…widely accepted. There are two variations on this theme: (i) Some accuse the Government of having recklessly relaxed the Regulations governing rendering, or of having failed to impose a sufficiently rigorous regulatory regime. (ii) Some accuse the rendering industry of having put the safety of their product at risk by cutting corners in order to cut costs.

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Neither of these accusations is valid. (paras 193 and 194) Finding 5 dismisses the two main alternative theories to the mainstream views, that is that the disease was spread by infected MBM in feed. These alternative theories are the organophosphate and autoimmune theories. The theory that BSE was caused by…OPs…cannot be reconciled with the epidemiology and is not supported by research. (para 1123) There are a number of reasons why this [the autoimmune theory] theory does not seem viable. (para 1124) Hence, Finding 6, the Inquiry accepts the main prion theory which now appears to have the support of a large majority of scientists in the field. They accept all the main tenets of that theory throughout the Report. Finding 7 is that contaminated feed was rapidly and correctly identified as the direct source the disease. Mr. Wilesmith and his colleagues are to be congratulated on the rapid identification of cattle feed as the cause of… BSE. (para 187) Finding 8 is that BSE did not arise as a result of scrapie infecting cattle as Wilesmith had concluded. He had calculated that this would imply a constant rate of infection of about 60 cases a month. The cause of infection of the cases being reported was not the scrapie agent in the feed, but the BSE agent itself. Far from the incidence of BSE infection being likely to prove constant, it had been escalating year on year and was, in 1988, infecting cattle at a rate that probably exceeded 10,000 cases a month. (para 189) Finding 9 is concerned with the relatively small dose of infective material required to transmit BSE orally in cattle. The Inquiry appears not to have got wholly to the bottom of this saga which they hold to be the cause of some of the suboptimal decisions taken. On the one hand the Inquiry claims that there were those who always expected the required dose to be small. On the other there were those who expected it to be relatively large. This latter group included those making policy; they were quite open about their views yet were apparently never contradicted by the proponents of the former view. The surprise at the result of the attack rate experiment in 1994 (when it was found one gram of brain from a BSE case would infect a bovine) is noted. Yet the NPU had had comparable results in respect of sheep in 1990 apparently not communicated effectively to those making policy. Though there is some evidence that SEAC were concerned that small amounts could prove infectious they never explicitly said as much. The malevolent consequences of this state of affairs were cross-contamination in feedmills and as, regards human health, the decisions on MRM. Some of the responses to BSE were inadequate because those responsible for them were not party to aspects of the state of knowledge at the time which

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should have informed their decisions… An… . example is provided by the consequences of the failure to focus on the question of the minimum infective dose. At the end of 1990 interim results of the…NPU experiment to transmit BSE to sheep and goats had indicated that eating infective material weighing only half a gram had sufficed to infect a sheep… Yet the result of the attack rate experiment, which showed at the end of 1994, that a single gram had transmitted BSE orally to a calf, caused widespread surprise and concern… When the ruminant feed ban was introduced, some officials within MAFF were under the impression that a cow would have to eat a substantial quantity of infective material to contract BSE. (paras 1191, 1195 and 1196) When the animal SBO ban was introduced in 1990, none of those involved appreciated the extent to which contamination of MBM with SBO in rendering plants would give rise to infectivity in that MBM, let alone that this would be enough to pose a threat to cattle as a result of a second round of crosscontamination in the feedmills… The question…was equally of importance in the context of the safety of human food… An assumption was made that any contamination of MRM with spinal cord was unlikely to be sufficient to be significant. (paras 1197 and 1199) SEAC…gave some indication that the Committee considered that a small quantity of contaminant was cause for concern. SEAC never so stated expressly, and a paper on the safety of beef was capable of conveying the false impression that only a substantial quantity of infective material would pose a risk of transmission by the oral route. (para 1200)

Section II: Southwood Committee Finding 10 deals with the Southwood working party and its Report. It is clear that, though the Inquiry recognize that it had some good features, they consider many of the subsequent problems in dealing with BSE stem from Southwood and that some of them ought to have been avoided. Of the 30 ‘individual criticisms’ made by the Inquiry of a vast number of actions taking place over a decade, no fewer than four are directed at the working party. They find on the positive side that the Committee helped in bringing about the establishment of the slaughter and compensation scheme; recommended some important research and that an advisory committee on BSE research should be established; that they also ensured that the ruminant feed ban was extended indefinitely; recommended that steps should be taken to alert those responsible for occupational health and the safety of medicines to the potential risks; and advised that babies should be protected by excluding cattle offal from baby food. However, they also find several aspects to criticize. These include the failure of the Committee to reveal the extent to which their report had relied on others which contributed unfortunately to its reassuring message; that in describing the risk the disease posed for humans as remote it was not made clear that steps should be taken to reduce it as far as possible; that no measures were recommended to protect humans (other than babies) from animals

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incubating the disease; and that they understated their real concerns about the risk from medicines. … the Working Party… lost no time in making important interim recommendations…after their first meeting on 20 June 1988, Sir Richard wrote to Mr Andrews recommending that carcasses of clinically affected animals should be destroyed…The measure proved of crucial importance in protecting humans. (para 252) The Working Party made further immediate recommendations; that an expert working party should be set up to advise on…research… that priority should be given to a study to see whether BSE transmitted from cow to calf; and that tests be carried out to see whether scrapie could be transmitted to cattle. This was further wise advice promptly given. (para 253) The first eight pages of the Report consisted of a history of BSE… These were largely written by Mr Wilesmith… There then followed a chapter on ‘the cause of BSE…’ This had been written by Mr Wilesmith. It set out tentative conclusions… A subsequent chapter, also written by Mr Wilesmith, dealt with the future course of the disease… The Working Party did not see it as their role to conduct a critical review of Mr Wilesmith’s conclusions. We do not suggest they should have done. The report did nothing… to dispel the impression that the conclusions in question had been… endorsed by the… Working Party. In a covering letter to Ministers, published with the report, the Working Party added… ‘The Report… remains our own’. We think that the Working Party should have made it plain that the section of the Report dealing with epidemiology… was based on data which they had not been able to review. In the event their Report added weight to… conclusions… which gave the false reassurance that it was very unlikely that BSE was transmissible to humans. (paras 258–60) We have a number of criticisms to make of… the Working Party’s Report. In the first place they did not make it clear that, in describing the risk as remote, they were intending to indicate that steps should be taken to reduce the risk as low as [sic] reasonably practicable. We think they should have done… In the second place, we do not consider that the Working Party correctly applied the ALARP (as low as reasonably practicable) principle… No steps were to be taken… to protect anyone other than babies from the risk of eating potentially infective parts of animals infected with BSE but not yet showing signs… We do not criticize the Working Party for failing to recommend… the SBO ban. What we feel they should have done was to point out that cattle subclinically infected with BSE were entering the human food chain, that some tissues of such cattle were potentially infective, and that consideration should be given to identifying such steps as were reasonably practicable to prevent their being eaten… by everyone. (paras 272, 273 and 275) There is a further aspect of the way the Southwood Report dealt with risk that caused us concern. The Working Party said of the risk of transmission of BSE

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through the use of medicinal products: ‘Although the risks appear remote…’ The Working Party told us that they had described these risks as remote only because of the action that they had been assured was being taken to address them. They had initially considered that some medicinal products sourced from bovine materials, which were injected, might carry a relatively high risk of transmission… They had taken all proper steps to get those responsible for the safety of medicines to start taking action to address this risk. However… they had been persuaded to tone down their Report… It led… to their Report giving the reader a false impression of their assessment of the risks relating to medicinal products. (paras 276–8)

Section III: the overall government response The Inquiry recognizes that over the years the public has developed a number of perceptions about the official reaction to the disease and comment on the main ones. In particular they note: Hardly a day goes by… without BSE being referred to in the media as epitomising maladministration, usually by the use of an epithet such as ‘the BSE scandal’. (para 20) Finding 11, commenting on this, says in effect that that epithet is not justified: As we shall shortly explain in the years with which we are concerned most of those responsible for responding to the challenge posed by BSE emerge with credit. (para 21) Another frequent allegation is that the facts were kept hidden or treated as secret. On this the Inquiry finds that the existence of BSE was concealed for a part of 1987 in a section of the State Veterinary Service. However, otherwise their finding 12 is that the claim is without foundation. They make no finding about a ‘culture of secrecy’ in Whitehall often referred to by commentators as though it were an established fact confirmed by the Inquiry. In the first half of 1987 there were restraints on the release of information about BSE. After this there was no attempt to conceal facts from the public. (para 1179) We have examined with care the public pronouncements that were made… and have concluded that allegations of a government ‘cover-up’ of the risks posed by BSE cannot be substantiated. (para 116) The other serious charge is that the public were told lies about the risks. The Inquiry have criticisms of the way in which information was communicated which we will come on to; but finding 13 is to reject the main charge: The Government did not lie to the public about BSE. (Executive summary page xviii)

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Perhaps the most frequently made criticism of the UK governmental structure for dealing with the disease is that it was wrong to have one department (MAFF) responsible both for food safety and for sponsorship of agriculture and food manufacturing. It was held to be inevitable that MAFF would favour production interests to the detriment of safety (though I do not recollect ever seeing an explanation of why this should be the case). At all events the Inquiry’s finding 14 is that this is not true: We are concerned… to deal with the criticism that… MAFF leaned in favour of the agricultural producer to the detriment of the consumer. So far as the policy decisions are concerned we are satisfied that this criticism is without foundation… The fact is that MAFF never did less and on occasion did more than SEAC recommended. MAFF officials and Ministers were… as concerned as anyone else that if there was a possible risk to human health, appropriate measures should be taken in response to it. (para 1173)

Section IV: the actions of commercial enterprises The findings in Section III showed that the Inquiry do not accept some of the most widely canvassed explanations for the BSE phenomenon. Surely someone must be to blame? Perhaps it is big business? One favourite target of some is the rendering firm of Prosper de Mulder. When I appeared before the European Parliament’s Temporary Committee on BSE in late 1996 there was one MEP who clearly thought the whole crisis could be laid at their door. Mars is an even bigger firm, a subsidiary of which, Pedigree Petfoods, is the UK’s largest manufacturer of pet food. Finding 15 covers both. Referring to information supplied to MAFF by Prosper de Mulder the Inquiry say: This was typical of the cooperation provided by the company to MAFF throughout the BSE story. The company operated to high standards and showed a consistent concern that the Regulations should be effectively implemented. (para 436) For their part Pedigree Pet Foods went out of their way to inform MAFF of the advice they had received on the infectivity of different bovine tissues and the Report explains how this had a beneficial effect on the measures subsequently adopted. It states: We wish to commend Pedigree for their initiative in seeing that this information was provided to MAFF. (para 559)

Section V: the detailed government response Finding 16 is that in general the right policy decisions were made: We have no doubt that the policy decisions that there should be a ruminant feed ban, that clinically affected cattle should be destroyed and that SBO should

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be kept out of human food and animal feed were right. Because the right policy decisions were taken, BSE is today within reach of eradication and millions have received a high degree of protection… This reflects credit on our system of government and on the… SVS. (para 1168) However, finding 17 is that there were also shortcomings: Shortcomings attended the introduction, implementation, enforcement and monitoring of the measures pursuant to these decisions. (para 1153) Turning to individual responses and measures, finding 18 is that the disease was identified as quickly as could be expected: The CVL pathologists identified the emergence of a new disease, which they considered might be a bovine form of scrapie, as soon as could reasonably have been expected. (para 174) It is to the credit of the system of… veterinary surveillance and the skill of the… CVL pathologists that the disease was identified at a relatively early stage of the epidemic. (para 1149) Finding 19 is that the ruminant feed ban was vital and necessary though with problems of implementation. MAFF is congratulated for rapidly banning the inclusion of ruminant MBM in ruminant feed. They find that some feedmills deliberately sold cattle feed containing ruminant protein after the ban had come into effect and deplore the fact; note the difficulties of enforcement in the absence of a test for contamination of feed with MBM; judge that local authorities made no attempt at enforcement; find that insufficient thought was given to implementation; note that MAFF had no legal powers to carry out sampling; but note also that despite these weaknesses the ban has been within limits highly successful. Mr Wilesmith… is to be congratulated on… the advice of a ban on feeding MBM to cattle and sheep… This… cut off most of the source of infection, turning an escalating disease into one that would peak and decline. (para 187). This Order has been described as ‘spectacularly successful’… It has… come close to eradicating an epidemic… of gigantic proportions. (paras 202–3) We have concluded that at the time the ruminant feed ban was imposed there was a lack of rigorous thought about its implementation. (para 214) When the ruminant feed ban was introduced, there was no test which would detect animal protein in… feed… Without such a test the Order was unenforceable. (para 216) In general we do not believe that any steps were taken by local authorities to enforce the ban. (para 301) We are satisfied… they… reflect deliberate breaches of the ban by some compounders and others. (para 318)

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MAFF’s difficulties were compounded by the fact that they had no legal power to carry out random sampling. (para 320) … we can deduce that the measures MAFF had already taken had had a dramatic cumulative effect in reducing infection year on year… But for the events of March 1996… MAFF would have been able to claim that… they had virtually eradicated infection of cattle with BSE. (para 348) Hindsight confirms that, between 1989 and 1994, the ruminant feed ban had resulted in a steady but substantial year-on-year reduction in the numbers of infections, and that the measures taken in 1994 and 1995 radically accelerated this decline. (para 95) The report notes that MAFF officials recommended to the Minister (John MacGregor) in February 1988 that to protect public health a publicly funded slaughter and compensation scheme should be introduced for infected animals. They criticize the fact that DoH were not consulted beforehand; note that MacGregor was initially resistant to a slaughter scheme but decided to consult the CMO; that at the latter’s instigation the matter was put to an expert committee (the Southwood Committee); and that their advice led to a decision to introduce a scheme though only some six months after MAFF officials first proposed it; it finally came into force on 8 August 1988. Finding 20 is that the slaughter and compensation scheme was highly desirable; and that the delays in introducing it were regrettable but are not a subject of criticism except the failure to consult DoH early on. Thus those who proposed the measure are criticised while those who delayed its introduction are not. The submission was perfected on 16 February 1988… The option recommended was a policy of slaughter of affected animals with payment of compensation… The submission took some pains to emphasise that payment of compensation was appropriate as the measure would be taken mainly for public health reasons, not in order to eradicate the disease. (paras 229 and 231) It is remarkable that MAFF officials had prepared this submission… without involving anyone at DoH… Had this course been followed, we have little doubt that a joint submission would have been made to both MAFF and DoH Ministers to the same effect as that which went forward to Mr MacGregor… which would have carried more weight… The consequence was a lengthy delay. (paras 233–4) Mr Andrews wrote to Sir Donald Acheson [CMO] on 3 March 1988… Sir Donald’s reaction was to call an interdepartmental meeting on the matter… Those present at the meeting were not able to form a firm view… whether… BSE posed a risk to human health. It was agreed to recommend… that a small group of experts be set up to advise on… risks and possible preventative measures. Sir Donald… thought it highly likely that the advice would be that carcasses of

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infected animals should not go for human consumption. We found this decision disappointing… A better and more robust response would have been to recommend that the practice of eating diseased cattle should cease at once. (paras 238, 240 and 241) The Order providing for compulsory slaughter and destruction of cattle suffering from BSE came into force on 8 August. Nearly six months had gone by since MAFF officials had first recommended this course. (para 247) Finding 21 covers the introduction of the human SBO ban. The Inquiry recognize that the introduction of this measure was of vital importance for the protection of human health. They chronicle how it was decided upon by MAFF despite initial opposition from DoH. However, those responsible for introducing it get little praise, the process by which the decision was made being characterized as ‘haphazard’. Ministers and officials in both MAFF and DoH are criticized for not ‘reviewing’ the Southwood Report, in particular the decision to recommend protective measures for babies only. Mr Ken Clarke’s claim that DoH did so is rejected especially firmly. (Clarke made the mistake of blustering to the Inquiry while demonstrating an imperfect grasp of detail.) The Inquiry note that no questions were raised on the alleged illogicality of protecting babies and not others in DoH, though two officials did so in MAFF. The heroes of the eventual decision to protect everyone are identified are Sir Donald Thompson, the MAFF Parliamentary Secretary, and Pedigree Petfoods whose adviser, Richard Kimberlin, persuaded the CVO of the necessity of this. For a mixture of reasons the MAFF Minister, John MacGregor, decided to implement a complete ban and overbore initial DoH objections which were based on the incompatibility of this course with Southwood. However, the presentation of the ban as an administrative convenience only is criticized. The relevant press release by MacGregor is quoted which, interestingly, does not fully support this last finding. The introduction of that ban at a time when most considered it highly unlikely that BSE could be transmitted to humans was one of the most far-sighted measures introduced in response to BSE – or it would have been had it been introduced as a result of foresight… The process that led to its introduction was haphazard… Did it matter that the process was haphazard? We think that it did. (para 538) Good government does not blindly follow the advice of scientific experts… It must evaluate the advice… There was a team failure… to subject the Southwood Report to a proper review in order to evaluate whether the unexplained differences in approach to the food risks posed by BSE had explanations that appeared to be sound. (paras 539 and 554) In the months that followed the publication of the Southwood Report, a number of influences combined to drive MAFF towards the decision to introduce a ban on using for human food those types of offal that were most likely to carry

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BSE infectivity… Mr Donald Thompson… made the suggestion that cull cows might be excluded from the human food chain… Mr Thompson returned to the charge, seeking advice on removing brains and certain other types of offal of cull cows from the human food chain… On 16 May 1989 Pedigree Pet Foods invited… MAFF officials to meet Dr Kimberlin. Dr Kimberlin gave details of the advice he had given to Pedigree, including the categorisation of offal into four categories of risk… Within days Mr MacGregor had decided to go ahead with a ban… He told us that his reasons were that he wished to reassure the public; that it was easier to introduce a general ban than a baby food ban; that it would deal with any clinical animals that might slip through the net; and that it would deal with any risk from subclinical animals… Sir Donald Acheson had got wind of what was afoot and was unhappy about it. (paras 555, 558, 559, 561 and 563) Mrs Attridge made a suggestion about presentation… the way to proceed was to say that the Minister considered the easier and more enforceable way to implement the Southwood recommendation on baby foods was to remove the offal in the slaughterhouses… The Minister would thereby not be appearing to contradict the scientific advice in the Southwood Report. (para 564) In his press release announcing the ban. Mr MacGregor…added…This approach also deals with a separate problem, namely ensuring that if there is any risk that there are cattle incubating the disease but not showing clinical symptoms which are not being slaughtered and destroyed, their offals do not enter the food chain either. (para 567) Finding 22 relates to the introduction of controls on MRM. It is clear that the Inquiry find policy in this area unfortunate in both senses, that is there were both human lapses and bad luck. Initially they believe the consideration given to the matter was inadequate. Warnings were received about the dangers and later a satisfactory paper was prepared by MAFF but owing to a mix up with SEAC this did not lead to the required action. Again in 1994 a paper was prepared but was not considered by SEAC. Finally in 1995 action was taken to ban production of MRM from bovine spinal column when, following the establishment of the MHS, it was established that sections of spinal cord were occasionally not being removed from carcasses and hence could be finding its way into MRM and hence products for human consumption. MRM was in the Inquiry’s view the main breach in the human health controls between November 1989 and 1995. We now come to a topic which we have identified as a serious flaw in MAFF’s precautions to prevent SBO from entering the human food scheme. (para 591) The consultation process in relation to the human SBO ban provided… warning of the danger that spinal column would be contaminated with residues of spinal cord… A meeting was held… on 27 September 1989 to consider the response to the consultation letter… MAFF’s note of the meeting

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recorded… ‘No action should be taken on MRM’… The issue of MRM was a complex one… Those present at the meeting were not in a position to provide definitive answers… but they were in a position to identify that such questions needed to be addressed… We found this unsatisfactory… On this occasion the chance to identify the danger posed by MRM was lost. What would have transpired had that danger been identified? We do not think it likely that it would have led… Ministers to decide that… MRM from the spinal column should be banned…We think that this would have led MAFF to emphasise to slaughterhouse operators and local authorities that it was essential to remove spinal cord in its entirety. (paras 597, 598, 601, 603 and 610) Mr Gummer decided…that slaughterhouse practices should be referred to SEAC. MAFF set about drafting a paper… The paper…gave…the following information… Inevitably some contamination of the vertebrae with central nervous system tissue can occur… Those responsible for preparing the paper had reached the conclusion that some action was called for. In the event it was decided… simply to ask SEAC to advise ‘whether any action or guidance is required in relation to slaughterhouse practices…’ SEAC dealt with that item by advising… that so long as the rules were properly observed… there was no need to recommend further measures on grounds of food safety. It does not seem that there was any discussion at the meeting about MRM… The events that we have summarised demonstrate a serious breakdown of communication. MAFF officials knew, as their paper expressly stated, that a degree of contamination of the spinal column with spinal cord was inevitable… SEAC… proceeded on the basis that clean removal of spinal cord was easy… There are… lessons to be learned… SEAC should have been asked expressly whether the contamination described in MAFF’s paper was cause for concern… It was unfortunate – and possibly tragic – that the intervention of SEAC should… have left MAFF falsely reassured about… MRM. (paras 629–35 and 637) On 8 April 1994… Mr Meldrum suggested that one way to increase security would be to prohibit the use of spinal column for MRM. Impetus was given to this suggestion in July when the European Commission’s Scientific Veterinary Committee Recommended that vertebrae from cattle killed in the UK should no longer be used for the production of MRM… MAFF prepared a paper on MRM for SEAC to consider at its meeting on 30 August 1994… The item was deferred… A revised paper was prepared for SEAC’s meeting on 21 June 1995. This annexed MAFF’s paper… that had been before SEAC in 1990 and the EU Scientific Veterinary Committee recommendation… SEAC concluded that… ‘Provided… the removal of spinal cord was done properly, the MRM process was safe’. (paras 696, 748 and 751) When SEAC met on 28 November 1995, it… was informed that there had been 14 instances, involving at least 25 carcasses, in which SBO had been left attached to carcasses after dressing… SEAC decided… it would be prudent to suspend the use of vertebrae from cattle… in the production of MRM. SEAC’s advice was accepted. (paras 753 and 754)

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Has MRM infected humans with BSE in the years up to 1995… ? It is too early… to answer this question. What is… clear is that this was the route by which infectious material was most likely to end up in human food during that period. (para 757) MRM presented a possible risk because of possible deficiencies in the human SBO controls. Finding 23 deals with this subject. The Report makes it clear that the most vital need was to exclude bovine brain and spinal cord from human food. With the help of SEAC a satisfactory regime was established for brain. Given the generally low hygiene standards in UK slaughterhouses performance in respect of the removal of spinal cord was better than might have been expected. MAFF had rightly recognized in 1990 that under the conditions of the time occasional failure to remove spinal cord was inevitable. This could only be addressed satisfactorily after the MHS was established. At that time such failures were discovered leading to a vigorous campaign to improve standards and to the ban on the extraction of MRM from spinal column as described above. The Inquiry note that prime responsibility for compliance with the rules rested on the slaughterhouse operators themselves and on local authorities as the enforcement authority. There is criticism of both, though in the Inquiry’s view the structure for enforcement was fundamentally unsatisfactory; notably insufficient resources were devoted to the task. MAFF might have done more to help by issuing guidance. Monitoring by MAFF on behalf of central government was desirable but not fully effective; these deficiencies could well have been reduced if such monitoring had been provided for by statute. Responsibility for implementing the human SBO Regulations lay with the operators of the slaughterhouses. Responsibility for enforcing the Regulations rested fairly and squarely on the local authorities, not on MAFF. The legislation did not even provide for MAFF to exercise a monitoring role… Slaughterhouse operators were not fulfilling their statutory obligations and local authorities were not enforcing them. (paras 454 and 455) Most councils spent no more than was barely essential to cover enforcement duties in slaughterhouses. Some did not spend that much… Insufficient resources had been employed by at least some local authorities to ensure that the obligation imposed by the human SBO ban… was universally enforced… In this situation monitoring by central government of the performance by local authorities… was desirable… The shortcomings in monitoring… might well have been reduced if that monitoring had had a statutory foundation. (paras 1240 and 1243) On the introduction of the Single European Market on 1 January 1993, 544 British slaughterhouses sought temporary derogation from compliance with European hygiene requirements… EU Veterinary Inspectors… found 68.5 per cent were of concern or grave concern… Standards of removal of spinal cord do not… appear to have reflected the poor standards prevailing elsewhere in the slaughterhouse… The occasional failure to remove all the spinal cord had been

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described in MAFF’s paper to SEAC in 1990 as inevitable. Under the structure in place before the MHS took over we believe that it was. After the MHS was in place, by adding resources and monitoring a campaign aimed at ensuring 100 per cent removal of spinal cord, MAFF and the MHS appear to have come close to achieving this goal. (paras 680 and 685) Finding 24 relates to the animal SBO ban, and the Inquiry devotes considerable space to tracing the story in detail. They find it an unhappy one in several respects. They note that initially MAFF opposed an animal SBO ban for acceptable reasons; however public disquiet was raised by the discovery of a feline encephalopathy and matters were in effect forced by the discovery in 1990 that BSE could be transmitted to pigs by injection into the brain. An Order banning the incorporation of SBO in animal feed was drafted in haste and secrecy so that it could be announced as a response to this latter discovery; some of its defects were due to this procedure though more thought ought, nevertheless, to have been given to the difficulties. There were significant financial incentives to circumvent the controls while enforcement was the responsibility of local authorities but not those responsible for the human SBO ban. To oversimplify somewhat, the Order was in some respects unenforceable while little attempt was made to enforce it. Reports were received that the Regulations were being flouted and many BABs were born after the animal SBO ban was introduced. This led eventually to a reappraisal of enforcement and the nature of the Order. The establishment of the MHS allowed for proper enforcement for the first time. Before then, though things could have been done better, the institutional structure was such that strict enforcement was not possible. A comprehensive and satisfactory Order came into force on 15 August 1995, and this was overtaken by the measures introduced in March 1996. On 9 May 1990 Mr Gummer was informed that a Siamese cat had died of a spongiform encephalopathy… The public reaction was predictable. Had the cat caught BSE?… A paper was prepared for SEAC on the inclusion of SBO in feed for non-ruminants. This set out MAFF’s reasons for concluding that there was no justification for preventing this… In August 1990 the whole picture was changed by the experimental transmission of BSE to a pig by injection of infectious material into the brain… SEAC concluded that the result of the pig experiment… and… the cases of FSE suggested that a cautious view should be taken… Accordingly SBO should be excluded from the feed of all species… SEAC confirmed its advice on 20 September… MAFF announced the making of the Order on 24 September and the Order came into force the following day. [A MAFF official] was to describe the Order as made in ‘haste and secrecy’. That was a fair description. (paras 362, 366, 368, 371 and 374) The large number of BABs born after September 1990 shows that something was very wrong… The primary source of the infectivity that resulted in BABs… was that SBO was mixed both deliberately and by accident, with carcass remains that were rendered for animal feed… The financial temptation to pass off SBO

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as offal fit for incorporation in animal feed was considerable… Problems were compounded by the form of the Regulations that were put in place. They were, quite literally, unenforceable. (paras 377, 378 and 379) The provisions in the Order bringing in the animal SBO ban were very short and simple. They made it an offence knowingly to sell or supply for feeding to animals or poultry, any SBO… There was a fundamental problem… Neither the feed compounder nor the farmer had any means of knowing whether animal protein incorporated in the feed had been derived from SBO. They were reliant on renderers… The renderer in his turn relied on the slaughterhouse, the knacker’s yard and the hunt kennel to ensure that material supplied was separated into SBO and other offal. Yet the Order did not require this. (para 398) … Returns received in respect of visits to slaughterhouses gave a satisfactory report of practices observed… This picture contrasted with a series of unofficial reports to MAFF of evasion of the animal SBO ban. In November 1990… Reports continued to come in from ‘trade sources’… that the Regulations were being disregarded… These reports led… to… instructions on 1 February 1994 that all renderers processing SBO should be visited… Mr Simmons… conclusions were that a small but significant amount of the total SBO processed… was finding its way into processed protein that was being incorporated in animal feed… The only error in Mr Simmons’s conclusions was that the amount in question was not small. (paras 433, 434, 436 and 441) On 3 May 1994 Mr Eddy… chaired a meeting. He later wrote that at this meeting we spent a great deal of time clarifying in our own minds how the current arrangements work. This was an exercise that should have been done in 1990… It was about this time that MAFF officials began to appreciate the true significance of breaches of the animal SBO ban. The numbers of BABs were soaring… Some had been born after the animal SBO ban had come into force. On 10 August 1994 the new Minister… received a submission proposing radical changes to the animal SBO ban… A lengthy consultation period then ensued… On 1 April 1995 the MHS was launched… With the MHS in place it was possible… to carry out rigorous monitoring of the standards of enforcement of the Regulations… In… June every slaughterhouse… received an unannounced visit on which a thorough inspection was carried out. Mr Fleetwood summarized the result there is a widespread and flagrant infringement of the regulations requiring staining of SBO… The human SBO Regulations… did… require SBO to be stained… This requirement was frequently disregarded. Slaughterhouse operators were not fulfilling their statutory obligations and local authorities were not enforcing them. (paras 444, 445, 446, 451, 453 and 455) We agree… that, however well drafted the Regulations, the statutory structure of local authority enforcement would have prevented strict enforcement of the animal SBO ban… More than half the plants visited in June 1995 were not meeting the statutory requirements on staining, and 60 out of 435 plants were

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not separating SBO correctly from other material. Sixteen were not separating at all. (paras 1242 and 457) One of Mr Hogg’s first actions was to approve… the new Order… The Order was admirably comprehensive and yet… simple… By the end of the period with which we are concerned there was at last in place… an effective animal SBO ban which was being properly implemented and monitored. (paras 458, 459 and 467) Finding 25 is concerned with the establishment of the MHS. This is a major theme but since I have already covered it in Chapter 3 I give only a brief summary here. The Inquiry note that the creation of a national organization was proposed by John Gummer when Minister of Agriculture in response to the generally low levels of hygiene found in UK slaughterhouses. Successive MAFF Ministers and officials pushed this project forward because they were convinced it was in the public interest despite intense political and media opposition. After it was established in 1995 serious BSE-related lapses in the previous local-authority regime were discovered. It would not have been possible to put matters right under the previous arrangements. However, no commendations are given to those in MAFF who argued for the MHS against extensive criticism and without any support from elsewhere. In an era of deregulation a convincing case had to be made out for the introduction of the centralised MHS. Standards of hygiene in British slaughterhouses provided that case. Mr Gummer gave this vignette… in October 1992: Slaughter hall floor heavily soiled with blood, gut contents… Knives and utensils not being sterilised… Missing window panes in roof – birds, flies and vermin entering… congealed and dry blood on offal rails… In July 1991 Mr Gummer wrote to… propose the setting up of… the MHS. Mr Major announced on 9 March 1992 that a new Meat Hygiene Service was to be set up. The decision proved controversial. When the Conservative Party was returned to office after the General Election… there was backbench opposition from its own MPs to the need for additional hygiene measures. Many, including the meat industry, major retailers and some journalists, considered that MAFF was… pandering to… European over-regulation. (paras 679, 686 and 687) The establishment of the MHS had a beneficial impact on the implementation of both the human and the animal SBO ban. (para 690)

Section VI: communication of risk One of the most commented upon aspects of the BSE saga concerned the way in which risk was transmitted to the public by the government. Finding 26 is on this subject. We have already seen that the common allegation that Ministers/departments told ‘lies’ is explicitly rejected (finding 13 above). Nevertheless the Inquiry criticizes what was said by official spokesmen on a number of occasions, essentially

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because of a failure to give the whole picture – either important qualifications were omitted or the reasoning was not set out. One important fact was not mentioned at all. The public took the message to be that BSE was not and had never been a danger. As the Inquiry sees it, the original advice from Southwood that BSE was highly unlikely to be transmissible to humans was obviously significantly qualified when it proved to be transmissible to other species, notably cats. Official statements on BSE and the safety of beef were throughout overconcerned with the possible reactions of the public. In the long run this campaign of reassurance was counterproductive and contributed to the explosion following 20 March 1996. They advocate instead putting the full facts before the public relying on them to respond in a mature manner. Out of 30 individual criticisms, five or six (one entry covers two separate occasions) are directed to a Minister and CMOs on the communication of risk and in addition there are three similar criticisms of the MLC. This is consistent with rumours one heard during the course of the Inquiry that they regarded the failures in this area particularly seriously. The… casualty of the BSE story has been the destruction of the credibility of government pronouncements. Those responsible for public pronouncements… were aware that humans might have become infected before… the SBO ban… They saw no reason to draw attention to this… Ministers and…CMOs made statements about the safety of beef which were intended to reassure the public. Insofar as these statements were believed, many clearly treated them as assurances that posed no danger to human beings. (para 115) The first case of FSE (feline SE) was… of concern to SEAC… No specific observations or recommendations were ever made on the effect of FSE on the risk to humans… We had evidence from a number of scientists that transmission of BSE to cats was an event which altered their belief that BSE posed no greater risk to humans than scrapie. The public were never told that scientists’ appraisal of that risk had changed. (para 674) From… December 1986…to…20 March 1996…officials and Ministers followed an approach whose object was sedation… The campaign of reassurance focused particularly on the safety of beef. Successive DoH CMOs and a CMO for Scotland, made unqualified statements that it was safe to eat beef. They did so, not on the basis that they were satisfied that BSE was not transmissible in food, but on the basis that they were satisfied that the portions of the cow which might infect were not permitted to enter the food chain. This was not made clear to the public… The need to provide a reassuring message also featured strongly in the presentation of measures to ensure the safety of medicines. (paras 1179, 1181 and 1183) Throughout the BSE story, the approach to communication of risk was shaped by a consuming fear of provoking an irrational public scare. This applied not merely to the Government, but to advisory committees, to those responsible for the safety of medicines, to Chief Medical Officers and to the Meat and Livestock

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Commission… Our experience of this lengthy Inquiry has led us to the firm conclusion that a policy of openness is the correct approach… We believe that food scares and vaccine scares thrive on a belief that the Government is withholding information. If doubts are openly expressed and publicly explored, the public are capable of responding rationally… We note… that SEAC and MAFF have made public… the question of whether BSE has passed into sheep. We do not understand that this has led to a boycott of lamb… Lessons… The public should be trusted to respond rationally to openness. (paras 1294 and 1301)

Section VII: ‘contingency planning’ Finding 27 is concerned with events during the last few weeks before 20 March 1996 and is in two parts. First, the MAFF and DoH secretaries to SEAC are criticized for not properly alerting their senior hierarchies to the alarming fact that on 1 February the question had been raised in SEAC as to whether the cases of CJD in very young people reflected the advent of BSE. Second, they deplore the lack of what they call contingency planning in February and March. MAFF and DoH ought to have been in intense discussions at top level following this questioning (despite the fact that, according to the first half of the criticism, those concerned would have been unaware of what had happened) in which case there is little doubt, it is claimed, that they would have identified the need for a 30-months scheme well-before SEAC had come to a view. Waiting for the latter’s opinion was regrettable. It is implied that the government as a whole would certainly have accepted a recommendation from MAFF/DoH in favour of a 30-months scheme if it had been drawn up in this way. Hence the de-boning option eventually advocated by SEAC could have been dismissed earlier and the question about the susceptibility of children identified and answered before a public announcement was made. SEAC met again on 1 February… Mr Eddy1 circulated a minute about the meeting… We think that he should have included a clear warning of the concerns that had been expressed about the young cases… He did not do so. (paras 801, 804) Dr Wight2 minuted Sir Kenneth Calman3 about the meeting… her minute was inadequate in that it failed adequately to express the concerns of SEAC about the young cases. In describing the conclusions that might be drawn from these, she used language which suggested that there was, in reality no likelihood of a link between BSE and a new variant of CJD. We are inclined to think that this was, in fact, Dr Wight’s own understanding. (para 805) We have found that there were no interdepartmental discussions about the possible implications of the findings of the CJDSU in either January or February.… Mr Hogg proceeded to decide on the response that he considered appropriate without reference to Mr Dorrell or Sir Kenneth Calman. When we asked him whether he should not have discussed the 30 month scheme with Mr Dorrell,

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he replied: No, forgive me, the 30 month rule was down to me… it was something for which I was answerable. What was the reason for the inertia on the part of both departments prior to March? [A MAFF official] gave this answer… I think that both departments will have been looking to SEAC to bring forward a firmer scientific view. It was not merely SEAC’s scientific view that the two departments were awaiting. By 1996 the practice had become firmly established of looking to SEAC to advise on policy decisions – to an extent that came close to delegating them to SEAC… Waiting for SEAC was not a satisfactory alternative to examining policy options. (paras 841, 843–5) The major policy decision taken on 20 March proved almost immediately not to be viable. The deboning option was not acceptable… When Mr Dorrell made his statement to Parliament, he was unable to answer an obvious question. Were children more susceptible than adults to BSE?… Contingency planning should have led to the anticipation of that question. SEAC could have been requested to answer it. Had its advice been obtained before 20 March, parents could have been reassured rather than alarmed. (paras 846–7)

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Finding 1: BSE was caused by a new mutation in the PrP gene, probably in cattle, and it was spread mainly by cattle consuming feed containing BSE-infected MBM. Finding 2: The practice of feeding MBM to cattle was by the early 1980s of long-standing; hence BSE could not have been anticipated (with the clear implication that its occurrence was nobody’s fault). Finding 3: Because of the lengthy incubation period of BSE the disease got a hold in the UK cattle population and (probably) people were infected before it was noticed. Finding 4: Changes to rendering processes were irrelevant to the spread of the disease. Finding 5: The two main ‘alternative’ theories accounting for BSE, the autoimmune and organophosphate theories, are wrong. Finding 6: The prion theory is essentially correct. Finding 7: Contaminated feed was rapidly and correctly identified within MAFF as the source of the disease. Finding 8: BSE is a specific disease and not a variant of scrapie; this accounts for the very rapid spread of the disease; by 1988 some 10,000 animals were being infected each month. Finding 9: There was a widespread belief among policy makers that a large dose of infectivity was needed to transmit BSE orally. This belief, which SEAC and other scientific advisers did nothing to dispel (and indeed seemed to share to some extent) had adverse consequences for the enforcement of the feed ban, for the drawing up and enforcement of the animal SBO ban and for the decisions on MRM. Finding 10: After commending the Southwood Committee for various recommendations the Inquiry criticize them for (a) not disclosing that they had been

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unable to review the epidemiological data on which their recommendations were based; (b) not making it clear that the risk posed by BSE should in any case be reduced to as low a level as possible; (c) not pointing out the risk posed by cattle incubating BSE; and (d) downplaying their assessment of the risk posed by exposure to bovine products included in medicines. Finding 11: The frequent media references to the ‘BSE scandal’ are not justified by the facts; most of those responsible for responding to the advent of BSE emerge with credit. Finding 12: Apart from in the first half of 1987 there was no attempt to conceal the facts about BSE from the public and allegations of a government ‘cover-up’ are untrue. Finding 13: The government did not lie to the public about BSE. Finding 14: MAFF did not favour the interests of producers over those of consumers. Finding 15: Some commercial enterprises acted with commendable responsibility in helping the authorities to respond to the crisis (though some acted irresponsibly). Finding 16: In general the right policy decisions were taken. Finding 17: But shortcomings attended the management of the measures adopted as a result of these decisions. Finding 18: The disease was identified as quickly as could reasonably be expected. Finding 19: The 1988 feed ban was vital and necessary; unfortunately the authorities were handicapped by the absence of a test for ruminant MBM and local authorities made no attempt at enforcement; some feedmills deliberately sold feed containing ruminant protein after the ban had come into effect; insufficient thought was given to implementation when the ban was introduced; despite the weaknesses the ban had, within limits, been highly successful. Finding 20: The slaughter and compensation scheme for animals showing clinical signs of BSE was highly desirable; MAFF ought to have consulted DoH before proposing such a measure; regrettably the CMO when consulted did not immediately confirm it was desirable; for this and other reasons the scheme was introduced six months after MAFF officials had proposed it. Finding 21: The adoption of the human SBO ban (only partly recommended by Southwood) was of the utmost importance, but it was unfortunate it was decided upon by a ‘haphazard’ process. Finding 22: Even though MAFF recognized as early as 1990 that spinal column from which MRM was manufactured was bound to be contaminated with some spinal cord and SEAC was alerted to this, the production of MRM from this source was not banned until 1995 due to both bad decisions and bad luck. Finding 23: Implementation of the human SBO ban faced difficulties from the low standards of many UK slaughterhouses necessitating rigorous enforcement which local authorities were not capable of providing. Matters improved when the MHS took over responsibility for enforcement on 1 April 1995.

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Finding 24: The 1990 animal SBO ban, though necessary, was not drafted in an enforceable form in part because the normal process of consultation with the interests concerned was not followed. The defects in the Order, the deliberate transgressions of some slaughterhouses and the inadequate enforcement by local authorities were together responsible for many of the BABs that occurred in the 1990s. A new much more satisfactory Order came into force in August 1995 which, together with more effective enforcement provided by the MHS, provided an effective regime. Finding 25: The establishment of the MHS allowed more effective implementation of both the human and animal SBO bans. Finding 26: Statements by government spokespersons that ‘beef was safe’ wrongly did not make it clear this was dependent on the human SBO controls being effectively operated; the (alleged) modification of SEAC’s views following the discovery of BSE in a cat was played down; what amounted to a campaign of reassurance was misconceived; rather the full facts should be put before the public which should be relied upon to respond in a mature manner. Finding 27: (a) The joint secretaries of SEAC failed properly to notify their superiors of the concerns expressed at the meeting on 1 February 1996 that cases of CJD might be linked to BSE; and (b) ‘contingency planning’ from 1 February would have led to the identification of the need for a 30-months scheme and reduced the scale of the public reaction to the announcement of 20 March.

Notes 1 MAFF secretary. 2 DoH secretary. 3 CMO.

7 Consideration of the Inquiry’s Findings

The previous chapter has summarized the Inquiry’s view on the emergence of the disease and the response to it. The Report represents the output of an enquiry which engaged virtually full-time a senior judge, later the Master of the Rolls and Lord Chief Justice, and two other senior individuals for nearly three years. The process necessitated hundreds of man-years of work by witnesses, involved dozens of highly-paid lawyers, was hugely stressful for a few and cost nearly 30 million pounds. The public is entitled to expect a lot in the circumstances. As with many other matters in this life, opinions are likely to differ on the value of an exercise of this kind. In my view, however, BSE has been such a national trauma that an enquiry of some kind was inevitable at some stage. Inevitable or not we now have the Report and two main questions that arise are, first, is it sufficiently substantial to justify the effort expended, and, second, does the evidence produced justify the conclusions reached? Of course we must also address what, if anything, we can learn from the process of compiling the Report and from its conclusions.

The status and standing of the Report We have already seen that the conduct of the Inquiry had its defects. That is important in itself but it ought not to detract from the fact that the Report is in many respects impressive. It examines carefully virtually all of the main areas of importance – scientific, political and administrative – in the saga of BSE up to March 1996. The story is told as clearly as its complexity allows. Major attempts have been made, with considerable success, to come to balanced views on the questions posed. It gives equal attention to the broad picture and to a detailed account of events, and its conclusions have the more force by being expressed in moderate language. It directly confronts each of the popular explanations of the disaster (‘lies’, ‘conflict of interest’, ‘deregulation’, and so on) and gives a firm and clear judgement in each case quoting the evidence (or lack of it) on which they have relied. One telling fact is that the frustration and irritation that many witnesses felt towards the Inquiry, with some justification because of the way it had been 129

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conducted, largely disappeared when the Report was produced. This was not because all accepted that everything it said is right. Inevitably in such a comprehensive document there are judgements which are questionable or even plain wrong. It is rather because witnesses recognized that in the Report a genuine attempt has been made to understand matters and to be fair. I turn below to some quibbles and points of outright disagreement: I also suggest a number of ways in which the Report could have been improved. However, overall it is a considerable achievement, and is likely to remain a first point of reference for those wanting to discover what happened. The Report’s findings I comment below on the individual findings. The findings are set out in detail in Chapter 6, and summarized at the end of that chapter.

Section I: the origin and science of the disease Findings 1–8 show that the Inquiry accept the bulk of the mainstream theories for the origin and science of the disease, that is the views supported by SEAC and government. They explicitly reject the organophosphate and autoimmune theories, both of which had received extensive media publicity and accept that the prion theory is the best explanation of BSE currently available. They agree that the disease was spread by contaminated MBM in cattle feed and that dealing with it was made difficult by its lengthy incubation period in cattle and people. This led to animals and people becoming infected before the existence of the disease was suspected. Nevertheless the Inquiry did come to one surprising conclusion. The scientific establishment were somewhat taken aback by the certainty with which the Inquiry stated that the ultimate origin of the disease was a new mutation rather than a manifestation of scrapie in cattle, and that there had been cycles of infection before 1986 probably back to the 1970s. An independent group of senior scientists asked by MAFF to review these and some other scientific conclusions of the Inquiry did not endorse (though they did not reject) these views.1 These scientific disagreements need not detain us since, as the Inquiry notes, the answer to them does not affect the nature of the appropriate response to the emergence of the epidemic. The picture the Inquiry draws is one where no blame can be ascribed for the emergence of the disease. It was unforeseeable and unforeseen. Indeed I am tempted to observe that one might perhaps describe it as an ‘act of God’. The significance of the latter phrase is explained below (p. 198). Thus the emergence of the disease should not be blamed on the relevant industries, government or anyone else. The broad truth of this analysis is, I suggest, apparent to anyone who examines the facts. Finding 9 on the lack of appreciation of the ‘small’ dose required to transmit BSE orally in ruminants is one of the Inquiry’s hobbyhorses; they return to the point several times to explain responses which they regard as suboptimal. The Inquiry is

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on to something here though they do not help themselves by the way they often explain matters. A ‘dose’ of something is the product of two factors, namely the concentration of agent in the medium in question and the amount of medium used. Throughout the Report the Inquiry refer only to the weight of infective material in the context of dose which led some expert witnesses to conclude that they never properly understood the concept. One valid question is whether others were, perhaps, similarly confused. Another is what constitutes ‘large’, since most references to the alleged need for a large dose to bring about infectivity give only a comparative and not a quantitative indication of what is being claimed. Nevertheless, the record shows many statements by SEAC, the CMO and the CVO that ‘large’ doses were needed to cause infection. Further evidence that this view was widespread is given, as the Inquiry point out, by the general reaction to the attack-rate experiment and, indeed, as I suggest above, by the design of the experiment itself. As late as December 1995 the Deputy Chairman of SEAC included in a newspaper article a statement that large doses were needed to cause infection. I speculate above (pp. 64, 67–71) on the sort of considerations that might have led to a view that ‘large’ doses were needed. I have not found these to have been articulated clearly, and that may be part of the problem. Possibly such considerations as I have mentioned led to widespread shared assumptions which were never properly articulated and challenged. One thing is clear. Many statements were made by leading scientists that a large dose was needed to cause infection and no statements to the contrary. Hence Ministers and administrators cannot be blamed for taking this to represent the established scientific position.

Section II: the Southwood Committee Despite having some praise for the Southwood Report, in Finding 10 no less than four of the total of 30 or so criticisms made by the Inquiry reflect adversely on the actions of this Committee, a fact that appears not to have percolated into public consciousness. Is this justified? Sir Richard Southwood was a distinguished figure and the other members of the Committee only slightly less so. We can be sure that when they agreed to give their time for the public good they did not anticipate subsequently receiving criticisms of their actions from a Public Enquiry. It must be recognized that the Committee were in a very difficult position. In 1988 little was known of BSE; that was why the Committee had been established. Among the little that was known was that TSEs had substantial incubation periods. So the Committee would have to make recommendations years before the truth or otherwise of their assumptions and deductions became apparent. They had little option but to work by analogy with what was known about other TSEs. Three important facts were known. The first was that humans were susceptible to a TSE: the second that TSEs could be transmitted orally (as in kuru) and in other ways; the third that scrapie had been known for hundreds of years without any implications for human health becoming apparent. This probably seemed highly significant since, like cattle, sheep are ruminants.

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Although the Committee may have concluded, as the Inquiry suggest, that BSE was probably a variety of scrapie which had been transmitted to cattle, this would not necessarily have affected their recommendations on precautionary measures. Physically cattle are a lot closer to sheep than to humans. Since scrapie, the TSE of sheep, seems not to affect humans it would be reasonable to judge that a TSE in cattle would probably not do so either. Of course there is always a risk that matters will turn out differently. The Committee were well-aware of that possibility. It is not clear that even had they believed that BSE was a new disease of cattle the Committee would have recommended different precautions to protect humans. Moreover the Committee had no means of knowing that BSE was a new disease; indeed 15 years later this is still not certain. Further, in 1988 there was no suggestion from any quarter that steps should be taken to keep scrapie-infected material out of the human-food chain. Though this was the consensus view it was not based on any direct evidence that such material was safe; there was merely an absence of evidence it was unsafe. At the most it might have been sensible for the Southwood Committee to have included in their Report some general statement to the effect that tissues which might harbour BSE should, so far as possible, be kept out of the human food chain though whether that would have led to any useful action must be doubtful. All in all I regard it as a bit harsh to criticize the Committee for not recommending that tissue from animals not showing clinical symptoms should be kept out of the human-food chain. Even though the Inquiry deny it, effectively the Southwood Committee are criticized for not having foreseen the need for the SBO ban. But the best assessment they could make was that the risk from food was ‘remote’. How far expensive measures are justified in such circumstances is always a matter of fine judgement. Indeed one could take the view that it was fortunate that they recommended protective measures for baby food. It seems the Committee were by no means certain this was necessary but in the event it led to the human SBO ban. Where the criticisms of the Southwood Committee seem better based is in relation to the wording of their Report. It was unwise of them to have included material provided by another2 in the Report without making this clear in some way. They could have included such a text as an annex on which they could have commented. It was also, perhaps, unwise of them to allow themselves to be persuaded to tone down their references to the possibility of transmission via vaccines and medicines. However, even on this there is another point of view. Had their view that transmissibility was a real risk in respect of vaccines been put frankly to the public is it not quite possible that a substantial withdrawal of children from vaccination would have occurred? As the Inquiry acknowledge this could well have led to children not being vaccinated and hence to extra deaths. If such deaths had in fact occurred and if, as seemed likely at the time, BSE had been subsequently shown to pose no risk to humans would there not now be those only too willing to criticize Southwood and his colleagues for unnecessarily raising alarm? The Report suggests that it should have been possible to avoid public concern at a level that would have led to such an outcome. Here and elsewhere the Inquiry are too ready to assume that the action they (with hindsight) regard as optimum

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would not have led to adverse consequences. If, as now seems certain, we are to embrace a culture of openness in all such warnings and judgements we need to be clear that we are doing so because on balance it is the best policy. If we imagine openness will never give rise to problems we face some large disappointments.

Section III: the overall government response Findings 11–14 were presumably highly surprising to many commentators. At any rate they contradict the explanations most of them had put forward to account for the epidemic. That there was a ‘BSE scandal’ was normally taken as obvious and explanations of what it comprised almost always included one or more of ‘concealing facts’, ‘cover-up’, ‘government lies’ and ‘unacceptable conflicts of interest’ leading to the ‘favouring of producer over safety interests’. For a decade most articles on BSE, and indeed other food-safety issues, have taken as their theme the opposite of some or all of these findings by the Inquiry. In other words the most comprehensive, thorough and independent investigation of the most serious food-safety issue of our time has found that the great bulk of comment, high-brow and academic as well as low-brow and popular, to be fundamentally wrong. Some readers may have paused at this point to reflect that they do not remember these surprising findings being widely reported at the time. Their recollection is correct; such reporting as occurred was somewhat grudging. One reason for this was probably that ‘good’ news – in this case that the public authorities were not guilty of misdemeanours against their own citizens – is simply less newsworthy than the opposite. I would suggest two other possible reasons for the lack of reporting of these findings. One is that much of the immediate reporting of the Inquiry’s findings was prepared beforehand obviously on the basis of what was expected. Such prepared material will have reflected what had been said before. Pressures of time prevented those concerned from sufficiently adjusting drafts prepared on this basis to reflect what was actually found. The second explanation is that many of the media commentators were precisely those who had espoused the opposite of Findings 11–14 in numerous earlier discussions and articles. They would not, perhaps, have striven to identify findings which contradicted what they had previously asserted; nor would they necessarily have given the findings maximum publicity if they had noticed them. From the wider perspective these findings could be regarded as among the most important in the Report. At any rate it must be reassuring to know that a detailed investigation has found serious and widely accepted claims of what would amount to an abuse of power unjustified. The opposite view to Findings 11–14 were thoroughly rehearsed before the Inquiry on 30 October 1998 when it took evidence from consumer groups including the Consumers’ Association, the National Consumer Council and the Consumers in Europe Group. Sheila McKechnie of the Consumers’ Association was the leading light. She and some others made their views (roughly the opposite

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of Findings 11–14) very apparent. Some of their initial comments were rather unguarded; for example in response to questions from Phillips McKechnie confirmed that she had directed a policy of being deliberately awkward with MAFF. Phillips undoubtedly noticed that this sat oddly with her earlier claim that MAFF was awkward with her. Eventually Phillips indicated that while he had fully grasped the views of the witnesses before him, he would prefer to base his own view on evidence; what he wanted was evidence to justify the claims made, not assertion. This seemed to come as something of a shock to the consumer representatives. They were used to having their views treated seriously especially if critical of government and its agencies without the need for details like evidence. They gave every impression of believing their views were self-evidently true and of being taken aback by the suggestion that they should produce evidence to support them. In particular they asserted several times that information had been concealed. Phillips asked them to give an example. They could not do so. Eventually one of them pointed to the important qualification in the Southwood Report that if their (the Southwood Committee’s) view that BSE was unlikely to represent a threat to human health proved wrong then the matter would be very serious. Unfortunately for him Phillips immediately produced the relevant MAFF press release which included the very phrase it had been suggested had been concealed by government. ‘Concealing the truth by putting it in a press release’ may be an old Whitehall joke, but it was not one that appealed to Phillips. Phillips came back to this point later and it appeared to make a marked impression on him. The inept performance of the consumer representatives on this occasion, and the indication they gave that they based their critical views of government in general and MAFF in particular on prejudice rather than evidence, undoubtedly contributed to the clarity of Findings 11–14.

Section IV: the actions of commercial enterprises I have included Finding 15 in the list partly because it illustrates a point not wellappreciated. This is that large organizations have at least as great an incentive to take care on health matters as small ones, because they have more to lose especially if they have important brands to protect, and often act accordingly. However, against the evidence of ethical commercial behaviour given by Finding 15 we also need to consider Finding 19 which shows some (different) commercial enterprises in a much less-favourable light. There the Inquiry found evidence for unethical behaviour by some feed manufacturers in marketing feed which they must have suspected contained BSE infectivity. One reason for this difference may lie in the closeness of enterprises to final consumers; the need to be scrupulous in matters of safety may be particularly well-entrenched in companies which market directly to the final consumer. However, this explanation only goes so far, since it does not account for the difference between some feed manufacturers and Prosper de Mulder.

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Section V: the detailed government response Setting aside the dismissal of the critics’ main claims about malign and dishonest actions by government (Findings 11–14 discussed above) the overall findings of the Inquiry are in Findings 16 and 17. The judgement that the right policy decisions were taken is obviously fundamental. The truth of the finding is shown by the absence of any sensible suggestions for alternative action; criticism focuses on why matters could not have been done quicker or better. Equally, even after making all allowances there are some areas where matters were unsatisfactory. Overall these two broad judgements seem right. Equally, Finding 18 seems correct. It is very difficult indeed to identify new diseases. The ruminant feed ban (Finding 19) was the main measure taken to eliminate the disease, and the Report notes that from some standpoints it was highly successful. However, it also states that a ‘lack of rigorous thought’ attended its introduction. Could a better measure have been chosen? And was the response good enough as the view that the existence of BABs was wholly explained by a carry-over of feed from the period before the ban was introduced became progressively less plausible? To answer these questions we need to bear in mind the constraints under which those concerned worked and what alternative actions were in practice open to them. The main constraint was the absence of a test for ruminant protein in feed. At the time the first Order was made it would have been apparent that in the absence of a test it would not be possible for the enforcement authorities (local authorities) or manufacturers to test for accidental contamination of ruminant feed with ruminant protein; similarly, local authorities would have great difficulty in preventing the deliberate marketing of any contaminated feed. The Inquiry finds that initially there were some deliberate breaches of the ban by manufacturers and others, and that no steps were taken by local authorities to enforce it. These factors would not have helped, but over time the greater problem arose from accidental contamination of ruminant feed with ruminant protein included in pig and poultry feed. In the absence of a test the obvious way to have prevented this happening would have been to insist that ruminant protein could only be used in plants (or in production lines) producing non-ruminant feed. One difficulty with that is that manufacturers might have responded not by dedicating plants or lines to ruminants or non-ruminants but by refusing to use ruminant protein which would as a result have lost its value. This loss in value of a byproduct would have had a serious adverse effect on the beef industry. The responsibility for this loss of income would have been placed on the government. Claims for compensation might well have been put forward which would have been difficult to resist. There would also have been a major environmental problem of waste disposal. There were therefore obvious downsides to this course. A fine judgement was necessary as to whether such a draconian measure would represent a proportionate response to a risk, the extent of which was largely unknown. Furthermore, it was not clear that any accidental contamination that would occur in feedmills would be sufficient to cause further cases of BSE.

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This last is a significant point and it is important to be clear that it is not simply a point invented after the event to justify those who, with the benefit of hindsight, may have chosen the wrong option. One of the puzzling facts about BSE is the extent to which single cases occur in herds which are otherwise free of the disease. This point has been noticed almost from the beginning. A plausible explanation for this factor was that the concentration of the infective agent in the feed consumed by the infected animal was at a level only just capable of infecting. This would account for the other animals in the herd not becoming infected. In these circumstances it probably seemed that measures which greatly reduced the amount of the infective agent in feed would prove successful even if some small element of contamination remained. What this latter argument misses is that in 1988/89 the number of animals incubating the disease was very much greater than was realized at the time. Hence any contamination of ruminant feed with bovine material would be likely to involve material contaminated with BSE to a much greater extent than would have been expected at the time of the introduction of the ban. I suspect that it was thought processes like those suggested in the previous paragraphs which led to the decisions not to introduce a feed-recall scheme in 1988 and not to require dedicated production facilities for ruminant feed when the feed ban was introduced. There may also have been a lack of detailed knowledge in government of the processes at the many sites at which feed was produced (some feed was produced by individual farmers). This would have made it difficult to judge the precise risks of contamination. The introduction of the animal SBO ban in 1990 would also have given a false reassurance that any leaks in the system ought to have been plugged. Unfortunately of all the measures adopted to deal with BSE the animal SBO ban was the least effective. The Inquiry obviously found some difficulty in deciding quite what to make of all this. Hence their quoting approvingly a description of the feed ban as ‘spectacularly successful’ while at the same time judging that its introduction displayed a ‘lack of rigorous thought’. Is this last judgement reasonable? Those who decided on the modalities of the feed ban in 1988 were wrestling with difficult choices on the basis of little information. While with hindsight it would have been better if different choices could have been made on some issues we can be grateful that the measure was as successful as it was. By 1994 when vets at the CVL published an analysis in the Veterinary Record it had been demonstrated that the ban had had a marked effect in reducing the rate of infection though it had not completely prevented new cases from arising. What was not known accurately was the amount of pre-ban feed in the system. However, by 1994 it had also become apparent that the continued emergence of BABs could not be satisfactorily explained by contamination from carried-over feed. Steps were taken to tighten up processes both in feedmills and by introducing substantial improvements to the animal SBO ban which took effect in September 1995. The effects of these improvements are illustrated by the figures for the number of confirmed cases by year of birth set out in Figure 4.2. Though the figures for 1996

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are obviously affected by the complete ban on the use of ruminant SBO for any purpose introduced at the end of March it can still be seen that the number of cases was in very steep decline by the beginning of 1996. The question is, should some of the problems solved by the 1995 measures have been anticipated beforehand especially when the ban was introduced in 1988 and extra steps taken then to prevent cross-contamination? Of course the ban was very successful up to a point and had it been a bit more successful – and had the animal SBO ban introduced in 1990 not been so defective leading to many more BABs in animals born after that date than would otherwise have occurred – probably nobody would have thought of criticizing the terms of the original ban. The matter is so finely balanced that it would be wrong to take a strong view either way. Finding 20, on the slaughter and compensation scheme for cattle showing clinical symptoms, concerns the first measure introduced with the primary objective of protecting human health. The Inquiry is clearly impatient with the hesitations which attended its introduction, though the only criticism is levelled at certain MAFF officials for not consulting DoH before recommending a scheme. There can be no doubt that it was vital to have introduced the measure since it is now established that the amount of infectivity in an animal increases markedly towards the end when clinical symptoms appear. Of course we must remember that this was not known in 1988 when it was under discussion. To understand the situation faced by those dealing with the matter we must think back to the politics of the day. The leaders of the Conservative Government which came to power in 1979 had as fundamental aims the reduction of public expenditure as a proportion of national income and resistance to the claims of special interest groups. Ministers who gave the impression of doubting the importance of these tenets did not last long. The government was unhappy with the cost of agricultural support and frustrated that, because most support was set by EU regulations under the common agricultural policy, so little could be done to reduce it. These factors served both to discourage MAFF Ministers from putting forward to the Treasury bids for public funds to compensate farmers in new ways and to discourage their officials from proposing such measures to them. MAFF, Ministers and officials alike, realized that the instinctive Treasury view on any such bid would be that it was a ploy to increase support for agriculture by backhand means. All this would be especially clear to John MacGregor whose previous post had been Chief Secretary. He would also be alive to the danger that his Ministerial colleagues might judge him harshly if, after serving as a rigorous Chief Secretary, he seemed to go ‘native’ as Minister of Agriculture. Given these factors, some might think it commendable that officials put the slaughter and compensation scheme forward as quickly as they did and that it was taken forward by Ministers and put in place. The detailed criticism is based on the Inquiry’s view that it is ‘remarkable’ that the relevant submission had been prepared without involving anyone at DoH. The obvious inference to be drawn from DoH not having been consulted is that it did not occur to anyone in MAFF at the time the submission was prepared that

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involving DoH would be helpful. It is not self-evident that this attitude was unreasonable. Probably this state of mind reflected experience over the years. Certainly it would have been the MAFF view that involving Edwina Currie (a Health Minister at the time) in 1988 in the problem of salmonella in eggs had not proved to be of benefit to them or to the government more generally. Moreover, had John MacGregor agreed the submission when it was put forward there is no doubt that the measure would have been put in place quickly. It must also be borne in mind that the safety of food was a responsibility MAFF shared with DoH on which the former usually took the lead; MAFF were accustomed to taking decisions on food safety mostly without awaiting DoH’s views – and DoH were happy with this situation. The Inquiry take the view that involving DoH in the preparation of the submission would have speeded up matters. This is possible though the evidence in the Report suggests otherwise. When the CMO was involved on this very question the direct result was the delay in reaching a decision to which the Inquiry object. Why it should be thought that involving a more junior official would have led to a quick decision is not clear. Likewise the Report’s account on medicines and cosmetics, which I have not had space to cover in detail, refers to long delays in dealing with matters in DoH. This is not necessarily to assert that DoH is for some reason ‘slower’ than other departments. The point is rather that, certainly at that time and until BSE became a much bigger issue, food-related illnesses were for them a low priority with which MAFF was expected to deal. One can see that compared to heart disease, cancer and the problems of the NHS, food issues were for the DoH pretty small-beer. Thus in 1988 there was no reason to suppose that DoH would give any priority to an obscure animal disease closely related to another such disease (scrapie) believed not to affect human health. Later experience did not demonstrate that that view was erroneous. Also the history of the human SBO ban, to which I turn next, does not suggest that involving DoH at an earlier stage would necessarily have led to a quicker or better outcome. I regard Finding 21 on the human SBO ban as somewhat churlish. Ministers and officials in MAFF were faced in 1989 with a Report by a distinguished group, which they and DoH had appointed, recommending, so far as human health was concerned, only that high-risk material should be excluded from baby food. The group had made clear that they regarded this recommendation as ‘cautious in the extreme’. Nevertheless, those Ministers and officials, with no support (indeed some opposition) from DoH, managed to introduce a much more far-reaching measure which, with hindsight, was vital for the protection of public health. They did so without undermining the credibility of the Southwood team. Admittedly the record shows that progress towards the measure was not smooth, but, overall, credit would seem to be due. Instead all the senior people get at least one criticism. Further, top management in both MAFF and DoH are criticized for not ‘reviewing’ the baby-food recommendation in the Southwood Report; the clear inference is that such a process would have led to a decision in favour of the SBO ban, but one adopted by a satisfactory process. Presumably such a process would have

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involved officials or Ministers questioning Southwood as to why he had put this recommendation forward. As a second step it would have been necessary to put to Southwood, a distinguished FRS, that his scientific reasoning was defective. The third step would have been to substitute the department’s view for his and that of the rest of his Committee. This scenario gives rise to a number of problems. To take the practical aspect first it is far from clear that following such a process would have led to a result that would have been ‘better’. The Southwood Committee were far from insistent on the necessity of excluding potentially infective tissue from baby food. (Of course Southwood had agreed that clinically affected animals should be excluded from the food chain but this did not deal with affected animals not showing clinical symptoms.) Southwood himself is on record as saying that the recommendation represented a policy of ‘extreme caution’. For their part the government’s internal scientific advisers knew little about TSEs; that is why the Southwood Committee had been appointed in the first place. Had the baby-food recommendation been challenged by government, which is what the Inquiry envisage, it is as likely as not that the ensuing discussion with Southwood and his Committee would have ended in ‘agreement’ that no measures were needed to protect human health. Had this been the outcome of a process like that envisaged by the Inquiry both sides would have had a lot invested in what had been agreed between them. Such a policy once agreed and put in place would have been difficult to change. This is one of the instances where the Inquiry show a naïve and unjustified faith that if something had been challenged at the time the outcome ‘must’ have been better. Putting the real possibility of a worse outcome aside, it is wholly unrealistic to envisage that recommendations from an independent group like Southwood’s could have been challenged by those within government who would either be non-scientists or those occupying a place in the scientific hierarchy several rungs lower. One can be confident that Southwood and his colleagues would not have been pleased and would have had ways of making their displeasure felt at the highest levels. When the media heard of what was happening they would have claimed that it was ridiculous for government to call into question advice from such eminent quarters. Sinister motives would almost certainly have been adduced. Moreover such an approach would negate what from the government perspective is one of the advantages of appointing expert committees, namely external validation for the policy adopted. At the least such questioning would detract from the authority and credibility of the committee and hence weaken the case that government had matters under control. It would lead to justified claims that the government was trying to set aside the recommendations of their own advisers. In the context of an issue of food safety, then, whatever the government’s real motives this would almost certainly lead to claims that the public was being unnecessarily put at risk. Of course such charges can be refuted, but experience shows this is difficult to do successfully. It is naïve to assume the truth will carry the day, at least in the short run. What underlies the points made in the previous paragraph is that the establishment of an expert advisory committee by government especially on an issue of

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public safety is a political act which limits the government’s own subsequent freedom of manoeuvre. In particular it is difficult for the government to question what is recommended. This reality is by no means limited to BSE. E coli is another, more recent, example. In that case the recommendations of an expert committee were over-prescriptive but, though this was widely appreciated in government, it proved impossible to disown them. The Inquiry show little sign of understanding the political reality described in this paragraph. Against this background the fact that MAFF with the eventual support of DoH succeeded in strengthening the measure recommended without antagonizing or undermining the committee was on any reasonable view a considerable achievement, but one that goes unrecognized in the Report. Finding 22 on MRM is not a happy story. Now it appears obvious that MRM produced from the bovine spinal column is bound to contain traces of spinal cord; and hence given the high infectivity of that organ in infected animals that the process of preparing MRM from spinal columns should have been banned from the beginning. However the Inquiry correctly recognize that right at the start this is unlikely to have been the outcome even had the facts been more explicitly faced by SEAC than was, apparently, the case. Effectively to have shut down a significant industry because of fears of potential contamination expected to be very low and which it ought to be possible to prevent or at least to keep to an absolutely minimal level if operators showed sufficient care when the potential risk in question had been officially described as ‘remote’ would have been seen at the time, understandably in the light of the known facts, as unjustified. Nevertheless, an expression of concern by SEAC would probably have led to some tightening up of slaughterhouse practices and, conceivably, to the production of MRM being banned earlier than it was. Hence it is reasonable to suppose that an earlier proper consideration of the matter by SEAC would have led to less infective material reaching consumers. Why did this problem arise? The description of the relevant sequence of events in the Report shows how concerns about potential contamination of MBM made from spinal column that existed in MAFF were not fully brought home to SEAC because they were lost in a sea of paper on the SEAC agenda and/or because SEAC was deliberately asked ‘unloaded’3 questions. This is unusual since generally people are criticized for asking loaded questions. In this case it would have been better to have done so and for the MAFF concerns to have been prominently and deliberately placed under SEAC’s nose. This is a good illustration of the fact that there is no such thing as a method or principle which is correct independent of circumstances. One can understand how the MAFF concerns came to be overlooked. Everyone was anxious not to compromise the Committee’s independence; the Committee made it clear more than once that they wanted to keep their distance from government. This was positively beneficial up to a point. However, with this kind of arrangement there needs to be a fall-back mechanism. Both the department and the Committee needed to be especially vigilant that the establishing of a distance between them did not allow the full significance of an issue to be missed.

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Unfortunately they were not successful on this issue and hence both must bear some culpability. Finding 23 deals with enforcement of the human SBO ban. Here the main issue is institutional. The generally low standards in British slaughterhouses necessitated rigorous enforcement which local authorities were incapable of providing not least in respect of the removal of spinal cord (though the Inquiry find that slaughterhouse standards for the removal of spinal cord were better than was the case for some other tasks). It is worth pausing a while to note the unsatisfactory nature of the Local Authority (LA) enforcement system. The Report makes critical remarks about LAs’ efforts at enforcement in respect of other controls also. The failure of LA enforcement in these important areas is an important conclusion of the Inquiry which has not received the attention it might. Hence the key to proper enforcement on all matters of slaughterhouse hygiene was the creation of the Meat Hygiene Service (MHS). As discussed in a previous chapter, the creation of the MHS in 1995 has been of great public benefit as the Inquiry’s Report confirms. Given the opposition they faced it is a matter from which successive MAFF Ministers and officials can take considerable satisfaction as is pointed out in Chapter 3. Pushing forward with the creation of the MHS was difficult given the strength of the opposition to it and the absence of any counter pressure from elsewhere. The consumer organizations, which might have been expected to favour or at least take an interest in a proposal designed to improve the protection of the public, were invisible. They seemed to prefer to concentrate on matters where they could criticize the government. Shortly before the Report was published I was one of many of those involved who received several approaches from the press. They all asked whether I expected to be criticized. I replied that I hoped not but that I hoped to be commended instead. In part this was a ploy on my part to direct the attention of the media to commendations; I had a suspicion that their first instinct would be to look for criticisms. In fact I was commended about an incident where I had helped ensure that the evidence about the safety of beef was not misrepresented to the public, and The Times, helpfully for me, somehow found this out before publication and referred to the point on page one. However, I had certainly not had this incident in mind. What I had had in mind was the MHS story as described above, though I was only one among several responsible for keeping the project on track. There is one further point on which it is worth commenting. This is the extent to which it was government’s job to monitor the performance of LAs in enforcing the human SBO ban (and indeed the other tasks with which they were charged notably enforcement in feedmills and the animal SBO ban). During the early part of the Inquiry’s hearings the trend of the questioning suggested that MAFF as an institution might be criticized for not having monitored LAs more effectively at some periods. This would have been hard since no such task had ever been imposed on MAFF. In the event the Inquiry concluded such a criticism would not stand up. There are two comments I would like to make. First, it is very easy to envisage a situation in which a government department is criticized for concerning itself

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with tasks allocated by statute to other authorities. One can imagine the references to ‘interfering’ government. Second, the resources allocated to a government department are provided to allow the tasks which it has been given to be done properly. It follows that undertaking extra tasks for which it is not responsible can only be done by transferring resources from areas of work and tasks for which it does have responsibility. Any deficiencies which come to light in these latter areas will certainly be laid at that department’s door. Hence a government department has a large incentive not to become too involved in areas outside its direct responsibilities. Of course a very large department or one in political fashion and which knows that it could, if necessary, secure funds from the Treasury would be in a different position. Neither consideration applied to MAFF in the 1980s and 1990s. The Inquiry’s findings on the human SBO ban, quoted above, implicitly accept these points. The story of the animal SBO ban (Finding 24) is not a happy one. The Inquiry agree that the measure was necessary and have no criticisms of the timing of its introduction (1990). Here again the Report explicitly accepts that LAs (though in part different LAs from those concerned with the human SBO ban) were not in a position to implement the ban properly and did not do so. This is, of course, yet more evidence that the creation of the MHS was both desirable and necessary. However, the Inquiry also finds the original Order implementing the policy to be unsatisfactory in several respects. The basic difficulty was that there was a strong economic incentive to circumvent the ban since including SBO in MBM would increase the weight of the latter which continued to have a value because it could be incorporated in pig and poultry feed. The rules therefore needed to provide for enforceable rules requiring SBO to be kept identifiably separate from material which could legally be processed into MBM suitable for feed. Unfortunately they did not do so.4 When the MHS was established in 1995 and proper enforcement and checking became possible for the first time, it was shown that the rules were widely disregarded. This came as a fearful shock to MAFF vets. The Report carefully chronicles how this situation arose. The Inquiry’s view – that a substantial part of the trouble lay in the rush and secrecy with which the Order was prepared – seems right. The difficulty was that the animal SBO ban was introduced as a response to events (a cat followed by a pig developing a TSE), which quite rightly had to be put into the public domain quickly. The political pressure to be seen to be doing something was clearly great. This case stands as a grisly example of the risks of operating in a rush and without normal consultation. I would draw another lesson. When matters have been rushed it is important to go back afterwards at leisure and test whether what was done stands up to cool analysis. When the true state of affairs was discovered in 1994/95 a requirement that SBO be stained with a die specific to itself was quickly introduced and a new wider Order was prepared on a much more satisfactory basis and by the end of that year, as the Report acknowledges, a satisfactory regime was being properly enforced. Finding 25 concerns the establishment of the MHS. I have commented above on this vital improvement in Chapter 3 and under the remarks on Finding 24.

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Section VI: communication of risk Finding 26 on the communication of risk is one of the most quoted parts of the Report. In this case the Inquiry have in part distorted the evidence and drawn unwarranted conclusions. The Inquiry are no doubt right in stating that when specific, professional advice is being given to the public the full basis for that advice should be set out; and that after 1989 (when the SBO controls were first put in place) one basis for the various statements on the safety of beef made by CMOs and others was that such measures provided a back-up if, unexpectedly, BSE proved to be transmissible to humans. It would have been better if this point had been repeated on each occasion a statement on the safety of beef was made. The fact that it was not does not, however, in my view imply that CMOs or anyone else were seeking to mislead. Rather they were concentrating on what they believed, rightly judged by media reaction, would be the question in which there was most interest – the safety of beef. The existence of the SBO controls was fully in the public domain. Probably the CMOs saw no need to reiterate what was already so well-known. The way the Inquiry explain this point shows that they believe that, as it became clear that BSE could be transmitted to cats, the danger that it might be proved to be transmissible to humans obviously increased. Hence all concerned whether with slaughterhouse rules or with reassuring the public ought to have become progressively more careful. With hindsight this appears reasonable. However, government was not advised in this sense at the time and the record demonstrates clearly that many scientists did not take the view that the Inquiry thinks they ought to have done and implies they did take. If SEAC had taken the view that the discovery of a feline encephalopathy had significantly altered the chances that BSE would prove a danger to humans they would no doubt have advised that the discovery altered the evidence so that Southwood’s advice it was highly unlikely that BSE would have implications for human health was no longer valid. Certainly that is what they ought to have done – had they formed this view. Had government received such advice it is likely that a review of existing controls would have been launched with a view to seeing whether they should be strengthened. No such advice was received. The obvious conclusion, supported by the evidence, is that this was because many scientists including those on SEAC did not take the view the Inquiry think they ought to have done. For example, at the time of the discovery of a cat with an encephalopathy SEAC advised simply that no changes to existing rules were required. The Inquiry state in the Report that SEAC’s September 1994 report on TSEs showed that they had concluded that the possibility of transmissibility to humans had increased compared to the view taken by Southwood. They quote (in Vol. 6, para 5.279) the following phrase from the report which occurs after a discussion of feline TSE which SEAC believed was caused by the consumption of BSE

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contaminated material: In conclusion, therefore, our scientific assessment is that the risk to man and other species from BSE is remote because the control measures now in place are adequate to eliminate or reduce any risk to a negligible level. Taken on its own this does seem to imply that the level of risk depends on the effect of the SBO controls. However, the report also includes the following phrase: Our conclusion therefore is that, as the Southwood Working Party determined, taking all the available evidence together, the risk to man from BSE is remote. This latter quote, which appears first, does not follow any reference to SBO controls. The two statements do not perhaps sit entirely happily together, but the natural and least difficult reconciliation is that SEAC believed both that the risk to man from BSE was remote for the reasons put forward by Southwood and that this risk was no greater following the discovery of feline TSE taking into account SBO controls. Certainly there is no hint that SEAC felt that the Southwood message had been superseded.5 If that was the case why refer to the Southwood advice in approving terms? In any case if such a significant change in advice were being given the natural thing would have been explicitly to emphasize the fact if not in the text then in an accompanying letter to the Minister. No such message was given or received. The Report is therefore wrong when it suggests that ‘careful’ readers would have detected that the Southwood message had been significantly changed. The Inquiry only reach this view by placing more emphasis on some parts of the 1994 report than others. In his evidence to the Inquiry Dr Tyrrell said that the cat had changed his views on the risk of transmissibility ‘a bit’ (para 712). That ‘bit’ was insufficient for him to conclude that the Southwood message was no longer valid. Further evidence that the likelihood of transmissibility to man was still considered remote by important players was shown by Dr Will’s (then Deputy Chairman of SEAC) reply when I asked him at a MAFF Ministerial seminar on 15 February 1994 why, if BSE had already jumped species as it was believed it had (I had in mind principally sheep to cattle), was it considered unlikely that it would transmit to man. This query was, of course, directed straight at the Southwood judgement on transmissability giving him an opportunity to disown or qualify it. Will’s reply indicated that he thought such transmission was unlikely and effectively that he still supported Southwood. This incident came up in my evidence to the Inquiry, but is not mentioned in the Report. One wonders why not. Again as late as December 1995, Dr Will6 published an article in the Independent and he and John Pattison7 wrote to The Times. As discussed above (pp. 87–8) neither article suggested that the assessment of risk had changed significantly from those put forward earlier. Moreover, all the evidence given to the Inquiry by those in DoH and MAFF indicated that they did not consider Southwood’s advice to have been brought into question before the reconsideration starting in

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1996. The Inquiry’s conclusion that SEAC advice changed in 1994 is therefore unsustainable. There is one caveat to this conclusion. It does seem that by late 1995 in the light of the finding of cases in dairy farmers and young people, Professor Collinge, an eminent worker on TSEs who joined SEAC in autumn 1995, had come to view transmissibility to humans as a definite risk. However, while he shared his views with the CMO neither he nor the CMO informed anyone at MAFF of his concerns at that time nor is there evidence he raised his concerns in SEAC before 1996. To sum up, before 1996 no recommendation or suggestion was ever put to government by SEAC that the Southwood judgement on the likelihood of transmissibility to humans had been overtaken by events. The evidence suggests that this was because the members of SEAC had not come to any such conclusion. If the members had developed doubts (and there is little evidence that they had) they were insufficient to cause them to speak up. The Inquiry’s apparently different view is based on evidence given after the event and a strained reading of the 1994 paper. They lament that the public ‘were never told that scientists’ appraisal of…risk had changed’. This muddles the issue. For government the important point was the opinion of SEAC. As shown above there was no reason for government to suppose this had changed significantly. The Collinge incident is described above for completeness but does not affect these conclusions. All this raises a further question. At the time (1994/95) nobody believed that SEAC’s advice had significantly modified Southwood’s that BSE was highly unlikely to pose a risk for human health, yet the Inquiry claims they had done so. Yet if we turn to Finding 27 below we will find that the Inquiry criticize the secretaries of SEAC for failing to deliver a clear message about a change in SEAC’s assessment of risk in 1996 even though in one of those cases (that of the MAFF secretary) all those who received his note had in fact appreciated that SEAC had modified its view. Why, therefore, is SEAC not criticized for failing successfully to deliver a comparable message in 1994? In the former case they criticize someone for failing to describe matters in an exemplary fashion even though all readers took the intended message. In the latter case no criticism is given even though nobody understood the alleged message and it was of the highest importance. This lack of consistency by the Inquiry is telling. The truth is that the Inquiry realized, possibly not fully consciously, that SEAC could not be criticized for being unclear in 1994 because they never intended to deliver a message in the terms the Inquiry claim. The Inquiry’s assertion that SEAC’s advice changed in 1994 is, quite simply, wrong. The Report’s suggestion that openness should form the basis of the government’s approach to the communication of risk was the overwhelming orthodoxy by the time the Report was produced. In any event no other policy is now politically possible given current attitudes. In its favour are two powerful arguments. First, there is our entitlement as citizens to be able to make informed judgements on the risks to which we are prepared voluntarily to subject ourselves. Second, there is the fact that public suspicion that significant facts are being withheld can

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be sufficient in itself to produce an economically damaging, possibly unnecessary response, for example avoiding specific foods. In any case nobody now argues in favour of any other policy so there is nothing to be gained by labouring the point. Nevertheless, the Report’s recommendation has been misinterpreted by some. Such commentators have assumed that a recommendation that in future a policy of openness should be followed must mean that in the past matters were kept secret. As we have seen (finding 12) the Report explicitly rejects that view. The Report is saying something rather more subtle – and more difficult. What it is saying is that uncertainties and probabilities including those which might be worrying should be explicitly drawn to the public’s attention. Thus instead of saying until 1996 only that there was no evidence that BSE was transmissible to humans, any such statements should have been accompanied by the observation that the incubation period in humans, if BSE were transmissible, would be likely to be a lengthy one and hence too much reassurance should not be read into the absence of evidence. One is entitled to point out that implementing such a policy is likely to prove difficult to put into effect. Thus in paragraph 115 of the Report quoted above it appears to be suggested that ‘those responsible’, presumably Ministers and CMOs, ought explicitly to have drawn attention to the fact that if BSE proved to be transmissible to humans, then people could have become infected before the SBO ban came into effect. Now this states no more than the obvious truth,8 but I very much doubt whether any Minister would have been prepared to go out of his or her way to say so. One can imagine the resulting headline if this advice had been followed, ‘Minister admits BSE can kill’. If this had produced a consumer reaction with a large drop in sales of beef one can also imagine the criticisms of the Minister concerned who would be said to have unnecessarily created a panic on the basis of no evidence. It is not fanciful to suppose that a Minister might not survive an incident of this sort, which his colleagues would regard as self-inflicted and for which they would not thank him. The Report is naïve in implying that if a policy of openness is followed problems will disappear. However, the Inquiry does not always have the courage of its claimed convictions, stating carefully that ‘if doubts are openly expressed’ then ‘the public are capable of responding rationally’ and ‘should be trusted’ to do so. But suppose that, though capable of doing so, the public does not in fact respond ‘rationally’ to such doubts, or their view of what is rational is not the one expected or hoped for? In these circumstances a Minister could end up in the awkward situation posited in the previous paragraph. The Report does nobody any favours by pretending that a policy of openness will solve all problems.

Section VII: ‘contingency planning’ Finding 27 is misconceived in several respects as I shall explain. Before doing so, however, I should make it clear that the second part of this finding is the only occasion when I am included among those criticized. Readers will, therefore, wish

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to consider the arguments with which I justify that conclusion particularly carefully. On the first part of this finding, so far as the MAFF secretary is concerned, the conclusion is, quite simply, wrong. The secretary’s note was not ideally phrased; it did, as the Inquiry point out, overemphasize the possible presentational difficulties, but it also indicated that the Committee might change their view on transmissibility as a result of considering the cases in young people. I was left in no doubt by the note that that was the position, nor to my certain knowledge was anyone else, Minister or official, at the top of MAFF. Further, we all made this quite clear in our evidence to the Inquiry.9 Given these facts the criticism does not stand up. I suspect one reason it is included in the Report, though it would be an inadequate one, is in order to treat the MAFF secretary like the one from DoH. (The latter’s report within DoH would probably not have alerted even a very careful reader to what was happening and, as described below, she is criticized for it.) It is to be regretted that the Inquiry’s judgement failed them in this instance. At first sight the criticism of the DoH secretary appears better-founded. Clearly a responsible secretary of a committee like SEAC needs to inform his or her superiors if a major development like transmissibility is in prospect. But even here there are some doubts. There is evidence, mentioned by the Inquiry, that it was not the case that she failed to pass on the concerns about transmissibility, but rather that she had not gathered that they had been voiced with the seriousness intended. Now this could be because she did not pay proper attention and/or did not understand what was being said and did not attempt to find out. In that case a criticism might be justified. However, often when an audience does not understand what has been said we choose to criticize the speakers not the audience. I was not there and it is not clear where responsibility lies in this case. In justifying their criticisms the Inquiry quotes the SEAC minutes, which are clear. However, they were produced weeks later and the original draft was amended at the insistence of Collinge to clarify his concerns. They are not, therefore, evidence of the clarity with which his views were expressed at the 1 February meeting. There is also the fact that, apparently, not all members supported Collinge on 1 February and he was a new member of the committee. While he proved right in the event this may not have seemed likely initially. The second half of this finding is concerned with the alleged lack of discussion in MAFF and DoH following the 1 February meeting of SEAC and with the absence of contingency planning in both departments in the period from 1 February until 8 March. Included in these strictures are the Ministers Hogg and Browning, me, three other MAFF officials (including the put-upon secretary of SEAC), the CMO, Deputy CMO and the DoH SEAC secretary. The CMO is also criticized for not alerting his Minister (Dorrell). In short all those at the top of both departments who knew of SEAC’s tentative conclusions are criticized. This criticism has a long history and was originally much more wide-ranging. In the original draft criticism it was suggested that contingency planning should have been undertaken years previously when it should have been apparent that what was needed was a 30-months scheme along the lines introduced in April 1996.

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I submitted a number of arguments in refutation, of which perhaps the strongest was that devising meaningful contingency plans necessarily entails deciding on the nature of the risk concerned. It was therefore relevant that until well into 1996 concern was growing not only about CJD cases in young people, but also among dairy farmers. A disproportionate number of CJD cases were found in dairy farmers in the period up to 1996, which is still an unexplained phenomenon. If this trend had continued to the stage where SEAC had concluded that the phenomenon reflected exposure to BSE – just as they concluded on the evidence of cases in young people – then any protective measures would obviously not have involved keeping meat from old animals out of the food chain. Presumably infection would have occurred not via food but via the atmosphere or via skin contact or perhaps via milk. This argument was also put forward by others and the Inquiry apparently felt the point was strong enough for them to limit the criticism to the last few weeks of the period after the 1 February SEAC meeting when attention began to concentrate on young people. It is in these last few weeks that the Inquiry’s imagination failed them. They have not understood the pressures existing at such a time though the evidence they accumulated would have allowed them to do so had they tried. I will try to remedy this defect. The main point I will be trying to get across in the rest of this chapter is that the reason I (and probably others) did not act as the Inquiry think ideal was not because I did not weigh the options, but because of the reality of the situation with which I was confronted. When it became apparent after 1 February that there was a real possibility that SEAC would conclude as they eventually did, the first question was one of timing. Kuru normally had an incubation period of over five years. Cross-species infection of humans with BSE would almost certainly imply a longer incubation period in humans than for cattle, at least so far as infection via food was concerned which seemed the most likely route. This, too, implied an incubation period of over five years. This made sense since before the slaughter and compensation scheme was adopted in 1988 and the SBO ban in November 1989, increasing amounts of SBO was finding its way into human food as progressively more animals became infected. After 1988, and certainly 1989, much less infective material would have reached consumers. Thus cases of CJD in humans in 1996 resulting from exposure to BSE almost certainly reflected infection many years earlier. Hence, contrary to the natural instincts of most people, discovery of BSE-induced CJD in 1996 did not necessarily imply that extra protective measures needed to be taken in 1996. Contingency measures were in place, the SBO controls, and the decisive point was how effective they were in 1996. The fact that they may not have operated with full effectiveness earlier did not logically prove that action was needed in 1996. On this as I explained earlier in this chapter there was good reason to consider the controls were operating satisfactorily. Accordingly, the first question to be asked in considering SEAC’s conclusions was whether any further measures were required. It is relevant that SEAC gave this question careful consideration before deciding to recommend the de-boning of older cattle.

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Thus the assumption implicitly made by the Inquiry, that when transmissibility was found extra protective measures would certainly be needed to protect human health, is unjustified. Further, I was very conscious that others, notably the Treasury, were aware that the increased resources devoted to BSE controls by the MHS had been put in place at considerable cost. There would in practice be no chance of persuading them that new measures, especially ones costing hundreds of millions of pounds like the over-30-months scheme, should be adopted without compelling reason. Such compelling reason could, for example, be a SEAC recommendation. A MAFF or DoH recommendation based only on the desirability of reducing a small risk would not wash. The Inquiry suggest that once it became clear that there was a possibility that SEAC would conclude transmissibility had occurred, those in MAFF and DoH should have discussed the possibilities intra and inter-departmentally and imply the need for a 30-month scheme would thereby have become apparent. A number of misconceptions lie behind that view. First and most prosaically, within MAFF there were such discussions as Douglas Hogg and I pointed out, though not in the intense way the Inquiry appear to envisage. It was these discussions which allowed Hogg to propose a 30-month scheme on 18 March. No claim has been made that such discussions occurred within DoH. Second, DoH had little to bring to any discussion since they lacked expertise. Remember that what is primarily at issue in protecting the public (other than for example reviewing the safety of medicines which DoH could have done on their own) is the detail of how BSE infectivity is distributed in cattle and this is not a matter on which medical practitioners in general are qualified to speak. It is true a few medically qualified persons were and are experts in TSEs and are well-qualified to take a view, but they were on SEAC not in DoH. Suppose, however, that MAFF and DoH had entered into intense discussions in early February 1996 on what to do in the event transmissibility were eventually confirmed. Suppose also that the possibility of a 30-months scheme had been mooted. It would have been difficult to take a definite view on such a major proposal without an input from experts, that is those on SEAC. But until very late in the day they were engaged in the vital task of deciding whether the evidence justified concluding that transmissibility had been found. There is one other point. Government rules require that discussions which might result in the possible expenditure of public money, let alone hundreds of millions of pounds, should involve the Treasury. Had a Treasury representative been present on a MAFF/DoH working party on BSE in February/March 1996 I am clear what their line would have been. They would have said that considerable sums had been spent on increasing the ability of the MHS to protect the public. They would have refused to consider anything more, and certainly a scheme costing hundreds of millions a year, until SEAC’s views were known. What else could they possibly have done? How on earth could a Treasury official have agreed to such a scheme unless it were clearly shown to be unavoidable? It is true that in theory it would have been possible not to inform the Treasury of the existence of such a working party, but that would have been unconstitutional and the Ministers and

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Permanent Secretaries concerned would have had a lot of explaining to do when the working party’s existence came to light to put it no more strongly. In any case such action would have prejudiced the Treasury’s attitude to what had been ‘agreed’, quite apart from souring the two departments’ relations with the Treasury more generally. The above analysis helps in identifying the fundamental problem with the Inquiry’s approach. What they advocate, a MAFF/DoH working party set up after 1 February, and which they refer to as ‘contingency planning’ is not correctly designated by that title. As normally understood a contingency plan reflects an analytical exercise conducted in a detached manner under no pressure from events. MAFF itself had well-established contingency plans for action should, for example, a disaster occur at a nuclear power station. There are a number of ways in which this example differs from the case of BSE in February 1996. One is that the threat posed by radioactivity was and is very much better understood than that of BSE. That obviously makes it easier to devise responses. However, there is also a more subtle point which can easily be overlooked. Consider the officials on the MAFF/DoH working party in February 1996 assuming it could somehow have been established despite the difficulties. They would not have been considering an abstract possibility which might occur in the distant future. The working party would have been established because SEAC had indicated they might conclude in weeks or even days that transmissibility had occurred. Consider in particular the position of the Treasury official on the committee. Presented with the idea of a 30-months scheme they know that the consequence might be not that some future Chancellor might at some distant date be presented with the plan including this proposal; rather they know that if transmissibility is confirmed the current Chancellor will in weeks or days be presented with a proposal costing billions to which his officials had agreed, the cost of which could only be found from the reserve when there is no scientific advice that all this is necessary. That is why, as I say above, any such Treasury official could not possibly agree to it. In reality the working party would not be discussing ‘contingencies’ but present policy, and a policy of great importance. There are two other points which need to be brought out at this stage. First, the Inquiry state that a working party could have been useful in establishing that a de-boning scheme was impractical unlike the 30-months scheme. This is an unjustified claim. As we will see in the next chapter, the 30-months scheme, when it was decided upon, was only got going with enormous difficulty. The logistical problems were immense and without consulting industry, notably the renderers, it would not have been possible to establish that it could be done at all. Also, while it is true a de-boning scheme would have been difficult to implement, it is not clear that it would have been impossible. If the same amount of resources in terms of people, time and money had been applied to make it work as were given to the 30-months scheme there is every reason to expect a viable scheme could have been devised. The Inquiry have not appreciated that the 30-months scheme was adopted essentially to bolster the market and restore confidence on the advice of and following pressure from the whole industry as a response to a devastating drop

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in sales and a refusal by leading retailers to sell mature beef. It is true that it also provides extra protection to the public but that was not the sole or even the main reason why it was adopted. Finally there is the fact that I am not presenting an abstract view, but one that was put to the test. On 18 March Douglas Hogg proposed to colleagues that a 30-months scheme be adopted. Although there had been no formal working party of a kind favoured by the Inquiry, he had told Dorrell, the Health Minister, of his intention and Dorrell had concurred. Yet the proposal got nowhere as I had feared might be the case without SEAC support.10 Why the Inquiry conclude that a formal process which ended by advocating the same proposal would have been more successful is not explained. The best argument I can construct which might support this suggestion is that without the other two proposals Hogg put forward at the same time (withdrawal of stocks and the establishment of an enquiry), the 30-months idea might have stood more chance. It might have. But there is no evidence to suggest it would have done so to the extent of getting it accepted. Finally, the Inquiry claim that one benefit of ‘contingency planning’ in February 1996 is that it would have allowed the question about the susceptibility of children to be cleared up beforehand so Dorrell would not have had to ask the unfortunate question of SEAC. As we have already seen, however, this question was posed unnecessarily and unfortunately, and SEAC’s eventual reply was entirely predictable. Indeed the essence of SEAC’s reply was given by Dorrell himself in explaining the question to Parliament. For all the above reasons it is my contention therefore that the Inquiry’s views on the desirability of MAFF/DoH planning starting in February 1996 are misconceived for several reasons. I do not say, however, that such planning would have been of no effect. However, the most likely effect would have been a negative one. If a working party had been established it is possible, probable some would say given the record of the government, that rumours of it would have leaked out. In that eventuality a full scale crisis would have ensued which would have been worse than the one that followed the announcement of 20 March. This is because we would not have been able to deny the existence of such a body nor the fact that it had only recently been established; the implication of that – transmissibility was now viewed as a real threat – would have been clear, yet until 8 March we could not have explained SEAC’s conclusion nor until 20 March what they recommended as a response. The whole thing would have been a nightmare. Ministers were quite capable of working all this out for themselves so this aspect – potential leaks – constitutes yet another reason why the Inquiry’s suggestion would not have been possible. If it had been suggested to Hogg in February 1996 that a working party be established on the lines the Inquiry advocate he would have vetoed the idea. He said as much to the Inquiry. Even if he had not objected the Prime Minister would have done so if asked; and if a leak had occurred and he had not been asked beforehand he would have been displeased. Moreover, all Hogg’s Ministerial colleagues in the same position would have acted similarly. They were also shown to be justified since the news of transmissibility was first put into the public domain via a leak to the Daily Mirror. Despite the fact that most

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witnesses including Ministers stressed to the Inquiry their concern over potential leaks in the last few weeks, a concern justified by subsequent events, the Inquiry have nothing to say on the point. Perhaps this is because they recognize that the course they recommend would have increased the risk of one occurring. The above arguments are, I suggest, convincing in showing that the course favoured by the Inquiry was not a practical one in the circumstances of early 1996. Yet it has to be admitted this seems odd. After all, at bottom the Inquiry are only suggesting that so far as possible the public authorities should plan ahead and this must surely be sensible. The explanation of this seeming conundrum lies in the circumstances in which developments come to light and the expectations and assumptions at the time – in other words in timing. The human SBO ban adopted in 1989 was itself a contingency measure adopted against the possibility that BSE was potentially transmissible to humans. Its adoption did not cause particular disquiet at the time because there was no expectation of any immediate unpleasant development. The ban could therefore be viewed dispassionately as an academic precaution. The same is true of another measure adopted at about the same time, namely the establishment of the CJDSU. This, too, amounted to a contingency against the possibility of BSE being transmissible to humans. At that time, in the late 1990s it would probably also have been possible to announce that consideration was being given to any further measures that might be desirable in the event transmissibility be shown to occur. However, it is likely any examination of this kind then or indeed later would simply have noted that according to the then present knowledge the human SBO ban should protect the public if properly enforced, that older animals constituted a potentially greater risk and that the situation should be kept under review as new evidence emerged. Consider now the position in early 1996. The announcement that the possible response to a finding of transmissibility was being investigated would have been sufficient to trigger serious public alarm. Public concern was very much greater; difficult questions would certainly have been asked about why the matter was now on the agenda. That is why all concerned assume that the existence of any such project would have had to be kept secret – as is proved by the universal fear of ‘leaks’. Obviously a leak can only occur of something that was confidential to start with. In other words contingency planning would only have been possible when the fear was remote – contingent in fact. Once it becomes real, different considerations apply. In the light of the above analysis I think we can see where the Inquiry has gone wrong. Relatively early in their deliberations they noted the explosion that occurred following Dorrell’s announcement on 20 March. They also noted that the 30-months scheme had been proposed in Hogg’s minute to the Prime Minister of 18 March, and concluded that if its establishment could have been included in the 20 March announcements matters would probably have been less fraught. Proper contingency planning ought, they decided, to have provided for this. Initially they assumed such planning ought to have taken place at an early stage and their initial draft criticisms were phrased on this basis.

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However, the responses of those receiving the draft criticisms persuaded them, reluctantly we might conjecture, that this view could not stand up. Eventually they decided it could only stand up in respect of the period after the first clear warning was given at the SEAC meeting on 1 February. The final criticisms are phrased in terms of the need for discussions among those concerned after this date. However, the associated discussion in the Report is phrased in terms of contingency planning. This amounts to a verbal sleight of hand since policy formation in the period in question was subject to pressures that necessarily gave it a quite different nature from contingency planning. There is no evidence that the Inquiry addressed any of the above arguments showing why this was the case, still less found answers to them. Accordingly their finding lacks credibility.

Further comments The above section discusses the Inquiry’s specific findings. Though I have disagreed with them occasionally and added glosses here and there as will be seen, I believe most of their findings are essentially correct. There are also, however, further important points which need to be made about how the Report is structured which can have the effect of misleading readers on some important matters. Finally I turn to an overall, perhaps inevitable, weakness in the Report – its lack of political imagination. The Inquiry direct their criticisms at named individuals and include all of them in a specific annex listing the criticisms and those criticized. This is fair enough, up to a point. The problem is that this structure has distorted the perception of what the Report is saying in a number of important ways. This is because the existence of an annex headed ‘Individual Criticisms’ will inevitably lead readers to the view that (a) what went wrong will be found in that annex, and (b) that what went wrong was the fault of those listed. Yet a careful reading of the Report shows that this conclusion is too simple. For example, it is clear that the Inquiry regard the structure of local-authority control that existed in slaughterhouses and feedmills as a major factor in limiting the efficiency of the response to BSE. The Report is quite definite on the point: The greatest impediment to the efficacy of the Government’s response to the emergence of BSE was the structure laid down by statute for the enforcement of the Regulations that were designed to keep potentially infective tissues out of both human food and animal feed. (para 1239) Referring to the human SBO ban for which District Councils were responsible: Most Councils spent no more than was barely essential to cover enforcement duties in slaughterhouses. Some did not spend that much. When the MHS took over enforcement, it found that insufficient resources had been employed by at least some local authorities to ensure that the obligation imposed by the human SBO ban to remove all spinal cord from the carcass was universally

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enforced. It also found that familiarity with the Regulations, efficiency of line management and diligence of local authorities in enforcing the Regulations were uneven across the country. (para 1240) The limitations on the enforcement capability of local authorities could only have been remedied had they been persuaded to devote more resources to that task. We can see no way in which that goal could have been achieved. (para 1241) On the animal SBO ban where it will be recalled (finding 24) MAFF is found to have drafted unenforceable regulations and for the enforcement of which County Councils were responsible: … however well drafted the Regulations, the statutory structure of local authority enforcement would have prevented strict enforcement of the animal SBO ban. (para 1242) It is crystal-clear that the Inquiry consider that both the structure of local-authority involvement in enforcement in slaughterhouses and the performance of many individual local authorities was a major contributor to the difficulties government had in getting completely on top of BSE. Yet media comment scarcely noticed the fact. Why? The answer is that commentators have assumed, not unreasonably, that such difficulties would all be explained in a section headed ‘criticisms’. They probably did not appreciate that ‘criticisms’ only covered matters that in the Inquiry’s view can be laid at the door of individuals. It is true that the Report includes a section on ‘what went right and what went wrong’; however, that proved insufficient to overcome the problem. As a result it has been wrongly assumed that everything the Inquiry found unsatisfactory was listed in the annex of criticisms and was the responsibility of those identified. Limiting criticisms to individuals has other disadvantages. One kind of problem arises where something has gone wrong, but it is not obvious who to hold accountable. The civil service, for example, works in hierarchies and in hierarchies work tends to flow towards the energetic more or less at whatever level they are to be found. However, responsibility is shared by the whole hierarchy. The Inquiry, when allocating criticism, appear to have solved the problems to which the existence of hierarchies gives rise by picking on the name which appears most often in the papers or in other words on the energetic. Thus those who have tried to do something are penalized relative to those who have done nothing. The Inquiry recognize that there is a problem here, and stated: Those who were most active in addressing the challenges of BSE are those who are most likely to have made mistakes. (para 1250) However, it is one thing to recognize that a problem exists and another to do something about it. The Inquiry has not solved the problem and in a number

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of cases criticisms are directed at one or two people only, when (assuming the criticism to be valid) others ought to have borne some of the blame. There are two other ways in which the annex of criticisms gives a distorted view of the Inquiry’s findings. First they explicitly note (para 33) that there are some cases where they have found an inadequate response but have not identified an individual as responsible usually because: … we have felt that, having regard to the constraints on our time… an attempt to identify individual responsibility could not be justified. Now this is all very well up to a point; one would not wish criticisms to be allocated without good grounds. The difficulty is that the Report is not structured in a way which enables such cases to be identified. Accordingly those who are criticized by name are bound to be regarded as responsible for a greater proportion of what the Inquiry believe went wrong than the Inquiry itself believes to be true since some ‘inadequate responses’ – examples are the deficiencies of local-authority control in slaughterhouses – are not included in the annex of criticisms. The Inquiry’s decision not to differentiate between criticisms is also questionable. In briefing the press on this aspect their spokesperson stated that this was despite the Inquiry’s regarding some as much more significant than others. It was claimed this would be apparent from the text. It is not, though the rumour at the time was that misleading or overoptimistic statements by those whose undoubted job it was to protect the public, such as CMOs, were viewed with particular disfavour. There seems no good reason why, if the Inquiry viewed some criticisms as more important than others, they could not say so. Surprisingly, the annex on individual criticisms is not balanced by one of commendations. Yet the Inquiry was at pains to stress throughout that they did not wish to be seen as a witchhunt and that they were determined to praise as well as to blame. Yet the structure they adopted for their Report, with individual criticisms handily summarized in an annex while commendations were scattered throughout the text, guaranteed that even the best disposed in the media would concentrate almost exclusively on the former. Further, it leaves those judged, notably those both criticized and commended, with an unnecessary sense of grievance which the moderate tone of the Report had done so much to dispel. There is one further observation to be made about the Report which is of a rather different nature. The Report contains virtually no recognition of the political dimension. It is true that government policies are mentioned in a low-key way; there are references to the Thatcher government’s drive to cut public expenditure; and there are references to the deregulation initiative. But it is all rather bloodless. The Report takes it for granted that everyone should act in the same way if presented with the same circumstances without, so far as I can see, even wondering if that is a realistic expectation.

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But politics is not like that. Governments have policies to which they attach importance, and inevitably the importance of the latest fashionable policy is emphasized at the expense of others. The senior figures in each administration expect to set the agenda; they also have views – prejudices would be a less polite way of putting it. Other Ministers and all civil servants take account of these facts if they are wise. Inevitably the Treasury expects to have a major input into all policies since all involve the commitment of resources. One consequence of these fairly uncontentious facts is that asking for money for areas which are unrelated to the government’s main objectives is not popular. In an area like agriculture, which both Conservative and Labour regard as absorbing too many resources in any case because of the effects of the EU’s common agricultural policy, this is especially true. It is relevant that while BSE was in its early stages the salmonella in eggs crisis came and went. From the perspective of those at the centre of government this episode, a lead story at the time, was deeply irritating. It damaged the administration and cost money (as it turned out not much) for what probably seemed to be no good reason. When BSE was raised subsequently the salmonella saga will have made those at the centre more impatient of irritating agricultural problems and decision makers in MAFF more wary of raising them. These factors have an effect on policy. This is where the political and media campaign about meat hygiene and in particular against the concept of the MHS is relevant. The reason why I took a risk in advising Gillian Shephard and William Waldegrave to proceed with the MHS and they displayed courage in accepting that advice stems from just this factor. Not every Minister nor every civil servant would have persevered in the face of near universal disapproval. Now anyone who wants to examine such matters as this will come to the Inquiry’s Report in vain. There is no hint of the tensions and animosities which often accompany politics at the top. There is no recognition of the pressures, often not overtly stated, not to ‘rock the boat’. This does not invalidate the Inquiry’s Report. But it does mean that consideration needs to be given to whether it represents the whole story. I have tried to explain above that the descriptions in the Report of both the establishment of the MHS and of the last few weeks (‘contingency planning’) leave out the most important parts of the story precisely because they fail properly to take account of this political dimension. Notes 1 A recent paper the main author of which is the leading TSE worker from the USA, Paul Brown, does not endorse the Inquiry’s view on the origin of the disease either; ‘Transmissable Spongiform Encephalopathy as a Zoonotic Disease’ , International Life Sciences Institute, 2003. 2 The senior MAFF epidemiologist, John Wilesmith. 3 The point is that the ‘unloaded’ question eventually put did not make it clear that in MAFF’s expert judgement some contamination of spinal column with spinal cord was inevitable. 4 A more detailed description of the deficiencies of the 1990 Order, probably the least satisfactory thing MAFF did throughout the whole crisis, is given on pp. 77–9. 5 As I confirmed at the time by consulting the MAFF secretary to SEAC.

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Deputy Chairman of SEAC and head of the CJDSU. Chairman of SEAC. Which was also pointed out by the House of Commons Agriculture Committee. Douglas Hogg’s second appearance before the Inquiry is the only occasion at which a contrary view was possibly implied. But that was at a late stage and Hogg had by then put on his lawyer’s hat. 10 Further support for the proposition advanced here is given by the fact that when SEAC did produce a recommendation it was instantly accepted by Ministers without their receiving any official advice.

8 Events after 20 March 1996: (A) The Period of Conservative Government until 1 May 1997

The announcement of 20 March made BSE the number-one political issue for months. Michael Heseltine remarked to an official that BSE broke with all precedent outside war in keeping on the front pages for over 20 consecutive days. In March 1996 the opinion polls showed that the Tories were in trouble, while a General Election had to be held in just over a year. Yet the economy was performing well which is normally taken to be the most important factor in winning elections. The last thing they wanted was an issue which would distract attention from economic success, cause public alarm and have an EU element which would be bound to expose the party’s philosophical disagreements. Unfortunately BSE met these undesirable criteria perfectly.

The first two weeks after the announcement The announcements of 20 March triggered a major food scare and the resulting immediate decline in beef consumption constituted an economic crisis. The repercussions rapidly spread far and wide geographically, economically and politically. All the factors particular to the BSE crisis, as everyone called it, emerged in the two weeks between the announcements of 20 March and Easter. Working method This was an extraordinary aspect of the crisis. For weeks a motley group of Ministers met regularly, often twice a day, under the chairmanship of the Lord President (Tony Newton) or the Prime Minister. Though initially the membership of the group was specified – it was never designated as a formal Cabinet Committee – other Ministers soon invited themselves along. Some whose appearance did not reflect any obvious departmental interest appeared to have an agenda which went well-beyond BSE. Meetings in the evening often came to different decisions from a meeting with a very similar, though not identical, cast that morning. In the 12 working days between 20 March and Easter there were over 20 such meetings.1 158

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All this was the antithesis of government process as it had been developed in the UK. In theory if a new problem emerges a Cabinet committee should be established with a defined membership. Non-members, even senior Ministers, are not expected to attend; indeed they are expected not to attend and can only do so if, exceptionally, granted permission by the chairman. Meetings are scheduled, papers circulated beforehand and minutes issued with clear conclusions. Above all, once taken decisions have status; they are defended by the government as a whole including those who played no part in agreeing them. None of these established conventions were followed for BSE. In brief the system broke down and no real attempts were made to bring matters back to an even keel – or if they were made they were so unsuccessful as to be undetectable.2 The standard procedures have been developed to provide order and minimize confusion; in their absence disorder and confusion abounded. Equally remarkably the discussions at these large Ministerial meetings were reported, mostly accurately, in the newspapers including on occasion the same day’s edition of the London Evening Standard. Someone went straight from the meetings to telephone the press. The press reports did not put the government in a good light and it seemed that this leaking was a calculated, deliberate attempt to undermine it. Major clearly thought one of his political colleagues was responsible. I was amazed that so little – so far as I could see nothing – was done to remedy the situation. The truth was that Ministers collectively panicked. No doubt they thought, rightly as it turned out, that the long Tory years might really be coming to an end. Some probably thought, equally correctly, that their careers in the House of Commons might also be coming to an end. They did not want to trust Hogg to take forward the government response to BSE. His political position, never strong, had been weakened by the reaction to the recommendations he had put forward on 18 March which colleagues had regarded as over the top. Ministers spent much time unproductively agonizing in large meetings. Following the normal procedures, that is expecting Hogg to make proposals to a specific Ministerial committee which would deliberate and come to decisions, which would thereafter be defended as established government policy, would have been more effective. Ironically Hogg himself was one of the few who did not panic. Indeed the crisis brought out the best in him. Previously, though never bad-tempered in the full sense of the term, he had been a little inclined to grumpiness on occasion. This completely disappeared with the BSE crisis. He endured appalling treatment from his colleagues both in London and in Brussels because he thought it was his duty to do so. He refused to retaliate3 when his colleagues made unjustified and malicious leaks to the press to his detriment – to my intense irritation since matters soon reached such a pitch that I saw my career disappearing down the plughole with his. He put up with ridicule in the press based on his alleged indecision – in fact it was the panic of his colleagues which was the biggest factor preventing progress – and, God help us, his choice of hat. In short he behaved like a Christian gentleman. One could not but admire this stoic resolve to do the right thing, which was why, despite the frustrations his turning of the other cheek induced on occasion, he retained the loyalty of staff throughout the crisis.

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Protecting the public Ironically, since the whole crisis resulted from concerns over public health, in many ways this area of policy presented fewest problems. SEAC had made two major recommendations on 20 March, first that beef from bovines over 30 months should be de-boned before entering the human-food chain and second that MBM should not be fed to farm animals. Both had been accepted by the government. The recommendation on de-boning was not, technically, easy to implement. Substantial work was required to determine how best to give effect to it and in the event the policy was overtaken. The government soon came under pressure from all sectors of the food chain to go further in order to boost public confidence and to support the market. Relatively soon it was decided to exclude all animals over 30 months from all food chains. This measure, though adopted for other reasons, also had the effect of providing substantial protection for the human population since clinical cases of BSE were only found very rarely in animals aged under 30 months. SEAC met on 23/24 March to consider the unwise question put to them by Dorrell about the implications for children of their earlier advice on vCJD. As was obvious would be the case SEAC advised that there was no evidence that children were more susceptible than adults.4 Market support Following the 20 March announcement consumption of beef dropped at once to about half its usual level.5 The immediate effect on the beef chain was, however, much more serious than this figure would imply. This is because there is at any one moment many days normal supply at various stages in the chain. If consumption falls by half then operators know it will take twice as long as usual to dispose of stocks. In proportion to sales operators at all stages have twice as much stock as usual. Clearly they will wish to get back to their usual ratio as quickly as possible, and the way to achieve this is simple – stop buying. This is exactly what happened. Accordingly slaughterhouses stopped purchasing animals for slaughter. No cattle were sold at some livestock markets by the Friday after (that is two days after) the announcement of 20 March. There was some puzzlement at the time as to how a reduction in consumption of 50 per cent could result in no sales of animals. The answer is set out above.6 If a 50 per cent reduction in consumption had been maintained for a prolonged period the position would have become untenable. A large beef surplus would have emerged while prices would have hit the floor. There would have been no way of disposing of the surplus because as very rapidly became clear exports would remain blocked for some time. One obvious, vital question, therefore, was for how long would consumption remain at such low levels? This was not an occasion on which it was realistic to think in terms of allowing the market to right itself over a period of, say, several weeks. Apart from the political clamour, which was quite large enough, the risks of economic disruption and damage were too great. Public discussions of how much public support was justified to mitigate the effects of the crisis tended both at the time and subsequently

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to concentrate on the plight of farmers. That was a major issue but it was not the first concern for MAFF. The objective adopted by MAFF was to ensure the maintenance of a viable beef chain. As described in Chapter 2 this chain can only function if farmers, slaughterhouses, renderers and retailers are able to operate and, most important of all, if consumers will buy the product. All the aforementioned sectors are essential. Others, such as the head de-boners also mentioned in Chapter 2, are peripheral. After a couple of weeks consumption recovered to a level close to 70 per cent of its previous level. That still left a substantial quantity – several thousand tonnes per week on normal production schedules – with nowhere to go. Exports were not possible; by then they had been banned by the EU and in any case foreign demand for UK beef had disappeared. To reassure customers the major retailers specified they would only take beef from younger animals, in practice those aged under 30 months. Most beef from older animals had traditionally been exported (most to France) so, exports being blocked, it was left without any market. McDonald’s went further. On 24 March they announced they would not use UK beef at all. They were quickly followed by the other burger chains. In brief it became clear before Easter that consumption would remain below normal levels by some 30 per cent, probably for many months; and that there was effectively no market for meat from older animals. Before the crisis UK production had roughly equalled demand.7 The lifespan of a bovine raised for beef is typically 18–30 months. Taking all these facts together it was likely that supply would significantly exceed demand for a matter of years. Extensive market support was inevitable. The standard mechanism for supporting market prices under the EU beef regime is intervention, that is the purchase of beef carcasses8 by the public authorities. The beef markets in all EU member states had been affected by the BSE crisis, some of them (astonishingly) by more than the UK market, and it was inevitable that intervention buying would expand9 enormously. Unfortunately, expanding intervention would not on its own support the UK market satisfactorily because intervention is limited to young animals and it was beef from older animals which had most difficulty in finding a market. Intervention alone would not suffice to stabilize the market. One other measure was also introduced which would reduce oversupply in the longer term – the so-called ‘Herod Premium’, which involved paying a premium for the slaughter of male calves within days of birth. However, this would have no effect on the market for beef for at least 18 months. Something more was needed. Hogg hinted as early as 23 March that culling older animals was an option he was looking at. Hogg raised it several times in the large Ministerial meetings but initially met with a sceptical response. No doubt others recalled that he had proposed something very similar on 18 March and that the consensus then had been that it was a foolish idea. However, others in the food chain were faced with the same market difficulties as the government. They recognized that the vital need was to increase consumer confidence. They, too, concluded that excluding animals over thirty months10 from the food chain was probably the best way forward. This would act in two

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ways – by both reducing supply and boosting confidence. Animals over 30 months normally constituted just over 20 per cent of total beef supply, while excluding them from the human-food chain would improve the protection of the public. On 25 March the Institute of Grocery Distribution representing manufacturers and retailers and the NFU pressed government to act accordingly.11 Crucially, representatives of the main retailers had indicated they would continue to support the UK beef industry if a 30-month scheme were adopted. That, too, was important. There were siren voices12 calling for more drastic action, but if the bulk of the industry were prepared to support UK beef, albeit on this condition, disaster could be avoided. There were also downsides to the scheme. It was arguably disproportionate to the risk given the effectiveness of the existing SBO controls and the much cheaper option of de-boning older animals.13 It would be a very difficult scheme to get off the ground given that mechanisms needed to be devised for destroying the entire carcass of every animal in the scheme. It would be very expensive; assuming compensation payments at levels something like prices existing before the crisis the cost would be about 400 million pounds a year. Finally such schemes, when started, often prove difficult to stop.14 Nevertheless, a dramatic gesture was necessary to claw back some of the initiative for government. The adoption of a 30-months scheme was the only credible option identified which might meet this need and which could secure the support of the whole beef chain. Unfortunately when the adoption of the scheme was finally announced by Hogg on 3 April it was included in a Parliamentary statement which also covered the outcome of the recently finished Agriculture Council. This was a mistake. It gave the impression that the scheme had been adopted at EU insistence and its potential merits in terms of consumer confidence initially got lost in the row with the EU. Although the retailers continued to support UK beef as they had promised it thus made less impact on confidence than it might have done. One sector of the beef chain which had undoubtedly had its position adversely affected by the crisis was rendering. This was because the acceptance by government of SEAC’s advice that MBM should not be used in feed for any farm animal had overnight transformed a product (MBM) which commanded a price in the market into one which could only be disposed of at a cost, that is had a negative value. The stocks of MBM held by the renderers had been devalued overnight. There would also be a knock-on effect on slaughterhouses. Without a subsidy renderers would in future have to charge slaughterhouses for disposing of MBM. However, given the market turmoil it was doubtful if many slaughterhouses would be able to pay for this in the short term. What was needed was a temporary degressive subsidy payable to renderers which would keep the beef chain open and allow the new market relationships between farmers, slaughterhouses and renderers to be established gradually over time. This would necessitate commitments from the renderers about the level of the payments they would make to slaughterhouses while the subsidy was payable, and this was more or less what was put in place during April.

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In normal circumstances the introduction of the rendering subsidy would no doubt have been regarded as unacceptably interventionist. After all things would no doubt have settled down to reflect the changed circumstances after a few days or weeks at the most. If there was a few days of confusion and a couple of slaughterhouses were forced to close so what? The point was, of course, that the situation was so fraught that additional and preventable market turmoil – and the associated recriminations – could not be contemplated. It would have undermined confidence further when the single most important thing was to boost it. One other significant subsidy decided upon – arguably unnecessarily – was a subsidy to slaughterhouses.15 It was justified in relation to the quantities of ‘unsaleable’ stocks with which they were stuck following the announcement. After 20 March many retailers refused to accept meat from animals over 30 months and any carcasses in this category might well represent a loss to the operators (assuming they could not reclaim from farmers). There was certainly a possibility that some carcasses would not find a market and that some operators would as a consequence make losses for which they bore little or no responsibility. That was the case for a subsidy. The case against, however, seemed stronger. It very rapidly became apparent that the BSE crisis would have a very large cost. This made it even more imperative than usual to ensure every proposal was justified. It was obvious that slaughterhouses would welcome a subsidy but nothing their representatives said convinced MAFF that our criterion – namely that the beef chain would not function without such a provision – was met. After some discussion MAFF Ministers, that is Hogg and Baldry, accepted that view and argued accordingly though unsuccessfully with their Ministerial colleagues. It must be highly unusual for public expenditure to be approved and spent16 when the department responsible never at any stage supported it. Moreover the meeting which finally decided to introduce such a subsidy took place on the morning of 3 April when Hogg was returning from Luxembourg from where he had given clear instructions to oppose it. Nobody told Hogg or me that a decision on the matter had been taken. Neither of us contemplated that Ministers collectively, including a representative of the Treasury, would decide to pay a subsidy against the expressed wishes of the department responsible nor that if they did so decide that they would neglect to tell the Minister and Permanent Secretary, responsible respectively to Parliament and the Public Accounts Committee for the expenditure, about it. By the next Ministerial meeting on the following morning, 4 April, no minutes of the decisions of the Ministerial meeting on the 3rd had been circulated. I was therefore taken aback when I was asked if I had yet appointed accountants to devise a scheme which I now learned had been agreed the previous day. Since it was already after 11.00 a.m. on Maunday Thursday, by the time I returned to the office there was no time to lose. Coopers and Lybrand was a relevant firm with offices near to mine so I telephoned them immediately and got hold of the senior partner on the government side. He came to see me at noon and started work directly, working all through Easter. His firm ended up several hundred thousand pounds to the good as a result of this unusual process. Fortunately, given the absence of tenders, they did a good job though at a high price.

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The EU dimension My experience is that those whose professional lives were unaffected by the BSE crisis remember few facts about it. Of those facts that are remembered, Douglas Hogg’s hat somehow qualifies. So does the row with the EU. In part this was because the media like euro-rows17 which offer excellent copy. The Continentals can be represented as cynical and duplicitous; allegedly rude remarks about Britain can be reported and British politicians asked for their reaction, which with luck might start another round of recrimination. This means that those who are seeking to solve problems would be well-advised to avoid euro-rows. Assuming their first aim was to solve the crisis, policy-makers on BSE both in the UK and elsewhere in the EU were spectacularly unsuccessful judged by that criterion. I described in Chapter 4 how following the identification of BSE EU rules were adopted in 1990 to control exports of UK beef and calves to the rest of the EU. Since then these rules had been amended from time to time but had retained their principal features – a reliance on certification while less-onerous rules were imposed in respect of de-boned beef and calves than for ‘bone-in’ meat and adult cattle.18 These rules were disliked by UK interests but they had allowed exports to continue. At the beginning of 1996 the UK was still exporting to the rest of the EU calves and meat to a value of about £500 million per annum. By contrast, from the late 1980s all imports of UK cattle and beef had been banned by most countries outside the EU. If the UK had not been an EU member then it is highly probable that no exports of British beef or cattle to other member states would have been permitted from 1990 to 1996. These trade benefits of EU membership did not, however, feature in the domestic political debate following the imposition of the EU ban. Very quickly after the announcement of 20 March there was a strong negative reaction by continental consumers which took everyone by surprise. Beef consumption plummeted throughout the EU, including in Italy and Germany both of which had by 1996 had very few cases of BSE, all in animals imported from the UK, and which also imported little beef from the UK. This fierce consumer reaction was not entirely rational. Some German consumers were recorded as questioning the safety of goods containing leather.19 However, in economic matters consumers truly are kings (or queens regnant) and, even if it was irrational, the BSE crisis struck a nerve with them. There was Europe-wide a spectacular loss of confidence in beef products which was greater in respect of but not limited to those of UK origin. Governments throughout Europe were, therefore, faced with the problem of sustaining their own beef chains. Economic disruption threatened and governments searched anxiously for a mechanism to boost consumer confidence. One obvious candidate, rapidly adopted, was to ban imports of all beef products from the UK. Of course the veterinary authorities in these countries were well-aware that this would achieve very little in terms of protecting the public. But that was not the point of adopting national bans on imports from the UK; the point was to reassure

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the public. An irrational worry might, it was hoped, be mitigated by such a response even if it were, strictly, itself irrational. The evidence is that European consumers strongly approved of their national bans on imports from the UK. However, this was because their governments justified them on the grounds that they were necessary to protect public health. By implication the authorities were claiming the existence of a significant current risk. Continental consumers did not find this reassuring. They seem to have taken the view that if the import ban was justified in 1996 then it ought to have been imposed much earlier, when all agreed the risk had been greater. On this analysis a glaring deficiency in public protection had been acknowledged by their governments and closed too late. Accordingly the import bans, intended to boost public confidence in beef, served only to reduce it. All this was very uncomfortable for the Commission. They were faced with substantial extra unbudgeted EU expenditure and the breakdown in the internal market in beef. Commissioner Fischler wrote to Hogg in what was for him remarkably unhelpful terms. He complained about not being consulted before 20 March and added that it appeared that if vCJD was caused by BSE then the UK ought to have adopted greater protective measures but if that were not true the UK had overreacted. No acknowledgement was made of the fact that the UK action was based on expert, independent advice. This unsympathetic missive, clearly designed for the record, took matters forward not a jot. Whatever the position on the BSE/vCJD relationship, the breakdown in the EU beef market was unacceptable to the Commission. As I remarked in Chapter 4 it is a fundamental axiom for the Commission that all trade involving the member states should be governed by EU rules. The existence of some dozen national bans on UK beef was for them an unacceptable affront to EU doctrine as well as being illegal. Accordingly the Commission called a meeting of the committee with responsibility for regulating the health aspects of trade in animals and meat, the Standing Veterinary Committee (SVC). The Commission were awkwardly placed in that they must have had a shrewd suspicion that several member states would not lift their national bans whatever happened, while the UK had made it clear that they expected the Commission to bring about their removal. The UK line was that UK beef was still on sale domestically and unless it were suggested such sales should be banned – never entertained at any stage by anyone – then national controls on UK products must be illegal. UK consumers were entitled to the same protection as consumers anywhere else – neither more nor less. The upshot was that the Commission put to the vote a measure banning the export of beef and bovine derivatives from the UK to all destinations. Exports to ‘third countries’, that is countries outside the EU, were included on the thin, not to say spurious, grounds that they might be diverted to the EU. This last provision was especially humiliating. What was good enough for British citizens was not good enough, apparently, for citizens of any other country in the world. The inclusion of third countries in the export ban particularly irked John Major. He was right in judging this aspect of the ban to be unnecessary and that it gratuitously increased his political difficulties for no good reason.20

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One other provision in the Commission’s proposal disappointed me. The regulation as put to the vote by the Commission contained no expiry date. I saw at once that the proposal once adopted would be very difficult to amend since this would normally require a qualified majority among the member states to achieve.21 By not including an expiry date in the proposal the Commission unnecessarily constrained their future flexibility.22 In politics that is rarely sensible. However, the drama was not over when the vote was taken in the SVC on Monday 25 March. The Commission proposal received a qualified majority (only the UK opposed) and would normally have been adopted rapidly. However, whatever their degree of support all Commission legal instruments – discussions in the SVC lead to Commission instruments – have to be approved by Commissioners before they are published. The outcome of the SVC vote was circulated to Commissioners on a special fast procedure which requires unanimous acquiescence. When the offices of the two UK Commissioners objected it was temporarily blocked. The same evening Major telephoned the President of the Commission, Santer, to protest. Major, no doubt frustrated at the adverse effect BSE was having on his government and judging rightly that an EU export ban would make matters worse, took some of his frustrations out on Santer and gave him what might in less august circumstances be called a good rollicking. Santer, never a strong President, referred to the resentment caused by the UK’s lack of consultation with Brussels on the 20 March announcement. This was not wise. It was tantamount to admitting that the Commission had been motivated in part by spite. This may well have been true but if so it was not statesmanlike. Probably this admission increased Major’s ire further. After what for him must have been a bruising encounter, Santer agreed that the SVC would reconsider the matter the following day when the UK would make available experts such as the Chairman of SEAC and the CMO. Predictably, despite the best endeavours of the UK experts at the reconvened SVC meeting on 26 March, the Commission decided not to put a revised version of the proposal to the vote. Most member states were content with the version voted on the previous day and the Commission would not advocate something different since to do so would be a tacit admission of error. The proposal was formally agreed by Commissioners on 27 March. The Commission have always defended the ban in public but before taking the story forward it is worth examining whether they afterwards had any regrets about adopting a measure which led to the UK’s non-cooperation policy a few weeks later. Like the national bans it was supposed to replace, the publicity the EU ban received and the furious UK response it provoked had the effect of keeping BSE in the public mind and hence exacerbated the crisis. It can safely be said that it contributed nothing to protecting the public. A public acceptance by Fischler that UK beef was safe made it appear hypocritical. It did not even lead to the withdrawal of all the national bans on UK imports. It was, therefore, a failure on all objective counts.

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This is not to say that the Commission could have avoided taking action faced with national bans which disrupted the EU beef market and threatened the integrity of the EU legal system. However, there were a wide variety of steps they could have taken which would have been less likely to provoke sharp reactions and would have protected consumers equally. For example the national bans could have been temporarily approved while the Commission examined the efficacy of the UK protective measures. It was also unfortunate that the Commission did not take any further steps about BSE in other member states. By 1996 BSE was already established in Ireland, France and Portugal and, it was apparent, was likely to occur elsewhere. Yet most of these countries did not operate any equivalent to the UK SBO ban nor did the Commission propose they should do so. UK political opinion may have been paranoid about the EU ban but the Commission did little to counter the impression that double standards were being applied. Most Commission officials are bright, competent and reasonably open-minded, and if the points above are valid one would expect them to have recognized their validity. Is there any evidence they did so? I have yet to hear a direct admission from Commission officials that the EU ban had been a mistake. However, it may be that the adoption of the UK non-cooperation policy later, regarded as unacceptable by all outside the UK, may have made some more reluctant to acknowledge Commission errors than they would have been otherwise. There is some evidence that the Commission regretted aspects of the ban. The presiding official at both meetings of the SVC was a bright, somewhat mercurial Spaniard. A few months later he was shunted aside into a non-job and eventually left under the special scheme for Commission officials who have been sacked but have not had their hands in the till. A reasonable conclusion would be that before the SVC he had had instructions to achieve a solution leading to the replacement of the national bans on UK beef with an EU measure, but that the detailed proposal he had put to the vote went further (and hence was more upsetting to the UK) than the Commission felt comfortable defending. Thus a week after the announcement of 20 March the BSE crisis already had several strands of which the health, economic, political (domestic) and political (EU) components were the most prominent. The EU aspect of the crisis was particularly unfortunate for the government because it fed straight into a deep division in the Conservative Party.23 The political reality was that if the EU were perceived as unreasonable the vociferous, ‘eurosceptic’ wing of the party would be strengthened. The EU ban was perceived in the UK as unreasonable. Since Major had identified himself with the other ‘europhile’ wing any eurosceptic success diminished his authority. His correct perception that the EU ban would strengthen the eurosceptics’ position and weaken his was probably the principal factor behind the frustration he had displayed in his conversation with Santer. However, sooner or later matters had to be got back on track. At one of the large Ministerial meetings it was agreed that in the first instance the obvious route was for Hogg to see what he could achieve with Fischler. Major decided that matters should be prepared beforehand at ‘top’ official level. He looked at me and I realized

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I had drawn a very short straw. This was because the government was fixated on the need to secure the lifting of the export ban, and I was clear this would be a difficult and lengthy process. No other member state wanted the ban to be lifted and the UK did not have the leverage to force rapid change. This meant that those working in the area – those who might be regarded as having ‘failed’ to achieve the lifting of the ban – would be in a highly vulnerable position. Accordingly I went to Brussels on 28 March, the first of many such visits over the next few weeks. My main discussions on these occasions were with Fischler’s chef de cabinet24 an Italian called Pirzio-Baroli. Normally I also met the chefs to the UK Commissioners (then Leon Brittan and Neil Kinnock) and sometimes the chef to the President, Santer, and the Secretary-General, David Williamson25 also. The others added glosses and gave insights but the real discussions were with PirzioBaroli. On this particular occasion my most vivid recollection is of the meeting with Santer’s chef, Jim Cloos. Cloos is a nice chap and normally well-disposed towards the UK.26 However, when I said that, judged by the response, the EU ban had served only to reduce confidence throughout Europe I got a vehement, indeed violent, reaction quite out of character. In effect for want of anyone better qualified to receive it I was dressed down in retaliation for the treatment Santer had received from Major. I concluded it was best not to respond. I also drew another conclusion – that Cloos suspected that the EU ban had indeed had precisely the effect I had suggested. I have often noticed that people respond most vigorously against statements that they hope are not true but suspect are in fact true. The discussion with Pirzio-Baroli identified the principal components of the discussions that would take so much time over the coming months. It was accepted that ending the crisis required agreement on a package which everyone could support. It was agreed that extra support for the beef market would be needed especially via intervention. It was agreed that there was scope for useful technical improvements in the rules governing renderers and slaughterhouses. The Commission expressed interest when I explained that UK Ministers were prepared to adopt a measure whereby cattle over 30 months would be destroyed at the end of their working lives. It was accepted by the Commission that such a measure would justify a ‘degree of Community solidarity’. In other words they agreed that the EU should pay some of the costs. However, on two other issues minds did not meet. The Commission were keen that a targeted slaughter policy should be put in place in the UK so as significantly to reduce the number of future cases of BSE. This is in line with the normal arrangements for many other diseases such as foot-and-mouth disease. Unfortunately BSE is not like other diseases in that it is much less concentrated in particular herds essentially because animals do not catch it from each other. Accordingly relatively few future cases of BSE are prevented however slaughtering is targeted. The cost/benefit ratio is unfavourable – very unfavourable. The MAFF epidemiologist, Wilesmith, had already done some work on targeted slaughtering and it already seemed that no scheme could be devised which the UK would contemplate in normal circumstances.

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The Commission suggested that the UK was in the best position to make a specific proposal. They hinted that EU funding for such a scheme might also be available. In line with my instructions I was as negative about the idea as I could be without rejecting it outright. It was already clear that if an EU agreement were to be reached on the way forward at an early date we would have to give some ground on this point. I said that an overall agreement would have to provide for the lifting of the ban, but the Commission were non-commital. No doubt they realized that any proposal to lift the ban would have to be put to the vote in the SVC and, as matters stood, would be overwhelmingly rejected. The Commission’s reticence on the ban was ominous. I reported all this to London making it clear that the Commission’s concept of a package that might be agreed at the Agriculture Council the following week had not included a lifting of the ban; and that in my view the only hope of achieving an acceptable deal would be to make concessions on targeted slaughtering. The two statements in the previous paragraph sum up the UK’s policy dilemma for the next few months. Targeted slaughtering was not an obvious response to the BSE epidemic. The concept rested on an invalid analogy with control measures for other diseases and seemed to be based in part on a primitive feeling that disease (read sin) can only be assuaged with blood. However, once the Commission had embraced it they were not going to recommend a lifting of the ban until such a policy was adopted.27 From the UK government’s perspective there was much to be said for refusing to countenance targeted slaughtering. Such a policy would be expensive and achieve little in terms of reducing future incidence of BSE as well as upsetting the farmers concerned and the Conservative Party. It was admittedly apparent that for the UK to adopt such an attitude would make it certain that the Commission would not propose a lifting of the ban. But as their reaction on 28 March showed this was in any case highly doubtful. Moreover, it was certain that foreign demand for UK beef would remain close to zero for a lengthy period even if exports were formally permitted so economically a quick lifting of the EU ban was not of great moment. One policy option was, therefore, to concentrate on managing the crisis in the UK. Success depended above all on increasing confidence among UK consumers and it could be argued that the European aspects of the crisis, with Ministers flying to crisis meetings and the subject being raised at summits, served only to alarm them. A national approach of this kind would have involved largely ignoring the EU ban. Targeted slaughtering could have been rejected. It would probably have also involved forgoing part of the EU funds made available for the UK for the various eradication schemes but the real benefit from these was much less than the headline figures according to the Treasury’s way of looking at matters where subsequent effects on the level of the UK budget rebate are taken into account.28 Overall there was much to be said for this approach which would have had the merit of retaining more control in our own hands. Over the next few months as the difficulties in the EU came to seem insurmountable Ministers occasionally flirted with this alternative approach, but never adopted it decisively. It would

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have required a very cool politician with the full support of his colleagues to deliver such a policy effectively. The problem with this alternative approach is that it would have necessitated explaining that the ban was of minor significance. The justification for that view would have had to be the practical one that the possibility of significant exports was in any case minimal. That is undoubtedly correct as a factual proposition but it ignores the symbolic aspects of the matter. The ban implied that the EU took the view that UK beef was safe enough for the inhabitants of the UK but for nobody else. It was hardly surprising the press emphasized the humiliating aspects of the ban. To return to the chronicle of events, the following day (29 March) Hogg had his first meeting with Fischler on the crisis. The evening before a group of Ministers, who had before them my report of that day’s discussions with the Commission, met to decide on Hogg’s brief. The meeting served only to demonstrate the difficulties Hogg would face over the coming weeks. Ministers were decidedly unenthusiastic about his entering into any commitments about targeted slaughtering but regarded the immediate lifting of the ban as an essential component of any deal. This was not achievable. The meeting with Fischler did not take matters much further although the bad temper evident in Fischler’s letter of the previous week was now in the past. The crunch point was that Fischler could not envisage the lifting of the ban at any specific date. At French request an emergency Agriculture Council had been called for the following week. Following the meetings with the Commission the prospects were clear – and gloomy. While on some technical issues of market support progress seemed probable there was no prospect of agreement on any lifting of the ban. Given the public position adopted by the government from the Prime Minister down such an outcome would be portrayed as a defeat for the UK. Hogg had come in for a lot of criticism since 20 March. Ominously some of it appeared to reflect briefing from close to the centre of government. His position was fragile. However, although his Ministerial colleagues appeared to see him as a weak link, his view of them was no more favourable. In particular he was exasperated by their inability to decide on a policy and then to stick with it. Against this background he sought to protect himself as best he could. He concluded that the best approach would be for him to agree with colleagues a clear remit for his position at the Council meeting. If he followed this remit faithfully he ought to be in the clear with colleagues whatever the press said – or so he reasoned. Accordingly he discussed the prospects for the Council on the telephone with Major over the previous weekend. Major had temporarily decided that a hard line would not achieve much so it was agreed that Hogg should be fairly conciliatory. He should achieve as much progress as he could in the desired direction. Following such a low-key approach would allow the outcome to be presented as a de-escalation of the crisis. Hogg had made it clear that this was likely to include a measure of targeted slaughtering and would be unlikely to include any lifting of the ban. These instructions were in accord with Hogg’s own views on the best path forward. However, he had by now began to have reservations about Major’s staying

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power when subjected to pressure from party lobbies so he decided to set out the line he had agreed with Major in a letter copied to his principal colleagues. Despite this in the event Hogg was obliged to depart from this agreed negotiating line as Ministers meeting in London hardened his instructions during the meeting. What was extraordinary about this episode was the way in which Ministers, including Major himself, regarded a negotiating line agreed by him with the relevant Cabinet Minister for an important international negotiation as having no special status. When pushed by colleagues Major just bent instead of slapping down critics by drawing on his authority. Nor was it the case that unforeseen matters had been raised; the points made had all been recognized when Major and Hogg had spoken during the weekend before the Council meeting. The implications of such a procedure were grave. How could the UK’s negotiators operate successfully if they could not rely on being supported if they followed instructions which had been approved by the Prime Minister himself? In such circumstances two consequences would follow. The negotiators would lack confidence and they would be distrusted by those with whom they were negotiating since they would not be able sustain a consistent line. The events at the Council, in particular the way his instructions had been changed and the implication apparent from the tone of Major’s remarks that he had somehow got matters wrong, undoubtedly tried Hogg’s patience. Unfortunately his difficulties were far from over. Luxemburg is a small city without good air links and is often subject to fog. For budgetary reasons it was unusual for MAFF Ministers to travel by privately hired planes. Moreover the meeting had not finished until well into the small hours on 3 April. For a combination of these reasons the MAFF party did not reach Whitehall until after 2.00 p.m. that day. We had prepared a Parliamentary statement to be made that afternoon on the outcome of the Council meeting. However, we had reckoned without the procedural innovations which BSE was stimulating. During the course of the morning of 3 April BSE had been discussed in Cabinet and in several other Ministerial groups. Decisions had been reached on several important issues (without any reference to Hogg though he was accountable for all of them to Parliament) and a statement (to be given by Hogg) drawn up. I have already commented that this was a limp document unlikely to convince anyone that the government had indeed got a grip on BSE and knew what to do about it. When he reached his office Hogg was met by a message to the effect that Roger Freeman, the Chancellor of the Duchy of Lancaster, would come to see him with the text he was expected to deliver. We had heard on landing that there had been Ministerial meetings on BSE that day but this was the first we had heard of the extent of these deliberations. From Hogg’s perspective others had taken decisions on matters within his Ministerial portfolio without consulting him, and in some cases29 contrary to his known wishes. Worse, an inadequate statement had been drawn up without reference to him and which emphasized the wrong factors most notably by underplaying the scope for an over-30-months scheme to bolster confidence, but which he was expected to deliver. This was a major slight,

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unprecedented to my knowledge, on top of the appalling treatment Hogg had received at the Council. Could Hogg’s flesh and blood stand it? Freeman clearly had worries about how Hogg would react when he arrived at MAFF shortly afterwards bearing the text in question. He was as elegant and smooth as ever but underneath I detected he more than half expected an explosion. Freeman had taken part in both the Ministerial meetings altering Hogg’s instructions during the Luxemburg meeting and in those earlier that day and had no doubt reflected that Cabinet Ministers perhaps ought not to be treated in such a manner. Hogg, I have no doubt, understood all this at once. He did not raise a fuss and later delivered the composite text virtually as drafted. At that moment or shortly thereafter he decided within himself the position he would henceforward adopt on BSE and towards the government and his Ministerial colleagues. Hogg decided that he would in future do whatever he considered to be the right thing, that is in the national interest, even if it appeared to be against his personal interests. He would not resign, though he recognized a further mainstream government job for him was improbable. He would control his temper and keep his thoughts to himself. From then on he steadfastly refused to leak or counter-leak whatever the provocation and maintained a friendly attitude towards officials even when errors had manifestly been made. With what he saw as his duty as his guide by an effort of will he raised his moral landscape to a plane above that which most could manage if placed in similar circumstances. In this way I believe Hogg gained a measure of self-respect despite the vitriolic criticism that constantly engulfed him. His attitude was also buttressed, I suspect, by a deep contempt for a number of the colleagues who had treated him so ill.

From Easter (5–8 April) until the Florence Agreement (21 June 1996) State of play Hogg took stock with his officials on 7/8 April (Easter Sunday and Monday). The outlook was bleak. The European aspects of the crisis had struck the government at its weakest point and it was under intense pressure not only from the Opposition and the media but from its own backbenchers. Having responsibility for a problem right at the centre of these pressures, which was certain to prove intractable in the short term, had been uncomfortable, was uncomfortable and was likely to prove uncomfortable for a long time to come. Among the principal aspects were the following. First the crisis showed no signs of abating. Of course a respectable case could be made for the proposition that there was no real crisis or at least not a large one. This case would rest, for example on the facts that, as SEAC had pointed out, cases of vCJD had almost certainly resulted from exposure to BSE before the SBO controls were established in 1989 so there was no action that ought or, indeed, could be taken to lessen the impact of exposure; that these controls had been progressively strengthened since then especially since 1995; that additionally from 20 March cattle over 30 months

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would be kept out of the food chain30 thereby eliminating the animals posing the greatest risk; that farmers whose plight was much in the news had been given substantial support; and that the EU ban was of little practical effect since there was no practical prospect of the UK exporting beef. However, whatever the theoretical truth of such an analysis an examination of the media and of the record of Parliamentary debates told a very different story. A crisis can perhaps best be defined as something that many people think of as a crisis and BSE certainly met that definition. Since 20 March the newspapers had every day been full of all aspects of the matter on page one and on inside pages and equivalent treatment was given by the TV and radio news. Since the EU ban had been imposed coverage had if anything increased and was consistently critical. Second the UK beef market was still depressed with consumption at a level wellbelow that which had applied before 20 March. It was apparent that market recovery would take months if not years. Consumers’ confidence would only be regained if they were convinced that the authorities were on top of BSE. Having BSE in the headlines would not help this process. Third, public health appeared well-protected mainly because the SBO ban was being properly implemented and older animals were not entering the food chain. Fourth, substantial aid had been promised to farmers and the other vital components of the food chain, slaughterers and renderers. Not all the schemes were yet up and running but this would only be a matter of time. Fifth, the government had just announced it would introduce a 30-months scheme. It was immediately apparent that slaughtering and entirely destroying the carcasses of every dairy cow in the country31 at the end of its working life – some 20,000 animals per week – would present a formidable logistic task. Sixth, the EU ban had turned what would have been a serious crisis into a bigger one. Whatever view one took on the ban it put right to the fore the arguments about sovereignty and European integration on which there has always been controversy in the UK. Politically this was especially awkward for Major since he had at the beginning of his Prime Ministerial term somewhat unexpectedly nailed his colours firmly to the pro-EU mast. The humiliating terms of the ban strengthened the hands of the opposite faction which were well-represented on the Conservative benches in the Commons. The scale of the efforts made by the UK to get the ban lifted, which exceeded what could be justified by any cool analysis of the national interest, is probably explained in large part by the adverse effects it had on Major’s standing. Seventh, the extraordinary series of large Ministerial meetings over the past two weeks had been a frightfully inefficient method of doing business. We needed a clearly defined and prioritized strategy to the aims of which day to day tactics could be deployed. This was why the way in which Hogg had been undermined at the recent meeting of the Agriculture Council had been so depressing. The trouble was that Hogg’s ministerial colleagues had not properly reflected on the realistic prospects for an alternative, harder policy. They were simply responding to pressure from Conservative activists.

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The upshot had been a change of line midway through the Council meeting and a series of minor decisions taken without establishing the views of Hogg, the Minister formally accountable for them. It was clear that whatever Major’s preoccupations might be, the dignity of his Minister of Agriculture was not one of them. Looking forward The main immediate issues were the ban and the operation of the 30-months scheme. It is time to look at the latter in a little more detail. The establishment of the 30-months scheme By the beginning of April the government had embraced the concept of this scheme and it was referred to in the conclusions of the 1–4 April meeting of the Agriculture Council. There were four interlinked potential advantages of the scheme. First, it eliminated from the food chain the older animals which posed most risk; second, because of the first point it could help to reassure consumers and hence boost confidence and, hopefully, demand; third, because it had been introduced at the instigation of, among others, the retailers it guaranteed they would continue to market UK beef;32 and fourth, it could help to restore equilibrium to the market which was seriously unbalanced. It was decided that the scheme should be operated by the Intervention Board Executive Agency (IBEA). This was logical because they had relevant experience including purchasing animals and operating cold stores. There were, however, also drawbacks to having IBEA in the lead. Its Chief Executive reported to the four Agriculture Ministers collectively33 and it was not located in London. IBEA normally worked on highly technical issues and its staff were unused to working under direct Ministerial instructions and inexperienced in dealing with matters in the political limelight. From my perspective there was a further disadvantage to having IBEA in the lead. This was that though I outranked the Chief Executive he did not report to me and I had no authority to give him instructions. However, these distinctions were lost on the public. For them ‘MAFF’ was responsible for matters agricultural and if things went wrong it was the fault of its Ministers and officials.34 In reality, for various reasons35 senior MAFF officials, (especially me) had considerable influence on the drawing up of the 30-months scheme. Nevertheless it is peculiarly galling to be criticized for matters where one lacks the powers to take the vital decisions. It was rapidly decided that the slaughterhouses used for the scheme would have to be specially designated for the task either full-time or for a given number of days per week. Some supermarkets tried to insist on the full-time option which in some respects would have been ideal. However, it would have involved some animals travelling very large distances to slaughter which was undesirable and inefficient and would also have given highly profitable contracts to a few which would have bred resentment. The last point illustrates a truth which underlay many of the difficulties with which MAFF and IBEA had to wrestle as they struggled to get the scheme

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established. The establishment of the 30-months scheme altered or threatened to alter the balance of equilibrium between the components of the beef chain. This was resisted by the potential losers. Those potentially disadvantaged pressed their representatives to seek policy changes from government, while those seeing potential advantages sought to hang on to them. Government was subject to a deafening chorus of representations which it was not in a position to ignore. The most serious change concerned the position of the renderers. It was decided very quickly that the only viable option was to render the slaughtered animals and incinerate the resulting MBM and tallow.36 Some thought was given early on to using incineration as the standard method of destruction of the carcasses, but this was quickly shown to be unviable since insufficient incineration facilities were available. Rendering would greatly reduce the weight of material needing to be incinerated since much of the weight of bovine carcasses is composed of water and this is driven off in the rendering process. Moreover, the products of rendering, MBM and tallow, could be stored much more easily and cheaply than carcasses which would need to be frozen. The 30-month scheme placed the renderers in a pivotal position. About 20 per cent of cattle would in future be wholly rendered while previously about half of each of these carcasses (by weight) had been sold as meat and hence had not been rendered. Total rendering throughput would therefore need to increase by some ten per cent. Moreover, this was the equilibrium position. Inevitably the scheme took time to establish during which period a backlog of animals over 30 months awaiting slaughter was growing by at least 20,000 animals per week. When the scheme did start the existence of a substantial pent-up demand37 would inevitably lead to demands for throughput to exceed what was technically feasible. Finally rendering batches of whole carcasses was new and posed technical problems. These practical problems would have created problems in any event. They were not the only ones however. The renderers would not have been human had they not noticed that the pressure on government to get the scheme operating increased day by day and that the strength of their negotiating hand increased in parallel. There is no evidence that the renderers unnecessarily delayed the start of the scheme, but if they did not it was not for lack of incentive. An even greater problem was to decide on the slaughterhouses to be dedicated to the scheme. More operators wished to take part than were required for the efficient working of the system. This was unsurprising since the scheme offered to operators many of whom were at the margins of viability the prospect of secure, relatively easy work likely, many may have suspected, to be well-remunerated given the political pressures. The initial details of the scheme were dealt with by the MAFF Minister of State, Tony Baldry, and he became the target of much vigorous lobbying from MPs and others. There was a tension between the dictates of efficiency and the political realities. Efficiency suggested using a few wholly dedicated slaughterhouses located as near as possible to the renderers; politics suggested having wide participation and spreading the participating slaughterhouses around geographically. After some wavering politics won.

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Decisions on which slaughterhouses to include in the scheme were reached over a period of a week or so at the beginning of May. Unfortunately it had been announced that the scheme would start on 29 April38 and the pressure on government increased steadily from that date. This was not surprising. Some farmers had been waiting six weeks to have animals slaughtered and in the meantime they were consuming feed. The difficulty was that while it was in the overall interest to get the scheme up and running quickly, it was in the interests of individual farmers to have a wide choice of outlets and of individual slaughterhouses to ensure they were included in the scheme even if pressing these interests held matters up for a day or two. As the number of slaughterhouses expected to participate increased the renderers objected that the scheme could not be efficiently managed with such a large number and pressed for a reduction. In the first few days of May the draft list of participating slaughterhouses expanded and contracted more than once. Nevertheless, by 10 May the scheme was operating. The initial limitation on throughput was dictated by the availability of rendering plant. Plans were quickly made to increase rendering capacity but this would take months to get on stream. Maximum throughput was thus expected to amount to about 25,000 animals per week until July at the earliest. Since some 20,000 cows were culled each week on average it was obvious the backlog would not be reduced quickly since by 10 May the number of cull cows awaiting slaughter could be calculated at well-over 100,000. Moreover this took no account of beef animals, mainly steers and heifers, that might be brought to market at over 30 months. One fact revealed by the 30months scheme that surprised all observers was how many more animals there were in this category than had been anticipated. This meant, of course, that in the short term the backlog was greater than had appeared likely when the scheme was under contemplation and the number of animals farmers would wish to present weekly would also be greater than expected. In time it was reasonable to expect farmers to alter production systems so that all beef animals would be finished within 30 months. But for at least six months the scheme would have to deal with more animals than had been calculated originally. In short, the backlog would be bigger than anticipated and it would take longer to clear. In political terms the scope for complaint was even bigger than expected. Meat from animals bred for beef fetches a higher price than that from dairy cows. The compensation rate under the scheme was set in the EU Regulation at 1ecu/kg39 equivalent to 85p/kg which reflected cull cow prices immediately before 20 March. Inevitably the NFU pressed for a supplement for ‘clean’ cattle, that is steers and heifers. The President (Sir David Naish) pressed Hogg for a level of 30p/kg. I objected to any supplement that would bring returns above the level being received by those marketing animals under 30 months which was then about 100p/kg on the grounds that it was objectionable in principle to pay more for animals going for destruction than for animals going for consumption. Hogg may have agreed with me on the merits, but politically he could not afford to have the NFU complaining. The government was on the run and he would have got no

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thanks from his colleagues for antagonizing the NFU to save a few millions. Hogg decided on a top-up of 25p/kg volunteering, and I am sure he meant it, that he would if necessary provide me with an Accounting Officer Direction.40 This top-up was initially set for four weeks though it was immediately apparent that not all qualifying animals would be slaughtered by the end of that period and that it would be difficult to pay any less to farmers simply because they had been stuck in the queue. Two obvious disadvantages of paying a supplement that takes returns above the level that could be obtained from the market were that it removed all incentive to market the animal below 30 months and created an incentive to keep animals longer than necessary to qualify for the premium. As time passed it became clear producers were responding to these incentives. The existence of a backlog gave rise to demands that access to the scheme be regulated. In particular there were demands that government should itself decide on an order of priority for different classes of animal and/or actually manage the scheme. This was an unappealing prospect. The rendering bottleneck meant that the backlog was destined to last for many months. Government was bound to be blamed for this but the blame was certain to be greater if it was actually controlling who could present animals for slaughter under the scheme. Accordingly it resisted the suggestion. From early May officials started searching for cold stores which could be used to store carcasses which could be processed later when rendering capacity had expanded. It was hoped that in this way the backlog could be reduced more quickly than extra rendering capacity could be installed. Eventually this policy bore fruit but at first it proved difficult to obtain suitable space partly because owners were reluctant to let it out for the scheme fearing that the ‘taint’ of BSE might blight the store afterwards. The Treasury also balked at the cost of converting stores normally used for other purposes. The frustration felt within the farming industry at the growth of the backlog gave wonderful opportunities to the Opposition to score off the government. The farming press described the situation as a ‘farce’ and this was gleefully quoted in the House of Commons in a debate on 13 May. Matters were not helped by the NFU who, because they consistently extrapolated from current trends and took no account of planned investment in rendering plant and cold stores, always took a pessimistic view of how long it would take to clear the backlog. By mid/late June the scheme was operating properly. Throughput had reached close to 30,000 animals per week so the backlog was being reduced albeit slowly. The supplement for clean cattle had been reduced to 15p/kg for animals reaching 30 months of age on or before 17 June albeit only after a squabble with the Treasury that had only been settled by the mediation of the Deputy Prime Minister. Plans had been made to bring more rendering capacity on stream and to lease more cold stores. There seemed every prospect that the backlog would be eliminated within a few months. The question was whether that was good enough politically. I come back to that in the next section.

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Relations with Europe: ‘non-cooperation’ and the Florence Agreement When officials reviewed matters with Hogg after Easter the agenda reflected the fact that the EU beef ban was regarded by the whole government as one of its most serious problems. Any government would have found the position very difficult, but for the Major administration the difficulties were exacerbated by the divisions in the Conservative Party over the EU. Unfortunately for Major, the ban had been imposed by his close European allies whom he had made a point of courting against the instincts of many of his party supporters. One problem was that the eurosceptics in the party appeared to attach more importance to their views on the EU than they did to party unity.41 To the public the ban seemed to epitomize one prominent characteristic of the administration particularly after the UK fell out of the Exchange Rate Mechanism in 1992, namely that it never seemed properly to be in control of anything. In short the existence of the ban reinforced the impression of government weakness. This is just about the worst impression a government can give.42 Accordingly it was taken as axiomatic that all efforts must be directed to getting the ban lifted. Enormous effort was put into achieving that objective and Major and other senior Ministers became progressively more frustrated when their efforts achieved so little. In their frustration they looked for someone to blame. The EU in its various manifestations was one obvious candidate and papers were soon demanded on the possibilities of ‘retaliation’. Major was even more frustrated when the FCO pointed out the pitfalls, suggested the member states had genuine concerns about BSE and came up with no useful ideas for retaliation. For their part the Commission and the majority of member states made use of every device to delay matters. The Commission hit on the concept of a ‘BSE eradication plan’. What was needed, it was claimed, was a highly detailed plan to give the member states confidence in UK controls. This suggestion was sensible and was to prove useful later as we shall see, but it was originally put forward largely because it served to delay matters. It would take several weeks to write a version sufficiently comprehensive to survive critical examination. The concern at the centre of government was such, however, that when a comprehensive text could not be produced in a few days the focus of irritation shifted to MAFF. Similarly, later, after the Florence Agreement progress on lifting the ban was made dependent on starting the selective cull of animals believed to have been exposed to BSE as calves. The attitude of UK farmers made it impossible politically to start on this before the backlog of animals eligible under the 30-months scheme had been cleared. When clearing the backlog took time this, too, was held to be a MAFF failure by Downing Street. As some of us suspected at the time, correctly as events demonstrated, in reality these ‘delays’ made no difference to the rate at which the ban was lifted but senior members of the government sometimes acted as though they believed otherwise. (At others they put the blame on the EU.) These attitudes expressed the frustration undoubtedly felt within government when the effort put into getting the ban lifted failed to yield significant results.

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Major found it particularly galling that when discussing BSE with his Prime Ministerial colleagues at meetings of Heads of Government he received much sympathy but this never seemed to result in action at the technical level. Sometimes he appeared to think that the reason for this was because of a lack of vigour in the UK administration in explaining the technical details. The attraction of this view from his perspective was that it offered hope that doing something at home – that is something within his control – might bring about some movement on the ban. Unfortunately for Major, as subsequent events amply confirmed, there was no substance to the view that it was some defect in Hogg or in MAFF that prevented progress on the ban. He overlooked the fact that the obvious course of action for other Prime Ministers who may have wanted to express sympathy for the UK – may have even felt it – but who had no intention of doing anything to help was to profess sympathy, demonstrate ignorance and demand extra reassurances. This all served to get through meetings as pleasantly as possible without giving anything away. What Major and many others in government could usefully have done was to reflect more profoundly on the position as seen from the perspective of the other member states. They gave too much weight to the fact that Santer and Fischler had both admitted publicly that UK beef was safe43 and that in private conversation others said the same. However it did not follow from this that the ban would be lifted quickly. The authorities in most other member states had responded to the UK announcement of 20 March by banning imports of UK beef. The administrations in the countries concerned had explained this action to their domestic constituencies as being necessary to protect public health. It had been expected that this action – national bans later replaced by the EU ban – would reassure the public and in this, as we have seen, it was unsuccessful. Despite the ban(s) beef consumption had fallen spectacularly, precisely the eventuality the national bans had been designed to prevent. It did not follow from this, however, that reversing the policy and lifting the EU and national bans would restore confidence elsewhere in the EU. On the contrary, since consumers in other member states had been assured that the ban on UK exports was necessary to protect them removing it would have reduced confidence even further and probably led to an even greater reduction in consumption. This would have put the administrations concerned in an impossible political situation. The fact that Prime Ministers might privately or even publicly recognize that UK beef was perfectly safe according to normal criteria was neither here nor there. If public reactions had been perfectly rational the fall in consumption would not have occurred in the first place. The FCO had half recognized the truth when they stated in their papers on the possibilities of retaliation that the other member states had genuine concerns. They were wrong, however, to imply these related to public health. The other member states were concerned above all with public confidence which is a very different thing. Accordingly, the majority of member states were not in a position politically to accept any significant lessening of the ban in spring/summer 1996. This

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conclusion was made all the more certain by the nature of the EU ban. As we have already seen this was in the form of a Commission regulation without time limit. The Commission could not, even it had wished, simply alter the regulation. This required a vote in the SVC and, depending on the result, in the Council. The complicated voting rules were such that to achieve any change on the ban then as an absolute minimum more countries had to vote for change than against it. Only one or two states – perhaps Ireland and Sweden – would have contemplated voting for a major lifting of the ban. The chance of rapid, major change was effectively zero. At this stage what was lacking during the large number of meetings on BSE many of them involving a dozen or more senior Ministers was any proper examination of the situation from the perspective of the others concerned. Any such examination conducted honestly must have drawn the conclusion that there was no chance of a significant lifting of the ban. (Of course this assumes that senior officials would have had the courage to tell Major what he least wanted to hear). It would then have been possible to identify a strategy which, given the realities, minimized the political damage. As it was the strategy followed was based on the assumption that because the UK wanted the ban lifted this must be possible and the only way forward was to demand this with ever greater emphasis. Since this policy did not – could not – succeed the political damage was greater than it need have been. In short, what was needed was less frenetic activity and constant lobbying and more reflection. It quickly became apparent after Easter that the UK and the NFU would challenge the ban in the European Court. Given what had been said in public about the lack of justification for the ban this was inevitable. Beyond this Ministers were divided into two camps. One party advocated chipping away at the ban on an incremental basis by patient negotiation. The leading advocates of this position were Hogg and William Waldegrave, the Chief Secretary to the Treasury and a former Minister of Agriculture and hence more familiar than most with the world of Brussels. Events were to show that this was the more realistic party. Unfortunately it was also the weaker party politically. The other party, led at this stage by Michael Heseltine and Michael Forsyth, advocated a more aggressive policy. Options mentioned included various forms of retaliation including import bans and the withholding of financial contributions. True to form reports that some Ministers were thinking in terms of an aggressive approach duly appeared in the press. A remark on these lines made by the Foreign Secretary (Malcolm Rifkind) on 22 April was especially widely reported. Such statements will have been picked up in Brussels and will inevitably have made the negotiations there even more difficult. One difficulty faced by both parties was that, given the attitude of the Commission and the member states, it seemed unlikely that much progress could be made in Brussels without a commitment to a selective cull. Yet the state of farming and political opinion in the UK seemed to rule this out. Nevertheless MAFF epidemiologists continued to work on the possibilities and by mid-April had concluded that if such a scheme were to be adopted the best option would be to

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slaughter entire birth cohorts44 on farms where cases had occurred after the feed ban had been adopted.45 The period from Easter until the next Agriculture Council held on 29–30 April passed with Ministers arguing over the merits of ‘hard’ and ‘soft’ negotiating lines and vacillating over a selective cull while being subject to regular Parliamentary assault by their own eurosceptic backbenchers. Numerous papers were demanded and prepared. None dealt with the fundamental point of whether any significant rapid lifting of the ban was negotiable. However, by 29 April Hogg had secured authority to float in Brussels the UK’s latest ideas on a selective cull but only on a non-committal basis.46 The Commission indicated at the Council meeting that they were thinking in terms of a possible measure to lift the ban in respect of tallow, gelatine and semen. Though the value of exports of these products was small,47 gelatine especially was included in a large number of manufactured products including all pharmaceuticals. At one point the status of UK manufactured pharmaceuticals under the ban seemed doubtful so it was well-worth settling the point satisfactorily. It is also probable that the Commission were prepared to contemplate lifting the ban in respect of tallow, gelatine and semen because they considered the ban was weakest in legal terms for these products. They would be keen to have any weak point removed from the scope of the ban before the matter was considered by the European Court. In summary the public would rightly not regard a lifting of the ban on these three products as a major advance but it was worth securing and seemed possible. In the Council it was agreed to consider further the possibility of a measure lifting the ban in respect of tallow, gelatine and semen. Again Hogg had to discuss draft Council conclusions on the telephone with other Ministers including the Prime Minister in London. Again the reactions of the London team implied that Hogg had done a poor job and demanded changes. For an agonizing period it seemed that we might be in for a repeat of the situation at the previous Council and the UK might again have to reject conclusions which most other delegations regarded as slanted in its favour. Thankfully Hogg unexpectedly achieved a couple of changes to the draft which the London end reluctantly accepted. Hogg’s parliamentary statement on the outcome of the Council on 1 May was notable mainly for the intervention of several Conservative eurosceptics taking the opportunity to preach an anti-EU line. The ban had turned the BSE crisis from a matter which gave the government problems with public opinion to one which threatened to tear the party apart. No doubt partly as a consequence Major wrote to his EU Prime Ministerial colleagues about BSE in a way which, with the benefit of hindsight, can be seen as a forerunner to non-cooperation. This probably reflected the fact that by now he saw himself as being boxed in with the ‘unreasonable’ EU on one side and the equally ‘unreasonable’ eurosceptics on the other. He was beginning to think that something much more radical than had been tried so far might be the only way forward. Frantic UK lobbying48 at all levels up to and including the Prime Minister was directed at the member states and Commission before a proposal on the three

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derivatives finally came to a vote in the SVC on 15 May when it became apparent that a qualified majority could not be secured. The Commission decided to hold the item over until 20 May when the next meeting of the Agriculture Council was scheduled. In London the atmosphere was tense. Downing Street concluded that the failure of the UK case to make better progress ‘must’ be due to a failure to explain things properly at the technical level, that is to a failure by MAFF. This view relied on the naive assumption that since the UK case for a lifting of the ban appeared justified to the UK others could only reject it out of ignorance. This UK-centric view of the world was at odds with reality. Eventually the Commission proposal was put to the vote in the SVC late on 20 May. It came nowhere near achieving a qualified majority, the vote in terms of countries being only 8–7 in favour. This was a serious setback given the enormous negotiating effort the UK had devoted to the issue. Further, it was not clear that the Commission would be prepared to take the matter forward with such poor support. At this the Prime Minister lost patience and embarked on the policy of ‘noncooperation’ in the EU. I was in Brussels with Hogg at the Agriculture Council but I heard afterwards that the proposal had been put with the full support of Major and the Foreign Secretary (Malcolm Rifkind) to a meeting that morning at which most of the Cabinet had been present. Apparently there was no opposition at the time.49 It is noteworthy that it had not occurred to anyone to seek Hogg’s views before the decision had been taken. After all the entire point of the policy was to make it easier to negotiate a lifting of the beef ban and Hogg knew more about that than any other Minister. To his eternal credit when told by Major by telephone on the morning of 21 May of the Cabinet’s ‘unanimous’ decision Hogg tried hard to dissuade him from embarking on what was obviously a foolish adventure.50 Predictably this had no effect. The relevant EU rule was that provided the proposal on the three derivatives on which the SVC had voted was approved by the Commission subsequently they (the Commission) could adopt it provided also that the Council did not reject it by a majority of member states voting. A special Agriculture Council meeting was called for 3–4 June to decide on this last point. It was inevitable that the build-up would be dominated by the fact of non-cooperation. Non-cooperation was defined by Major in a statement to the House of Commons on the afternoon of 21 May: … without progress towards lifting the ban we cannot be expected to co-operate normally on other Community business… We cannot continue business as usual within Europe when we are faced with the clear disregard by some of our partners of reason, of common sense and of Britain’s national interests. As is often the case when mistaken policies are announced the initial response was quite favourable. The Opposition were wary but muted. The numerous eurosceptics on the Conservative benches were delighted. This was perhaps inevitable but one is entitled to ask – what did they envisage might be the eventual outcome?

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On that it is clear as described above that the political situation in most other member states meant that non-cooperation could not have succeeded in achieving a significant lifting of the EU ban. It was also a policy that could not be operated for long since the work of the EU that was susceptible to blocking by use of the veto – a fair amount – would have ground to a halt. This would not have been acceptable to the other member states. It is accepted in the EU that member states will occasionally block proposals with which they are not concerned to achieve their way on one with which they are very concerned. But non-cooperation went well-beyond this,51 affecting the efficient functioning of substantial swathes of EU policy especially in the area of foreign relations. It also set a very awkward precedent. It could not be allowed to succeed. Accordingly if it had continued for a prolonged period, say several months, the outcome would not have been surrender by the Commission and the large majority of EU states and the repeal of the ban. The outcome would have been the creation of a legal mechanism to get round the UK veto which would probably have involved the progressive exclusion of the UK from an increasing range of EU decisions.52 In the very short term, however, non-cooperation may have helped to ensure that the Commission did in fact approve the text lifting the ban on the three derivatives and in the two weeks before the Council tried to ensure that the outcome was its adoption. They will have been especially careful – as it were through gritted teeth – to give the UK no excuse to claim it was being treated unfairly. This required taking the proposal the Commission had already launched to its conclusion. It would, in the Commission’s view, not require further action on lifting the ban until sufficient evidence had been gathered to justify their assuring the member states that they could have full confidence in the operation of BSE controls in the UK. It was already clear that in practice this meant the greater part of the ban would continue for a long time. Very few within the UK government acknowledged even to themselves that this effectively precluded further action in 1996 and perhaps longer. The UK BSE Eradication Plan, running to some 200 pages, was circulated directly before the Agriculture Council started on 3 June. After many hours of attempted wheeling and dealing when the matter was put to the vote only Spain changed votes so that the proposal on the three derivatives was supported 9–6,53 still wellshort of a qualified majority but likely to be enough for the Commission to adopt the measure, which they duly did a few days later. Everyone now looked towards the European Council which was scheduled to meet in Florence on 21 June. From the UK perspective this was the opportunity to agree on a framework for lifting the ban;54 for the others it was an opportunity to return to normal methods of working. It would be seriously damaging politically if Florence passed without the beef issue and its political consequence, noncooperation, being resolved. The period between 3 and 21 June was marked by more frenetic activity. Initially the Commission insisted it was for the UK to draft a ‘framework’ which could (in UK eyes would) lead to a lifting of the ban. Rifkind and Hogg and sundry senior

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officials departed on a tour of capitals to press the UK case during which they met Chancellor Kohl, President Chirac, Prime Minister Aznar and numerous other Ministers55 in most member states. The roadshow’s collective view on a possible framework developed as their tour progressed and their draft text became progressively more complicated. Meanwhile at a meeting with Pirzio-Baroli on 6 June I gained the first detailed intimation of what the Commission would be prepared to accept in a framework. The reality of negotiations in the EU, surprising as it might seem to outsiders, is that on a technical matter like BSE someone in Pirzio-Baroli’s position is more likely to be able to indicate the detailed way ahead than Prime Ministers. I was asked by the Prime Minister via the Cabinet Secretary to produce a draft framework of my own reflecting the Commission’s views. I hesitated. It is, to say the least, unusual for a civil servant to make recommendations different from and therefore implicitly criticizing his own Minister’s contemporaneous suggestions. Some Ministers I can think of would have reacted very badly to such an action by one of their officials even if demanded by the Prime Minister; and forever held the incident against the official concerned. Hogg, however, was not difficult in that way and I did put forward a different, simpler version reflecting more closely what Pirzio-Baroli had said. Hogg never gave any indication that he regarded this as in any way untoward. Both versions were put to Major who preferred mine to the consternation of Downing Street and the Cabinet Office who went to amusing lengths to avoid saying so directly. I was authorized to send a slightly revised version of my draft to the Commission. Unexpectedly the Commission circulated it to member states for discussion in the SVC. This showed that they regarded it as a serious attempt to deal with the issue; no doubt they also wanted to test the reactions of the other member states to it. However, it was never practical to imagine that a text drafted by the UK could prove the basis for an agreement to lift the ban. In the EU the expectation would be that this should be the responsibility of the Commission. The Commission’s game plan was revealed in detail at a meeting I had with Pirzio-Baroli on 13 June. This was in two main parts. First, the UK BSE Eradication Plan should be formally endorsed by the SVC just before or during the European Council. This would provide a solid legal proof that the EU accepted that the measures the UK had taken to deal with BSE were appropriate and sufficient to eliminate the disease.56 Second, the Commission would produce their own framework for the lifting of the ban which would be endorsed by the European Council before being formally adopted by due legal process.57 In this way a defined way forward would have been enshrined in EU law addressing the concerns of most member states on the one hand (the risk of BSE) and the UK on the other (the ban). By this time there was a vast amount of Ministerial activity at all levels up to and including Major himself. This all served to confirm how essential it was to resolve the issue at Florence. The Commission’s draft framework was first shown to UK representatives when I met Pirzio-Baroli on 18 June. It was at once clear that the text was probably sufficient to enable the crisis to be ended if the political will existed. It described

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circumstances in which the ban could be lifted progressively when defined criteria were satisfied. The drawback for the UK was the lack of any automatic aspect to the resulting action and the height of the hurdles to be jumped. Five significant ‘preconditions’58 were specified, some of which could not be met quickly if at all. Every step in lifting the ban would depend on the UK making a formal proposal, the Commission being willing to take it up and the member states acting and voting according to the scientific evidence. Provision was made for the results of EU inspections of the enforcement of the rules by the UK to be fed into the process. All this would provide plenty of scope for action to be delayed. Major chaired a Ministerial meeting later that day to consider developments. Though he did not say as much directly Major obviously sensed that matters were likely to be settled on a basis very close to the Commission’s draft paper. His attention now turned to how this could be presented. On that his main concern was to be able to claim that the ban, or at least a significant part of it, would (or if not ‘would’ then ‘could’) be lifted at the earliest possible date. It was made clear that I was expected to provide technical justification for such a claim. This was awkward. In one sense the issue could be likened to the well-known one about how many angels could dance on a pin in that I was confident that there would be no significant further moves in lifting the ban for many months and probably years. However, that was something the government would not be prepared to acknowledge in June 1996. The difficulty was that when agreement was reached Major was clearly determined to announce that this would lead to an early lifting of the ban; this would not happen; and that when it did not happen the question would arise as to why not; if it could be shown at that stage that the PM had based his earlier claims on incorrect advise then the ‘fault’ would lie with those who had provided it. I was therefore being implicitly invited to volunteer for the role of scapegoat should one be needed later. I did not feel confident that the temptation to make me the scapegoat in such circumstances would necessarily be resisted. On one interpretation of the draft text the conditions for the first steps in lifting the ban would be met when the selective cull was started, that is when the backlog under the 30-months scheme had been cleared. This could therefore be regarded as the crucial date. In estimating this I followed my usual policy in such circumstances of being as optimistic as could possibly be justified by anyone with a genuine knowledge of the facts. In my view this pointed to 1 November 1996. Of course this meant that I regarded the most likely date when this criterion would be satisfied as being some time later. 1 November was however, regarded as unacceptably late by Major. In the resulting silence Roger Freeman59 intervened to the effect that in his view 1 September should be possible. I was not clear whether this was just a noble action on his part reflecting his recognition of what Major needed or whether he had somehow persuaded himself that such a claim was in accordance with the facts. Unfortunately this, too, did not satisfy Major. He asked me to come up with an earlier date. Matters were now moving towards a resolution. On 19 June the UK Eradication Plan was adopted unanimously by the SVC. This was a big step forward. The

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Italian Presidency, statesmanlike throughout the crisis,60 continued to work effectively towards agreement, cajoling both the UK and the others. On 19 June Hogg wrote to the PM drawing on his legal skills to assess the Commission’s text. He pointed out the number of uncertainties and in particular that it did not link the specified steps in lifting the ban with specific events; also some of the provisions were ambiguous; overall there was plenty of scope for the ill-disposed to delay progress for a long time. Hogg went on to advocate accepting the text in the wider UK interest but placed unambiguously on the record that an early lifting of the ban would not necessarily follow. Since this was precisely the claim Major intended to make when the text was adopted, this was not wellreceived. No reply was ever received and the mood music indicated displeasure.61 The reasons for Major’s concern became apparent when the media began to change tack as the Florence meeting approached. In discussing the prospects on 20 June, in addition to criticism in the Labour-leaning press, the Sun referred to a likely ‘surrender’, the Mail mentioned ‘retreat’ and the Telegraph to how Britain had ‘capitulated’. These were all papers that had broadly supported the noncooperation policy. In truth compromise, and hence such headlines, had been inevitable from the moment non-cooperation had been adopted. Problems over beef exports were simply not sufficiently important to serve as a justification for the UK’s putting at risk its relations with the EU for any length of time;62 and a rapid lifting of the ban was out of the question. Major continued to fret about the way in which a deal could be presented most effectively including on the plane to Florence when he continued to press me to give an early date for the start of the selective cull. But to the dismay of some eurosceptic sections of the party it was clear that it was only presentation that was now really occupying him. He had decided to bite the bullet and do a deal. At Florence the Germans made a half-hearted attempt to delay matters but the deal was quickly done. A detailed framework which would in due course lead to the complete lifting of the ban – albeit many years away as Hogg had predicted – was agreed and non-cooperation stopped forthwith. In my view the non-cooperation policy was a predictable – and as Hogg had shown predicted – disaster. It had diminished the UK in the eyes of others in the EU to an extent that could only be healed by a change in the UK administration. It is doubtful if it achieved action on lifting the ban any earlier than would have occurred without non-cooperation and, indeed, without the Florence agreement.63 Large amounts of negotiating capital had been spent to little or no advantage. Domestically the outcome was probably on balance negative for the government. In announcing the outcome of the Florence meeting of the European Council to Parliament Major naturally claimed that the agreement vindicated the stance the government had taken. As regards a timetable Freeman had now suggested that the selective cull should be started by the ‘middle’ of September. I wrote to Major’s private secretary stating that MAFF was ‘unconvinced’ by this claim. I also said it would be better not to quote any timetable. In the event Major said that he expected to be in a position ‘by October’ to tell the Commission that the conditions had been met for the next step in lifting the ban, that is the selective cull would start by then.

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However, while non-cooperation had been a mistake it was certainly sensible to bring it to an end at Florence. Any continuation would have had serious implications for UK interests. On that Major did the right thing in difficult political circumstances.

From Florence (21 June 1996) to the End of the Conservative Administration (1 May 1997) State of play Though it would not lead to the rapid lifting of the ban as Ministers were too inclined to claim would be the case, the agreement at Florence had one useful consequence. It took some of the heat out of BSE as a political subject. Though potentially it remained a top issue liable to flare up at any time there were days when it did not feature in the news at all. This was a welcome relief after the pressures of the past three months. However, the Florence Agreement also required the UK to undertake a number of tasks which were substantial both in terms of the logistics involved and the potential cost. These included planning and undertaking a selective cull which itself necessitated eliminating the backlog on the 30-months scheme. Other tasks included introducing a computerized cattle-tracking system and a feed-recall scheme, that is removing from farms any feed which might conceivably contain MBM and hence BSE infective material.64 Of these tasks the most immediate was that of reducing the backlog of the 30-months scheme. This was what most concerned farmers and prevented the start of the selective cull without which there was no possibility of making progress on the ban. First, however, we need to note further developments in organization. These changes were introduced before Florence but consideration of them fits in more naturally here. Methods of working The Chancellor of the Duchy of Lancaster, Roger Freeman, had to some extent been involved with BSE since the crisis broke on 20 March. No doubt this was because as a Minister without a specific portfolio he had capacity to spare for problems which arose. However, at the time the non-cooperation policy was announced on 22 May he was charged by Major with chairing a Ministerial group65 to oversee action to eradicate BSE. His new functions were announced publicly. In practice he did more than chair a committee, but also met interest groups such as farmers concerned that the backlog in the 30-months scheme should be eliminated, and so on, and gave media interviews and the like. This was apparently what was intended. Inevitably this was seen as a snub to Hogg; whether or not it was intended as such it was clearly an expression of a lack of confidence in him. The Times suggested he had been ‘downgraded’. From an administrative standpoint all this was most unsatisfactory. In particular no responsibilities had been taken from Hogg who would still be required to report to Parliament on all issues on which Freeman might be taking decisions without

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his knowledge or, conceivably, agreement. Hence two Cabinet Ministers were in effect appointed to undertake the same tasks without one being given primacy. Officials were placed in an awkward position. Freeman had to rely on advice from MAFF officials since he had no staff of his own.66 The loyalty of MAFF officials was to their Minister. What were they meant to do if Freeman reached conclusions with which they suspected Hogg would disagree? Above all since Hogg and Freeman were talking to the media on the same subjects at the same time there was a constant risk of differences of approach emerging which would be exploited to embarrass the government. The whole arrangement was hopeless and it was surprising that it did not give rise to even more problems than it did. However in the event though Hogg and Freeman contradicted themselves occasionally the media appeared to be bemused by the whole subject and made less of these incidents than they might have done. Above all what saved the arrangement from disaster was that at bottom both Hogg and Freeman were reasonable souls who rather liked each other. With different personalities explosions would undoubtedly have occurred. How it could have been thought that such a loose arrangement would help to improve decisionmaking and/or the government’s image is difficult to see. If the reasoning was that Freeman would represent a better face for the government and/or would take better decisions why leave formal responsibility with Hogg? If the idea was to leave Hogg in charge why not make that clear? No answers were provided to these obvious questions and everyone, including the principals, were left to get on as best they could. At the same time an official group was established under the Cabinet Secretary (Robin Butler) consisting of the principal departments concerned (MAFF, DoH, FCO and Treasury) which theoretically met every day. Officially its remit was to service a new committee on BSE (again not designated as a formal Cabinet committee) also established on 22 May consisting of the Prime Minister, Rifkind and Hogg. I do not recollect this Ministerial committee meeting at least in this form. I was the normal MAFF representative on the Butler committee which did meet fairly often. Its main value proved to be helping in the avoidance of unpleasant surprises. Below that there were other committees on BSE also meeting daily checking on this and that. Certainly the few officials in MAFF67 responsible for devising policies and driving them forward spent a lot of time explaining things to others. The 30-months scheme As we saw earlier, by mid-June the scheme appeared to be operating effectively and throughput at over 25,000 animals per week was greater than the number believed to be available to come forward. Thus the backlog was believed to be diminishing though only slowly. Its precise magnitude was unclear. Throughput had reached the current level after only six weeks of operation and if it continued to improve the backlog would quickly be eliminated. That was the hope. Unfortunately this optimistic view was not borne out by events. Existing throughput represented about the maximum that could be delivered by existing

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plant and processes.68 Throughput stuck at significantly less than 30,000 animals per week for several weeks. Estimates of the size of the backlog put together by the NFU and others grew bigger and bigger. It soon began to be feared that at the current level of processing the backlog might not be decreasing at all – or might even be increasing. Partly because of speculation of this kind farmers became progressively more alarmed as summer was succeeded by autumn and winter. Their cause was taken up by the media and the perceived failure of the government to deal with the backlog became a major political issue. Cattle are large animals easily photographed and pictures of surplus animals with stories of how difficult and expensive it was to feed them became a regular feature of news items. One awkward difficulty Ministers faced was the indication John Major had given after Florence that the backlog would be eliminated ‘by October’. Naturally MAFF Ministers had felt obliged to take the same line in a Parliamentary debate a day or two later. As a result there were lots of Ministerial predictions, proved inaccurate in the event, that were used to taunt them as it became apparent this prediction was wrong. The existence of a backlog was a matter of genuine economic concern. From the time a farmer decides an animal had reached the end of its working life, when it would normally be slaughtered directly, that animal represents an economic burden on him or her since it has to be fed until slaughter capacity is available. As autumn and winter approach this point assumes greater significance. Cattle cannot normally graze over winter when grass stops growing. Farmers have to produce or buy in feed for those animals they expect to have on farm over winter. They would not aim to provide winter feed for animals they would plan to dispose of earlier; and if they do provide feed for extra animals this represents a straight economic loss. Concern over the size of the backlog reached its height in late autumn – just when these concerns over feed would be at their strongest. A scheme for part pre-payment of subsidy for cull animals based on proof of ownership reduced concerns somewhat but did not eliminate them. As the summer passed and there appeared to be no improvement in the situation – indeed many gave credence to the view that the backlog might be getting bigger – the NFU leadership, no doubt under heavy pressure from their membership, became increasingly critical of government. They were quoted as describing the situation as a ‘shambles’. Given the degree of public financial support farmers had received since the crisis began this seemed ungrateful. Such comments were certainly unhelpful for the government. In reality the situation was never as bad as many, including the NFU, claimed. It was always apparent to those who carefully examined the facts that the situation would be resolved well-before the winter was out. Nevertheless those farmers who could not dispose of unwanted stock faced genuine difficulties; it was even more worrying for them given the alarming figures for the backlog quoted by some. On the basis of the figures quoted some may have feared that they might have to feed redundant animals indefinitely. Rendering was the crucial bottleneck in the system, and here there were two difficulties. Existing capacity was insufficient to process both those animals

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slaughtered for human consumption and those slaughtered under the 30-months scheme while also rapidly eliminating the backlog. Plans were made by the companies concerned to expand capacity but it was known this would take months to come on stream. The second difficulty was that plant processing animals under the 30-months scheme experienced an unusual number of breakdowns. This was not surprising. Rendering whole carcasses had previously been a very rare occurrence, while under the 30-months scheme complete batches consisted of whole carcasses. Over time the operators learned how to adjust their normal processes to maximize efficiency when operating under the scheme, and by September sufficient experience had been gained to avoid these breakdowns. A concern of government, heightened by the difficulties in reducing the backlog, was that the financial terms of the scheme might be sufficiently attractive to encourage the presentation of animals which could otherwise be slaughtered at under 30 months for human consumption.69 If so public money was being wasted. An examination of individual cases suggested that there might be something in this concern though not as much as the Treasury suspected. However there was in any event a good case for reducing payment rates which were too favourable relative to the price of beef in the market. Thus the top up per kilogramme for clean cattle was reduced from 25p to 15p on 25 June, to 10p on 14 July, to 5p on 1 September and ended on 2 November. The rate per kilogramme for all other animals (mainly cull dairy cows) was reduced from 1 ecu to 0.9 ecu on 14 October. At about this time a change in the value of the green pound70 further reduced the returns under the scheme in sterling. These developments and measures eliminated any incentive to produce animals ‘for the subsidy’.71 After initial opposition from the Treasury, throughput under the scheme was also increased by hiring extra cold-storage space. Carcasses were stored until they could be rendered. This was, however, an expensive way of dealing with a relatively small part of the problem. A problem government faced was the wildly exaggerated figures confidently quoted for the size of the backlog, which gave weight to accusations that no progress was being made in reducing it.72 In an attempt to deal with this the government adopted a registration scheme. Producers were allowed to register animals which they wished to submit under the scheme on the basis that registered animals would be given priority in the queue. Even this gave an implausibly large number for the backlog. The extent of the backlog was consistently exaggerated as MAFF suspected at the time. The essential difficulty was that in order to obtain a good place in the queue for slaughter producers had every incentive to claim animals were part of the backlog before they were available for slaughter; and there was no sanction if they did so. Thus estimates were often based on the number of animals notified to slaughterhouses as available for slaughter, that is those in the queue. However, some producers notified the same animal to more than one slaughterhouse, and thus the same animal could be counted more than once when the animals notified to every individual slaughterhouse were added to give an overall total. Also animals could be notified

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before they were genuinely available – for example while they were still milking. No doubt farmers’ thinking in such cases was that the backlog appeared so large that by the time it came to their turn the animal would be available; but such action led to the backlog being estimated as being larger than it actually was. The government’s registration scheme probably also suffered from the latter form of exaggeration. When at last the backlog did go down it did so faster than it ought theoretically to have done because some of the animals registered were not presented for slaughter directly the opportunity offered. Culling rates under the scheme finally started to climb in September when the renderers began to solve the technical problems with which they had been bedevilled and new plant began to come on stream. At the same time the payment system was altered so that renderers could receive a bonus equivalent to some 30 per cent of the normal rate if they processed more than a given amount each week. Though it was not clear at the time, and sharp criticisms of the government based on the proposition that the backlog was not reducing continued for some weeks,73 it was in September that the problems of scheme throughput were solved. Throughput in the week of 7 October was nearly 40,000 animals, in that of 14 October 45,000 and in that of 21 October 53,000. At these levels the backlog was quickly diminishing. By 4 November throughput reached a maximum of 60,000. The problem was effectively solved but this was still not yet appreciated. The results of the government’s registration scheme gave a figure for the backlog of 328,000 on 8 November. The Treasury advocated further measures to reduce the attractiveness of the scheme which MAFF opposed. However, by the middle of November it was becoming difficult to sustain slaughter rates since sufficient registered cattle could not be found. In late November the obligation to slaughter registered cattle only was removed. Since the slaughter rate never went above 60,000 and at least 20,000 new animals came forward each week meaning that the backlog could only be reduced by 40,000 animals per week at an absolute maximum it became obvious that the 328,000 figure produced three weeks earlier had been a serious exaggeration as some of us had said at the time. From the latter half of November, because of the difficulty in finding sufficient animals to sustain the rate of slaughter, it became apparent to all that the backlog was much smaller than had been claimed a few days before and that it was rapidly diminishing. The crisis was over even in Northern Ireland which had experienced some of the worst difficulties. At the beginning of December it was reported to the Prime Minister that the backlog would be eliminated in every part of the UK wellbefore Christmas. Well-before then public attention had moved on and the subject had ceased to be of general interest. Nevertheless, the overall impression that most of the public gained from the media was undoubtedly that the scheme had been incompetently administered and that the difficulties over the backlog ought never to have arisen at least to the extent they did. The incompetence of the administration of the scheme is still occasionally referred to when commentators want to give examples of government failure. Is that judgement fair?

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Those who played a role in shaping policy at the time, like me, can point to a number of difficulties with which they had to cope. These include the fact that since marketing beef from animals over 30 months was banned several weeks before the scheme came into operation a substantial backlog was inevitable, the fact that more steers and heifers were marketed at over 30 months than anyone had realized, and the sheer logistical task of establishing a major new scheme from scratch. Any such arguments are, however, likely to be dismissed as special pleading. As it happens the very point at issue has been carefully examined by an independent organization expert in assessing such matters, which can be relied upon to apply an exacting standard to the work of all government bodies. I refer to the National Audit Office (NAO) which reports to Parliament on all government expenditure. Their report ‘BSE: The Cost of a Crisis’ was produced in July 1998. They state: The Ministry74 and the Board75 had to set up the scheme within a very short time and under extreme pressure, to meet urgent political worry and concern. In doing so they had to deal with problems arising from the large number of animals eligible for entry to the scheme and the insufficient capacity of rendering, incineration and storage facilities. The European Union Regulations came into effect on 29 April 1996 and the scheme was fully operational by early May 1996. By November 1996 the Board had increased the weekly slaughter rates from 25,000 to 60,000… The National Audit Office regard these as impressive results in the circumstances. (Summary, paras 6 and 7) The NAO is not an organization given to hyperbole especially when administering praise. While I cannot say it has never used the word ‘impressive’ before I have not noticed any other occasion when it has done so. The obvious conclusion is that the establishment of the scheme and the elimination of the backlog were well-done – probably very well-done. The public perception may be different but this, I suggest, reflects the views of a media for which it is axiomatic that anyone in an official capacity dealing with BSE must be a fool or a knave and probably both. NAO’s comments reflect only the evidence. It is only fair to add that the NAO go on to point out that the scheme was costly especially in the early stages when it was vital to get it off the ground. This is because there was no time for tendering which was obviously desirable in principle. Gradually, however, matters were put on a more realistic basis. Thus the fee for slaughtering a beast under the scheme was set at £87.50 initially and reduced in September to £41. Scientific comment: the article by Anderson and others In taking the story of the 30-months scheme up to the elimination of the backlog in December 1996 we have rather run ahead of ourselves. While, following the Florence Agreement in late June, the backlog was one of the major BSE issues it was

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by no means the only one. Over the holiday break policy-makers reflected on the way ahead. Hogg and I both came to pessimistic conclusions. The essential reason was that the public had been promised something76 – the early lifting of the ban – which would not happen. It was clear to us both that the Commission would not propose any significant lifting of the ban and that, in the unlikely event that they did, it would be opposed by most member states. While we were reflecting how best to deal with this awkwardness the position was complicated by the publication of an article on BSE in the prestigious journal Nature. The leading contributor was Roy Anderson FRS then a leading professor at Oxford. Anderson is one of those people who find it all too easy to arouse antagonisms. Since 1996 he has been obliged to move university following comments he made about other scientists and in 1996 his relations with some MAFF scientists and vets were poor. The more important fact, however, was that he is generally accepted to be the leading epidemiologist in the UK and perhaps more widely.77 Anderson’s paper78 coming from an authoritative source and being published in one of the world’s leading scientific journals commanded much interest. Attention focused on three points all of them awkward for the government. First he predicted that BSE would virtually have died away by 2001 even if existing policies remained unchanged – that is without a selective cull. Anderson also showed this date would be largely unaffected by any selective culling strategy and highlighted the very poor value for money any cull would achieve in terms of the slaughter of animals incubating BSE. What, therefore, commentators asked was the value of the cull? These were of course precisely the considerations that had made the government so reluctant to accept a commitment to institute a cull in the negotiations that led up to Florence. That the cull would be of dubious value was already understood by the public, but having the position set out authoritatively and clearly by an independent scientist made the position much more clear-cut. The overall effect on public and Parliamentary opinion was to make it more difficult to proceed with the cull, which was, following Florence, a legal obligation. Second, Anderson’s analysis of the data from a MAFF experiment the end of which had been rushed because of pressure from several sources led him to conclude that maternal transmission occurred for BSE as it had been reported to do for scrapie. This led to claims in the EU that the scope of the selective cull should be expanded to allow for maternal transmission. Later, when there was time for more reflection,79 the original conclusion that the experiment demonstrated the existence of maternal transmission was questioned since the data, which showed more BSE cases occurred in cattle whose mothers died of BSE than others, could not distinguish between maternal transmission and inherited genetic susceptibility. However, the likelihood of maternal transmission had by then registered in the minds of other member states whose predictable reaction was to argue that this development demonstrated the need for an extension of the selective cull. As will be seen, the effect of the Anderson paper was at the same time to lower support for a selective cull in the UK80 and to lead others to argue it should be extended.

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Third, Anderson calculated that hundreds of thousands of animals incubating BSE had entered the human-food chain since the beginning of the epidemic. This, too, came as a shock to public opinion though not to those working in the area who were well-aware by now that the rate of infection must have been climbing very steeply in the middle and late 1980s. September 1996: a reassessment of whether to proceed with the selective cull and the implications for the ban In September 1996 the reaction to the Anderson paper fed into the reconsideration within government of the merits of proceeding with the cull. In large measure this reassessment represented a rerun of the debate within government that had led to non-cooperation and the Florence Agreement. This earlier debate had been based on the assumption that securing a rapid lifting of the beef export ban had to be a principal objective of policy. That remained a view with many powerful adherents but over the summer it had come to be appreciated that the situation had changed in significant respects. First a greater sense of realism was spreading. Hogg and I consistently advised that the political reality was that whatever the merits the EU would not agree to any early (that is, 1996 and probably 1997) lifting of the ban. William Waldegrave (Chief Secretary) argued similarly. Some, (particularly the FCO) were initially reluctant to accept this, but eventually the UK Permanent Representative to the EU submitted formal advice which was virtually identical to MAFF’s position. As the days passed it came to be tacitly accepted that the MAFF position was realistic. Attention diverted onto the possibility of lifting the ban for ‘certified herds’, that is herds with no history of BSE. It was always clear that any such scheme would be of minimal economic importance and would initially be limited to Northern Ireland, though Michael Forsyth, Secretary of state for Scotland, renowned in government for trying to make water run uphill – or indeed for asserting it did run uphill – sought to argue that parts of Scotland could also qualify. Second, the legal position had changed. The Florence Agreement set out onerous and bureaucratic conditions for the lifting of the ban which had legal force but, as Hogg had pointed out to Major, lacked automaticity. Action to lift the ban depended on the Commission and the member states acting in line with the scientific evidence and in good faith. Neither could be guaranteed and in any case nobody outside the UK saw any need for haste. Third, the assessment within government of the Parliamentary mood and hence arithmetic was that the Regulations necessary to implement the cull could probably not secure a majority.81 On one view these considerations pointed to accepting that the ban could not be removed rapidly and abandoning the cull. The Anderson predictions could be used with some plausibility to justify such a course. There was a lot to be said for this line and it was the one advocated by MAFF. The advantages would be those of basing policy on a sound assessment of the realities rather than on make-believe, avoiding some Parliamentary difficulties (perhaps at the expense of others), saving

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money and, we suspected, avoiding the blame being placed on MAFF when the cull was seen not to be followed by the lifting of the ban. There was, however, also a case for proceeding differently. This was that the Florence Agreement represented a legal commitment which it would be wrong to disregard; arguably refusing to go ahead with the cull would cause relations with the EU to deteriorate again.82 Farmers were now strong advocates of going ahead with the cull and this was reflected in the attitude of the Secretaries of State for Northern Ireland and Scotland. However, this position was based on the unrealistic83 assumption that a cull would be followed shortly by the lifting of the ban. However, the most significant reason for going ahead according to Florence was never explicitly stated. This was that the Prime Minister had gone out on a limb over it, extolling its virtues to an extent that would make it difficult to change course in a matter of weeks. Accordingly, while the first option seemed to have the better arguments and more sympathy the second was the strategy eventually decided upon though only after much agonizing. Thus there were numerous meetings of UK Ministers, and of UK Ministers and officials with the Commission. Decisions taken were altered shortly thereafter. On 19 September, following exhaustive examination of all the options it was announced, following a meeting chaired by the Prime Minister, that the UK would not be proceeding with the cull. On 14 November this policy was reversed though it took further weeks to face down continuing Scottish opposition to proceeding with the submission to Brussels of a proposal for a Certified Herd Scheme, (because it would only benefit Northern Ireland). No decisions on lifting the ban were taken in the lifetime of the Conservative government. The cull eventually got underway during 1997 and eventually 75,858 animals were slaughtered at a cost of over £120 million. Rarely can such an amount have been spent on a policy that those formally responsible for it regarded as worthless. Other issues: (a) the feed-recall scheme (b) BSE and sheep; (c) cattle traceability; (d) the European Parliament’s Committee of Enquiry The feed-recall scheme One of SEAC’s recommendations in response to their finding that BSE had proved transmissible to humans was that MBM should not be fed to any farm animal. In response to that MAFF had decided to invite all farmers and others who had or suspected they might have had MBM on their premises to give any contaminated supplies to government (which would then destroy them). The concept was to remove any residual source of BSE infectivity on farms or feedmills. This feed-recall scheme was included in the Florence conditions though, since the idea was a UK one it was not controversial. It was completed by 1 August 1996.84 BSE and sheep From the time of Southwood there had been concern that sheep might be harbouring BSE and hence pose a risk to the public. This was because in the 1980s

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sheep feed had sometimes included MBM (though less was fed to sheep than to cattle) and it was known that sheep were susceptible to BSE. It was quite likely, therefore, that at some stage sheep had been infected with BSE. The really worrying factor was that in sheep it was conceivable that BSE would behave like scrapie; and it was believed that scrapie sustained itself in sheep populations by maternal transmission and perhaps by some other unknown mechanism. Hence if BSE had infected sheep in the past it might still be present in current flocks. All this had been appreciated by those working in the field for a long time, though in the absence of any evidence that BSE was present in commercial flocks SEAC had never recommended any precautionary measures. However, they revisited the question in July 1996 in the light of their findings on transmissibility. By this time it was known that scrapie could be detected in more organs in sheep than was BSE in cattle. Again the cautious assumption would be that BSE if present in sheep would be found in all the organs in which scrapie could be detected. The difficulty was that a really rigorous approach, which would involve excluding from the human-food chain all sheep organs in which scrapie had been detected, would make the commercial production of sheepmeat close to impossible. After wrestling with these contradictory factors, SEAC recommended simply that the heads of animals over one year of age should be excluded from the food chain. This would protect the population from any infected brains. SEAC acknowledged that their recommendation was a somewhat uneasy compromise between the desire to protect the public from a small chance of a big risk and the desire not to ruin an industry, probably unnecessarily. To complicate matters further the French had established their own committee equivalent to SEAC and, virtually simultaneously, this also recommended action on sheep – but, true to form, slightly different action. This led to a delay in putting SEAC’s recommendations into force while attempts were made to find a common way forward.85 Meanwhile Whitehall in general and Downing Street in particular was very jumpy indeed about the possibility that when the public heard of SEAC’s advice there would be an adverse consumer reaction which would have the same disastrous effects on the sheep sector as had already occurred for beef – and lead to equivalent costs. In fact the concerns in Whitehall proved to be misplaced. SEAC’s recommendation was made public on 24 July. Everyone held their breath – and nothing happened. There was no catastrophic fall in sheepmeat consumption or prices. Consumers simply did not react as all had feared and most had expected. Since it proved impossible to find a way forward which the UK and France could accept a UK Regulation implementing SEAC’s recommendation was adopted on 15 September. Again nothing happened. The same thing (did not) happen subsequently when fears were again raised about BSE and sheep. While the risk from BSE in sheep remains theoretical the public, it seems, refuses to be alarmed.86 Occasions such as this87 make me highly suspicious of claims that with enough foresight and effort consumer reactions can be accurately predicted and appropriate precautions taken to mitigate the effects. Public reactions simply cannot be predicted with sufficient certainty.

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Cattle identification and traceability Florence required the UK to adopt an effective cattle identification and movement recording system.88 The owners of cattle were already legally obliged to affix numbered eartags to them soon after birth and to record all cattle movements on and off their holdings, but experience showed that this was not sufficient to allow an accurate history to be constructed quickly for all animals. Something more was needed. As a first step all cattle born after 1 July 1996 were obliged to be issued with a passport which would travel with the animal until death. Obviously over time all animals would come to have passports. While this was useful it was, however, not enough even in respect of animals which had been issued with passports. If the authorities were to be able to respond quickly to any future event what was needed was a computerized system which could provide information on where an infected animal had been instantaneously. Also there were fears that some in Europe might use the absence of a computerized system89 as an excuse to delay steps on lifting the ban. As a consequence there was a lot of pressure especially from Downing Street to put a computerized system in place quickly. Accordingly, in July 1996 we asked a well-known firm of consultants to advise on how to take matters forward. In September they recommended that a system could be put in place by February 1997, which was what Downing Street was known to favour. I chaired the large meeting at which this conclusion was presented by what seemed to be a teenage IT expert.90 I was conscious of two feelings. The first was that I had no basis of technical knowledge on which to judge what was being presented. The second was that, notwithstanding the first feeling, I suspected what I was being told was wildly optimistic; and that if we went ahead accordingly we would come a resounding cropper. I was conscious that government had a poor record when it came to putting in place large IT projects to time and within budget. This suggested that taking an optimistic view of what could be achieved would not be wise. When the consultants had withdrawn from the room I told those present that I was disposed to recommend to Ministers that because the consultants’ advice was seriously overoptimistic they should not accept it. To my surprise nobody demurred. Normally there is someone who insists on taking an optimistic view, especially if any failure to deliver will not be held at their door, but not on this occasion. I put forward advice accordingly which Hogg accepted. As we will see in the next chapter, starting in September 1996 and proceeding as quickly as possible with a dedicated team (and dedicated consultants) we just managed to launch a computerized movement service successfully in September 1998. The chances of launching the service successfully in February 1997 as the consultants advised us was possible and as Downing Street wished would have been close to zero. I sometimes wonder whether some of the catastrophic failures of government IT projects might have been avoided if the Permanent Secretaries concerned had been more sceptical about recommendations put forward by teenage experts and had been more prepared to disappoint their Ministers.

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The European Parliament’s Temporary Committee of Enquiry The European Parliament is an institution that has so far not inspired the UK public’s imagination. However, its powers have been steadily increased over the years. A principal motive in this development has been to reduce the perceived democratic deficit in the EU institutions as a whole.91 The BSE crisis followed shortly after agreement on the Maastricht Treaty which gave the Parliament new powers. Specific provision was made for Temporary Committees of Enquiry and member states explicitly undertook to cooperate with them. Accordingly it was inevitable that soon after the crisis broke the Parliament should vote to establish such a Committee to investigate matters. It rapidly became apparent from its hearings that the attitude of the majority of its members might best be described as McCarthyite. It was taken as axiomatic that everything that had happened had been someone’s fault and that their intentions had been malign; that blame lay with the UK government and with the EU Commission; and that the Committee’s main task was to put together evidence to support these ‘facts’. They proceeded accordingly with gusto. Naturally the Committee wished to question the UK. The Treaty mentioned the possibility of Ministers appearing but did not oblige member states to make them available. It was apparent that any UK representative appearing before the Committee would be roasted and understandably Hogg did not fancy the prospect. He replied to the effect that the UK would make me available. The Committee made a great fuss about this, insisting the Treaty required Ministers to appear despite the absolutely clear wording of the relevant articles. All this was just about the worst preparation for the Hearing in Brussels on 8 October 1996. It could confidently be predicted proceedings would be hostile, though there was some hope Committee members might be slightly less-inclined to be difficult with me than they would have been with Hogg, if only because they would be less likely to get themselves into the newspapers as a result. I concluded that the best course would be to accept that some small share of blame for the BSE crisis lay with the UK in that before 20 March 1996 the enforcement arrangements had not been adequate to ensure that the SBO controls were 100 per cent applied nor that cross-contamination did not occur in feedmills.92 However, beyond that limited acknowledgement I would resist or reject claims about UK culpability pointing out that we had throughout acted in line with independent scientific advice and put all facts into the public domain. Hogg agreed this strategy, which I stuck to resolutely in the face of sustained hostile questioning. I said that it did not follow that because there had been an unhappy development then someone must be to blame for it. Most members seemed to have difficulty with that to me entirely reasonable concept. At one point I likened the outbreak to an ‘Act of God’,93 meaning to imply that no persons were responsible for it. Some members of the committee professed to be shocked at the mention of ‘God’. I apologized for offending the susceptibilities of any atheists but I do not think the point survived translation. Afterwards I had the impression of having done fairly well in difficult circumstances. Lord Plumb, who was of course a UK Conservative and had been

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the only member of the committee not to adopt a hostile stance, kindly passed me a note of congratulation on keeping my temper under severe provocation. That was, however, the last positive development. As part of his – doomed94 – campaign to ensure that the ban was lifted in Scotland as soon as it was in Northern Ireland, Michael Forsyth, the Secretary of State, complained to the Prime Minister about a remark I had made at the Committee meeting about the prospects for lifting the ban. This was in reality a sideswipe at Hogg about whose statements on the subject he also complained. In fact it was Forsyth whose statements were out of line with government policy, though given Conservative paranoia about the political situation in Scotland95 he was allowed more scope to depart from agreed policy than anybody else. The Report in the Suddeutscher Zeitung was more surprising. When I got the translation a few weeks later I saw the headline had picked up (unsympathetically) my reference to an Act of God. I was described as answering questions ‘cowering’ behind a pile of files. ‘Cowering’ is not in my nature nor do I think that the Committee members would have described my performance in that way. They would have been more likely to comment that given the facts less self-confidence on my part may have been in order. The giveaway was the reference to a pile of files. In line with my standard practice for Parliamentary Committees I had had before me my opening remarks and a few blank sheets of paper on which to take note of questions, that is a total of a dozen sheets at most. I had no files. The reporter had either not been present at the meeting or had submitted copy in line with what was expected by his editor and/or readership. The Committee’s Report was, as expected, heavily critical of the UK and Commission. Like virtually all emanations from the European Parliament it made little direct impact in the UK. However, there was a significant indirect effect. The Commission was very sensitive to Parliamentary criticism and I am sure the suggestions in the Report that they had throughout the epidemic been too easy on the UK made them more difficult in future especially in relation to lifting the ban. Since progress on this could not be made without active Commission help this was a major negative development. The vCJD epidemic In September 1996 I had a meeting with John Pattison, SEAC Chairman, in his office in University College Hospital where he was dean of the medical school. Pattison was contemplating the fact that since the 20 March announcement no further cases of vCJD had come to light. This was unexpected since at the start of an epidemic cases would be expected to be identified with increasing regularity. Perhaps, Pattison mused, there would be few further cases or even none at all. The subtext was, of course, that if no or very few further cases were found then all the fuss, cost, and economic and political disruption following the 20 March announcement had, arguably, been unnecessary. Pattison knew enough of life to know that if matters developed in that way then the likelihood was that he would be subject to heavy public criticism from which he would probably never recover professionally. Contemplating this possibility Pattison was impressively sanguine.

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His attitude was that as SEAC Chairman he had done his professional best for the public interest on the basis of the evidence available. That would remain true even if matters turned out unexpectedly. In the event new vCJD cases were identified shortly afterwards and a steady stream of others continued to be identified until the end of the Conservative government, although the epidemic never accelerated to the extent some had suggested it might. Later in the autumn clever work by Collinge, a SEAC member, showed that some chemical tests could distinguish between vCJD and some strains of scrapie but not between vCJD and BSE. This made it more likely that the same agent was involved in vCJD and BSE. Thus, though for a few days it had seemed the crisis might go away and it might even seem that much of the fuss had been unnecessary, it was clear this was not the case when the Conservatives left office. Progress on lifting the ban The single most important aspect of the BSE crisis was obviously the extent of the vCJD epidemic. However, the export ban received every bit as much publicity partly because the government itself had made such an issue of the matter and partly no doubt because it was a matter where political action could affect what happened. The Florence Agreement specified the hurdles that had to be cleared. Any lifting of the ban could only be made if the Commission were actively to support it and they were highly nervous. They had to be completely satisfied on each and every point of detail before a proposal could move to the next stage.96 For some weeks, however, progress was held up by the wrangle within the UK government as to whether the ‘Certified Herds’ scheme (CHS) on which effort was being expended was to be limited to Northern Ireland in the first instance or should include Scotland also as Forsyth wanted. Major tried to find forms of words which would satisfy everyone by dextrous use of language but such an approach was misplaced in this instance. Ambiguity could not be helpful since if matters were to move forward the Commission had to know where the scheme would apply and if it went outside Northern Ireland they would not accept it. Proposals for a scheme were announced on 16 December 1996, but supporting papers were only formally submitted to the Commission on 25 February 1997. Essentially the scheme was designed to be limited to herds which had never had a case of BSE. As the Commission examined minutely every aspect of the scheme over the coming weeks and demanded more stringent safeguards it became ever more apparent that the economic benefits of the scheme if and when it was agreed would be minimal. Decisions were, however, still some way away at the time of the General Election. The position in Spring 1997 At the General Election matters stood as follows. BSE itself was apparently on the way to extinction as a result of the measures taken from 1988. The number of BSE suspects restricted each week, which had reached 850 in the winter of 1992/93, and had numbered between 200 and 400 as

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late as 1995 had declined to under 100. A better indication of the effectiveness of the measures in force at the time (Spring 1997) is given by the number of cases of BSE listed by month of birth. In early 1987, at the peak of the epidemic, this had reached over 8,000 per month. By the latter half of 1995 this figure had reduced to under 100. As of 1 January 2004, by which time almost all animals harbouring the disease will have succumbed, animals born in 1997 and have been confirmed as having BSE do not exceed five in any month (see Figure 4.2). vCJD was an established reality though it had not become the runaway epidemic some had feared; since 20 March 1996 the case for linking it to exposure to BSE had strengthened. The 30-months scheme was running effectively and the MHS was rigorously and in the main effectively enforcing the SBO rules in slaughterhouses. A protective regime for sheep had been introduced without the feared economic disruption. All the other, lesser measures recommended by SEAC had been put in place. The export ban was, however, still in place and it had become apparent that securing any lifting of it would be a very laborious process and obtain only a small economic benefit. Expectations were different and that represented a threat for the future. Nevertheless, thankfully the political prominence of the issue had decreased significantly. The crisis had undoubtedly damaged the reputation of those associated with it including Hogg and Dorrell and, among institutions, MAFF. Perspectives would alter somewhat when the BSE Inquiry reported over three years later but by then attitudes had hardened to an extent that made them difficult to change even on the basis of new evidence. Did the crisis do the government significant harm? On that views will vary. It is clear BSE did not lose the 1997 election for the Tories. By March 1996 they were a long way behind in the polls. A major contributory factor had been the debacle over the ERM in 1992. Even worse the constant party rows, especially over Europe, gave an impression of a house divided against itself. Attempts by the party management to deal with this insubordination veered, like that of a weak teacher faced with classroom disruption, between indulgence and overreaction. By comparison Labour under Tony Blair looked fresh and united. Change was inevitable. Given that assessment, did BSE make the scale of defeat bigger? My answer would be possibly a little bit. The BSE-related rows with Europe, the party splits and the indecision and apparent lack of grip manifested in dealing with the crisis will have had some effect on voters as will the allegations, albeit unfounded, that ‘deregulation’ was to blame and that public health had been subordinated to economic considerations. Notes 1 My diary records my attendance at seven. I was in Brussels and Luxemburg for much of the time. 2 This reliance on unformulated ad hoc arrangements has continued, and possibly grown more pronounced, under the Blair government as the Hutton Enquiry has heard. Whether this is a good or bad thing will be for historians to decide. However, an informal undisciplined approach could only work (if at all) if the Prime Minister is a massively dominant figure in the government; Major was not.

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3 There was plenty of scope for retaliation, for example by leaking the fact that measures for which Hogg was being blamed had support from his colleagues and on occasion had been proposed by them. 4 Note that I am asserting only that it was obvious at the time (March 1996) that SEAC would give such advice since had they thought the contrary they would have advised to that effect on or before 20 March. I am not asserting such a view is necessarily correct. vCJD is still a disease of young people and this must have an explanation. One possible explanation is enhanced susceptibility in young people. The issue is unresolved. 5 Public reaction was, however, volatile and on occasion scarcely rational. Thus when the supermarket, Sainsbury’s, attempted to dispose of its (by then) excessive stocks of beef via a one-day campaign on 30 March they reduced prices to roughly half their normal level. Public reaction was startling – all beef stocks were sold in all stores, which took everyone aback including Sainsbury’s and government. Those, such as the BSE Inquiry, who suggest a government reaction to the crisis could have been planned in detail beforehand could usefully reflect on such an unpredicted (and, I suggest, unpredictable) outcome. 6 The grand title for this is Queuing Theory. A more familiar manifestation is that a relatively small increase in the number of cars on the road can lead to periods of stationary traffic. 7 There were extensive exports and imports of different qualities of meat but the volumes were approximately equal. 8 In practice only specified parts of specified qualities of male animals are purchased. 9 Traditionally the UK is decidedly unenthusiastic about intervention especially for beef since the product is frozen which destroys much of the value. However, we were in extraordinary times. 10 Aside from the case of breeding bulls 30 months was regarded as the normal maximum age for beasts raised for beef rather than milk. The BSE crisis showed that more beef animals were slaughtered at between 30 and 40 months than most people (including the NFU) had realized. 11 On 25 March the President of the IGD (Tom Vyner of Sainsbury’s) and the President of the NFU pressed this on Hogg. The same day the President of the NFU and the President of the Food and Drink Federation pressed me on the same point at a prearranged meeting. A couple of days later the Prime Minister was being lobbied. 12 McDonalds was one such. 13 This, however, assumes a market could be found for beef from older animals which was highly doubtful. 14 This certainly proved to be the case. In 2003 the scheme was still in operation and according to the Food Standards Agency was on best calculations saving much less than 0.1 life a year at a cost of £400 million. Spending over £4 billion a year on the NHS or road safety would save vastly more than 1 life. As I revise this chapter the scheme is expected to end in November 2005. 15 Strictly two subsidies for slaughterhouses were established and announced in the same statement. One was intended as compensation for MHS inspection charges though, since we were advised exempting operators from these levies was illegal in EU and UK law, a roundabout mechanism was adopted. The main text above refers to yet another subsidy. 16 The subsidy for removing surplus stock from slaughterhouses eventually cost £56 million according to the Report by the Comptroller and Auditor General, BSE: The Cost of a Crisis, Stationery Office, 1998, page 57. 17 My description of any significant row in the EU, especially one between the UK and the EU institutions and/or other member states. Euro-rows are not limited to disputes about the European currency. 18 Exports of adult cattle from the UK had been banned since 1990.

The Period of Conservative Government to 1 May 1997 203 19 The German Agriculture Minister, Borchert, remarked to us resignedly that the Germans were at least champions of the world in one sport – hysteria. 20 The Commission’s explanation was that the ban on exports to third countries was necessary to prevent diversion to the EU of product exported from the UK. This did not wash. There are standard EU mechanisms in many product areas to prevent trade diversion especially where subsidies differ on exports to different destinations. Further, the point remains that if the product was deemed safe for UK consumers it must have been safe for others. 21 The voting arrangements for EU committees are highly complex and take several slightly different forms. The Commission can in some circumstances adopt proposals that have not secured a qualified majority in the SVC but are reluctant to do so. The further away a proposal is from securing a qualified majority the more reluctant the Commission is to adopt it. 22 The point is that the inclusion of an expiry date would have required the Commission to bring forward before then a new proposal which could include changes to the expiring version for which it would have been very difficult to secure support by way of a specific amendment. 23 In fact since the formal entry negotiations started in 1970 the EU has been unpopular with large sections of Labour at least as often and as strongly as with the Conservatives. Despite Mrs Thatcher’s anti-EU reputation the Conservatives have never advocated withdrawal from the EU in an Election manifesto as Labour did in 1983. However, party tensions are heightened in government especially in one with a small majority. 24 The traditional UK system does not provide for cabinets, members of which especially the chef, can speak for their boss with authority including political authority that private secretaries in a UK minister’s office cannot. That said, arguably Jonathon Powell fills a role for Tony Blair very similar to that of a chef. 25 A former MAFF civil servant. In the early 1970s he and I had negotiated with the Commission the detailed conditions for UK accession to the Community’s market organization for milk. 26 He met his wife when they were both on a language course in Reading. 27 A more cynical view also has much to commend it. Once a targeted slaughter policy had been accepted as a component of a BSE plan it was an easy step to suggest that the lifting of the ban should await its completion. Drawing up a detailed plan for targeted slaughtering, identifying the animals concerned and carrying out the slaughtering and disposal would necessarily take several months at least. This would take the actual lifting of the ban off the agenda for this period much to the Commission’s relief. 28 The Treasury way of looking at matters is undoubtedly mathematically correct. I have, however, argued elsewhere that it is not the only valid way since it assumes the continuation of the present UK rebate indefinitely. 29 For example on aid for slaughterhouses. 30 Although the 30-months scheme did not come into effect until the end of April, no cattle over 30 months had been marketed since the announcement of 20 March because there was no demand for meat from such animals. 31 The great bulk of animals to be processed under the scheme were expected to be dairy cows which live on average to about 4 or 5 years old. In addition, breeding bulls were always expected to be covered. There were initially a surprising number of other animals (steers and heifers) processed for reasons discussed below. 32 The importance of this point should not be overlooked. The main retail chains continued to support British beef when others, such as burger chains, had abandoned UK beef entirely. 33 The Minister of Agriculture, Fisheries and Food and the Secretaries of State for Northern Ireland, Scotland and Wales. 34 This attitude was not limited to the public. The Cabinet Secretary. Sir Robin Butler, made the same assumptions. When I replied to criticisms he directed at me about the lack of

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The Politics of BSE speed in getting the scheme running by pointing out, inter alia, that IBEA had lead responsibility and I had no authority to give instructions to their staff, he brushed this aside as a trifling detail. I thought this rather ignored his own role. In so far as the structure of government was a matter for officials it was his responsibility. The IBEA set-up was not satisfactory and later I proposed a review which led, eventually, to its being absorbed into MAFF. Which included ease of access to the Minister of Agriculture who was primus inter pares among IBEA’s Ministers and perhaps the fact that many senior IBEA staff originated in MAFF. The relevant EU regulation required ‘destruction’ of the material. This meant the only practical option was incineration. Pent-up demand was inevitable because animals over 30 months could not be slaughtered until the carcasses could be processed. Animals that had completed their working lives had to be fed and were thus a financial burden until slaughtered. Virtually no animals over 30 months had been slaughtered since 20 March. 29 April was the starting date specified in the EU Commission Regulation providing for part EU financing for the scheme. An ecu was a notional EU currency reflecting the value of a basket of currencies of EU member states. It was replaced by the euro which, initially, was also a notional currency. A ‘Direction’ from a Minister (in practice always a Cabinet Minister) requires a Permanent Secretary to undertake a policy which the latter has formally advised the Minister (s)he regards as unjustified normally because it does not give value for money. See pp. 4–5ff. Their attitude was, therefore, idealistic rather than the cynical one with which politicians are often charged. They were, however, rarely accused of excessive idealism. As Machiavelli had pointed out centuries before. They had to do so since had they regarded UK beef as unsafe they would have had no satisfactory answer to the question why they had not banned its marketing in the UK also. That is all animals born in the same calving season. The justification was that infection with BSE was believed often to occur in the first few months of life. Hence if one calf became infected it was likely other calves in that cohort had also been exposed to infection. This scheme (very similar to the one eventually adopted) was calculated to have a slightly better cost/benefit ratio than those previously considered but there was still no enthusiasm for it. Thereby minimizing the negotiating benefits of accepting the concept. In 1995 UK exports of cattle and beef were valued at £675 million. Exports of gelatine, tallow and bovine semen were valued at £38 million. A proportion of the tallow and gelatine will have been of non-bovine origin (Information supplied by Food From Britain). There were also convincing accounts of strong German lobbying against any change to the Commission regulation. The Chancellor (Kenneth Clarke) said to me very soon afterwards in an aside at one of the frequent Ministerial meetings on BSE, that he ‘suspected his view on noncooperation was the same as mine’. Presumably for tactical reasons he had felt obliged to acquiesce probably by silence. The basis for this severe judgement is given below. Some commentators made much of the precedent of the French when in the early 1960s they blocked common market (as it then was) work for months. But the analogy is invalid. In the early 1960s ‘EU’ responsibilities had been extended to only a small fraction of those effective in 1996. Thus the economic and political damage caused then by total non-cooperation was much less. It is significant that an attempt by Peter Walker when Minister of Agriculture in the early 1980s to use the veto to achieve ends strongly opposed by most other member states

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(a reduction in farm prices) had been brushed aside with the connivance of the French, then supposedly the most in favour of protecting a national veto on EU policy. It was suggested afterwards that the production of the UK Eradication Plan was the vital factor. I did not find that convincing. Rather I formed the view at the lengthy bilateral we had with the Spanish Minister (Palacio) that she regarded the ban as disproportionate all things considered – and voted accordingly. She was sharply criticized domestically for doing so. It was already clear that any general agreement to lift the ban would need to take the form of a series of steps (e.g. calves born after a given date or meat from animals of a specific status), each step triggered by defined criteria. Communicating with the ‘roadshow’ (as Whitehall called it) added a touch of welcome humour to a grim subject. The FCO secretary with Rifkind used as the cover sheet for faxes etc a picture of a contented looking cow with the message ‘On the hoof with the roadshow’. As the price of their agreement to the text the Commission demanded the addition to the selective cull of a further year class (1989/90) of cohorts from which, where the facts justified it, animals would be slaughtered. This presented technical problems since relevant farm records only became obligatory in autumn 1989 and was opposed by the NFU. The nature of the selective cull caused political agonizing at a level which now seems extraordinary. The European Council makes agreements, sometimes of great significance, but cannot adopt legal texts. These were (i) a selective cull to include also an extra year class; (ii) the introduction of an effective animal identification and movement recording system; (iii) legislation for the removal of meat and bone meal from feedmills and farms and subsequent cleansing of the premises and equipment concerned; (iv) effective implementation of the over-30months rule including the destruction of the animal; (v) improved methods for removing SBO from carcasses. Freeman had been given particular responsibilities on BSE on 22 May (see below). Prodi (Prime Minister) and Dini (Foreign Minister) both had a good grasp of the facts and worked tirelessly for a settlement. Robin Butler reproved me for ‘allowing’ Hogg to send such a letter. I thought this was inappropriate and unreasonable. First, what Hogg wrote was accurate and I could not and cannot see that the process of government is enhanced by pretending things are other than as they are. Second, in the event Hogg had consulted me on the draft (which unusually he had prepared himself) and I had cautioned him about sending it on the grounds that it was not what Major would want to hear, though I had to agree that on substance it was right. Hogg decided to send it. Butler may have been misled by the fact that Hogg was known to accept my advice on many issues to assume that he always did so. This was untrue. Especially on issues he judged to be very important, while he always listened carefully to advice, Hogg came to his own conclusions. Compare the later incident involving Tony Blair (see pp. 222–6). It should be borne in mind that other countries with which the UK has important relations, e.g. USA and Australia, had banned beef imports from the UK for far longer than the EU. If this last assessment is correct (that the ban would have been gradually lifted on much the same timetable even without the Florence Agreement) then the selective cull was unnecessary. Of course as the UK government played matters the Florence Agreement was necessary to justify stopping non-cooperation. The feed-recall scheme was a UK suggestion in the first instance, but was also specified in the Florence text. This is the best description since it was not constituted as a formal Cabinet committee. Indeed the absence of such formal committees was a noticeable feature of the BSE crisis. This lack was probably a mistake since informal gatherings with undefined memberships

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The Politics of BSE are less easy to control. It must be recalled that some members of the government appeared not to put its success at the front of their objectives. In fact for BSE work he had one private secretary (provided by MAFF). As Hogg commented to the BSE Inquiry, it astonished him how lean the top structure was in MAFF compared to the other departments of which he had experience (FCO and DTI). This probably reflected successive waves of budgetary cuts over many years. It was mainly the suspicion that this would prove to be the case that led me to be cautious, rightly as it turned out, in reply to John Major. This was why I had opposed a top-up at 30p or 25p/kg. The rate used to change ecus (in which EU prices and subsidies were defined) into sterling. By this I mean an incentive for anyone calculating rationally. There continued to be anecdotal evidence of animals submitted under the scheme ‘unnecessarily’. However, this became rare. All these reductions in returns available under the scheme were attacked by the NFU especially the reduction to 0.9 ecu. Thus the NFU were at the same time sharply criticizing government for not reducing the backlog and for action designed to reduce it. For example at the end of May one farming organization estimated the figure to be close to 600,000. For example Hogg was subjected to hostility and abuse on account of the backlog at the South-West Dairy Show on 2 October. MAFF. IBEA. Though the precise wording of what Major had said allowed some scope for argument this is undoubtedly what he was generally regarded as having promised. He also formed part of a group based in the Oxford biology departments other leading members of which included Sir Bob May, then Government Chief Scientist and later President of the Royal Society, Sir Aaron Klug, then President of the Royal Society, and Sir John Krebs later Chairman of the Food Standards Agency. Sir Richard Southwood (of the Southwood Report) came from the same department. Members of this group surpassed others in terms of ability and cohesiveness. They constantly sang each others’ praises and recommended each other for appointments no doubt in line with genuine scientific merit. Inevitably, however, those outside this circle sometimes took a jaundiced view of this mutual back-scratching. R.M. Anderson et al, Transmission dynamics and epidemiology of BSE in British cattle, Nature, Vol 382, P 779–788. When pressed by Robin Butler and Bob May to bring the analysis forward I had said rush was always bad for science. However, this view was not accepted. More strictly in circles concerned with likely outcomes and value for money. This did not include the Farmers’ Unions. Now that at least starting a selective cull had been defined in the Florence Agreement as a necessary preliminary to any further lifting of the ban they were as strongly in favour of it as they had previously been opposed. This was probably true in September though over time the altered position of the Farmers’ Unions (see the previous note) brought about a change in a sufficient number to allow them to pass. Though when sounded out the Commission were privately more sympathetic to the possibility of the UK postponing the cull indefinitely than might have been expected. This was probably because they shared our assessment of the likely attitude of others. Except perhaps in the case of Northern Ireland. The scheme also involved the rigorous disinfecting of relevant equipment. Given the tenacity of the BSE agent this was very necessary. This was both desirable in principle and a practical matter since a substantial proportion of UK sheep were exported to France.

The Period of Conservative Government to 1 May 1997 207 86 Nevertheless this might not be sufficient to prevent accusations that the public had not been properly protected if ever it were discovered that BSE was indeed present in the UK sheep flock. 87 And the case of beef on the bone discussed in the next chapter. 88 Soon this requirement was extended to all member states partly because it became clear none were clear of BSE. 89 Computerized cattle-tracing systems existed in some member states and in Northern Ireland. 90 No doubt he was older in reality. I describe impressions. 91 For example historically EU legislation is mainly determined by the Council of Ministers, that is national governments, and/or the EU Commission rather than by a legislature. 92 Of course I was conscious that enforcement of these rules was the responsibility of local authorities but judged this would not interest members who would consider it was for the UK to ensure that its system of enforcement was adequate. 93 As the preceding chapters show, this was more or less the later conclusion of the BSE Inquiry. No single action had led to the outbreak, still less one which should be the object of reproach. However, most members of the committee preferred to assume adverse outcomes must imply culpability on someone’s part. 94 Doomed because the facts pointed to a conclusion other than the one Forsyth wanted. The prevalence of BSE was significantly less in Northern Ireland than in Scotland; it was easier to control imports from elsewhere in the UK into Northern Ireland; Northern Ireland already operated a computerized cattle-tracking system; and the Irish Presidency of the EU were active in pursuing a concession for Northern Ireland, partly because it was objectively justified and partly for wider political reasons. True to form Forsyth wanted water to flow uphill. 95 Perhaps justified by the fact that at the 1997 Election all Scottish Tories lost their seats. 96 A strong case can be made to the effect that this attitude was wrong. A vital principle of the EU is that trade can only be hindered for essential reasons. The Commission and everyone else were happy that UK beef could safely to be eaten by 58 million UK consumers. Articles were already appearing in the academic press pointing out that the incidence of BSE outside the UK was increasing and was probably understated. Yet most member states did not operate measures to protect the public comparable to the UK SBO ban. In such circumstances concentrating on the minute detail of the position in the UK was arguably misplaced and a better balanced approach would have put less emphasis on the detail of controls on UK exports and more on the need for controls elsewhere. However, this was not how majority EU opinion saw matters.

9 Events after 20 March 1996: (B) The Labour Government from 1 May 1997 Onwards

The period up to the election For a Permanent Secretary there are two ways of judging the likely policies of an incoming administration, namely via scrutiny of the manifesto and via the personal contacts that the Prime Minister traditionally authorizes with Opposition spokesmen before a General Election. So far as the manifesto was concerned two sentences were relevant. They read: Labour will establish an independent food standards agency. The £3.5 billion BSE crisis and the E coli outbreak which resulted in serious loss of life, have made unanswerable the case for the independent agency we have proposed. As it happens this proved to be an accurate indicator of how Labour would perform – very good at least initially at judging the public mood but less impressive when it came to constructing a coherent argument. The same facts, notably the BSE crisis, which in the UK led eventually to the creation of a Food Standards Agency led the Germans to move in the opposite direction and bring responsibility for agriculture and health closer together. The Germans, apparently, did not see the case for an independent agency as ‘unanswerable’. Gavin Strang, the Opposition spokesman, came to see me several times before the election under the remit agreed between John Major and Tony Blair. These meetings went off successfully in part because he and I had known each other since he had been a junior MAFF Minister and I was Principal Private Secretary to John Silkin in the late 1970s. When Labour won the Election he was one of the very few who had any previous Ministerial experience which in his case had been extensive. Not that this did him much good. Before long the Number-10 spin machine was briefing against him. He lasted less than a year in office.

After the election But he was not appointed to MAFF. The new Minister, as unexpected to him as it was to everybody else, turned out to be Jack Cunningham. He, too, was a member 208

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of the old guard having been Parliamentary Private Secretary to Jim Callaghan when he was Prime Minister. He was another of the few with Ministerial experience and had held Shadow Cabinet positions for many years. Cunningham appreciated a good dinner and on such occasions he sometimes lamented that Labour had been in Opposition throughout what had probably been his best years in large part because of its own follies.1 That is to look ahead. When he arrived, obviously somewhat taken aback by his appointment, he said the Prime Minister had given him two priority tasks, to establish a Food Standards Agency and to get the beef ban lifted. Here we are concerned with the latter objective the concentration on which did not augur well. At this stage Blair was granted superhero status not only within the Labour Party but also by the media. By putting matters to Cunningham, not a natural ally, in the way he did Blair had effectively preempted debate about whether any rapid movement on the ban was possible and, even if it was, whether the likely cost/benefit ratio2 was favourable. In effect the policy of the Major government had been taken over without examination – indeed without any recognition that it might be prudent to examine the issue. A major initial priority was therefore to impress upon Cunningham the extent to which the Florence Agreement put a straightjacket around progress. Though he was what might be defined as ‘pro’ EU, Cunningham was always a realist at least on matters where the responsibility for progress would rest with him, and he quickly took on board the severe political and legal constraints. Blair took longer to do so. Of course he had never been a Minister before and had not had to confront the limitations of that position. He was surrounded by what amounted to hero-worship.3 He could perhaps be forgiven for thinking that his success since he had become Labour Leader had shown that he might achieve more than others, used to the tired and useless Major regime (as he probably put it to himself ), might assume was possible. Downing Street immediately asked for Cunningham’s assessment of the prospects for lifting the ban,4 with a suggestion that Blair was considering raising the issue in the current Inter-Governmental Conference (IGC).5 The issues were fully discussed at a Downing Street meeting on 8 May. Blair took on board the fact that the details of the Florence Agreement provided vast opportunities for other member states to prevaricate. It appeared that he had not appreciated this previously. However, I sensed he was not convinced by the MAFF argument that there was not a better way forward than operating according to the Florence criteria. No conclusions were reached except that raising the matter in the IGC would risk comparison with non-cooperation and had best be avoided. However, he soon accepted, albeit reluctantly, that Florence represented the only way forward. The Commission were not unsympathetic. My parallel discussions with Pirzio-Baroli6 suggested they now7 rather regretted that Florence imposed so many obstacles. The difficulty was that the Commission had to take account of majority opinion among the member states and the latter were certain to insist the requirements of Florence be met in full. We were stuck with a procedure that would only yield progress on the ban at a snail’s pace. This frustrated Blair, as we shall see. However, a realistic alternative did not exist.

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But in these early stages Blair kept pushing.8 At a meeting with the President of the Commission (Santer) in early June he kept up the pressure. Santer appeared helpful and probably raised hopes in Downing Street, but inevitably and crucially said that progress would have to follow the requirements of Florence. At the same time separate discussions with the Chancellor of the Exchequer and the Treasury implied a radically different set of priorities. Now, years later, we have become so used to the Prime Minister and Chancellor acting independently on the same subject that the fact strikes us less vividly than it might. At the time it appeared extraordinary. Directly after the Election, Gordon Brown told MAFF he had decided that expenditure on BSE, running at close to £1 billion a year, would have to be reduced sharply. Cunningham was summoned to a meeting with Brown and Alistair Darling, then Chief Secretary, held in the Chancellor’s room at the House of Commons on 14 May to agree how this decision could be achieved. At the meeting Brown suggested the over-30-months scheme should be wound down while the selective cull was unnecessary. His attitude might best be described as brusque. Brown was none too pleased when Cunningham argued the toss rather than metaphorically doffing his cap. There were three major problems with Brown’s proposals. First, one of Labour’s main claims in the Election campaign had been that they would protect public health better than the Tories and that was scarcely compatible with immediately cutting back on schemes designed to protect the public from BSE.9 Second, both schemes were required under the Florence Agreement and if the UK ceased to operate them we would be in breach of our EU obligations, while antagonizing everyone. Labour had, of course, in the Election campaign claimed that they would improve relations with Brussels. Third, there would be no hope of achieving any movement on the ban if Florence was not scrupulously adhered to and Blair had made movement on the ban a major priority. After a few minutes Brown realized that his initial line could not prevail and suggested instead that, in the light of likely increases in expenditure on BSE, the compensation rate under the 30-months scheme might be cut by, say, 50 per cent. There was no chance of the Commission accepting a cut of this size. Also it would scarcely endear Cunningham to farmers if he were to propose such a savage reduction, though this did not seem the best point to make to the Treasury. We agreed to propose a cut of 10 per cent or so in the compensation rate. Eventually I thought I detected that Brown had grasped not merely that his central thesis – that if it could not be reduced then whatever level was fixed for expenditure on BSE had to be regarded as an absolute limit – was not accepted by MAFF, a department that he appeared to regard as beneath his notice, but that the political realities meant that the MAFF view was likely to prevail. Having set off like a raging lion laying down the law for all and sundry he now looked a bit of a fool; and others had noticed. He showed every sign of not liking the embarrassing position in which he had placed himself. There were two consequences. First, the Treasury continued to press for reductions in expenditure which MAFF was obliged to pursue to some extent in Brussels.

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This puzzled the Commission. They thought this constant harping on about expenditure was incompatible with Blair’s insistence that the ban be lifted. They were not to know that one of the defining features of the new UK administration was that the Prime Minister and Chancellor consulted each other as little as possible. The second consequence was more serious. Following the Labour Fundamental Review of government expenditure the 1998 settlement for MAFF was an appalling one which was not discussed with MAFF at any level and required major cuts in functions. As a consequence programmes had to be dropped to the consternation of the scientific community,10 other Ministers11 and with long-lasting effects.12 I went to see a Treasury Permanent Secretary about the settlement and it would be fair to say he was embarrassed. We learned from Treasury contacts that our difficulties followed instructions ‘from the top’. My suspicion is that the terms of the settlement were known in the Treasury to be unreasonable and reflected instructions from Treasury Ministers which, however justified, in reality amounted to a ‘punishment’ for making them look foolish on 14 May 1997.

Taking stock The cuts in the MAFF budget caused serious problems but had no major impact on policy on BSE. Whatever the Treasury might think it would have been unacceptable politically not to apply in full all the protective policies which might be recommended by SEAC or imposed by EU decisions. The strain just had to be taken elsewhere on the MAFF budget. The real difficulty was that Blair wanted and expected to achieve a major advance on the lifting of the ban to differentiate Labour from the previous administration. But the way forward was defined by the Florence conditions which were very difficult to satisfy; any advance depended on the other member states approaching any proposals with an open mind and in a helpful spirit. Unfortunately, because of their own political baggage the first objective of most of them was to exclude UK beef from their market. At this early stage of the Labour administration the UK position in the EU, and especially Blair’s position, was very strong. But it was not strong enough to overcome these difficulties. Meanwhile operating the existing controls represented a substantial logistical task involving a heavy commitment of resources in terms of money and manpower. This was by no means temporary; fully implementing Florence would require even more money and manpower. Moreover, the more complicated the system the more likely it was that something would go wrong that would provide ammunition to those who did not wish to make any progress on the ban. All this was a recipe for frustration.

Setbacks for the prospects for UK beef exports Early in the life of the new administration two setbacks occurred which reduced the already small chances of any rapid and significant lifting of the ban further.

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On 11 June the Commission’s Scientific Veterinary Committee (ScVC) delivered a highly negative assessment on the proposal for a Certified Herds Scheme (CHS) submitted by the previous administration. Officials had always been clear this only stood a chance of being accepted in respect of Northern Ireland where the incidence of BSE was lower and a cattle-tracking system was operative. However, because of the intransigence of Scottish Ministers the scheme had been submitted on a UK basis. Inevitably the ScVC was highly critical and the Commission was bound to side with them. The second setback was the discovery that beef had probably been illegally exported from the UK. Predictably this greatly agitated the Commission who sent teams to investigate, sent warning letters to the UK and so on. This absorbed much of their energy and it is not being unduly cynical to note that while this remained the case they were obviously far too busy to take forward awkward issues like UK requests to lift the ban. As part of the UK response, legislation was introduced to give effect to the ban in domestic law. Whether this reduced the likelihood of illegal exports may be doubted.13 Interestingly the Commission protested vigorously at the limited number of checks on exports carried out by the UK authorities. A few years before, in the context of the application of the Single Market, they had objected to any checks being carried out at borders. How the UK was meant suddenly to conjure into being the necessary resources to meet Commission wishes, having dismantled them at Commission behest, they did not specify.

A proposal for a revised certified herd scheme resubmitted: consideration is given to an additional export scheme We will not need to follow the toings and froings with the Commission and their scientific committees over the summer/autumn of 1997 while the pressure from Downing Street got steadily greater. Eventually the Scots agreed to the CHS being drafted so that its effects were limited to Northern Ireland which had the required computerized cattle-tracing system. A revised CHS involving de-boned meat only was submitted to the Commission in October 1997. The broad scope of a second export scheme, known as the date-based scheme (DBS) involving only meat from animals born after 1 August 1996, was also put to the Commission in October 1997, though it was evident that more work would be needed before this could take proper shape. There seemed to be a widespread expectation within government that rapid progress might be made on both schemes, though the more anyone knew about the subject the less optimistic they were. This was not a happy state of affairs.

Cattle-traceability: choosing a location for the headquarters of the British Cattle Movement Service (BCMS) Since consultants’ first advice on establishing a cattle-tracing service had been rejected the previous autumn the concept had been taken forward on a more

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realistic basis and by July 1997 it was hoped a scheme could be operative by 1 March 1998. One of the ‘preconditions’ for action on the ban specified by Florence was the ‘introduction of an effective animal identification and movement recording system with official registration’. The interpretation of this requirement rested mainly with the Commission and they had always made clear that a fully computerized system was what they had in mind. Great Britain did not have such a system. There was, therefore, much pressure to make progress quickly and the point had been reached where this required a decision on the location of the new organization. I was disturbed to receive an agitated message from the lead official on the project who was concerned about the line being taken by Jeff Rooker, the Minister of State. Apparently he favoured Workington, a surprising attitude given MAFF had no facilities there and it was likely to be difficult to secure the speedy establishment of the new body at such a remote location. Workington had only been included in the list of possible locations because Rooker himself had suggested it. Workington was in the adjacent constituency to that of Jack Cunningham and the MP, Dale Campbell-Savours, was friendly with both Cunningham and Rooker. Understandably, given the signs of trouble ahead, the official urged me to come to the next meeting on the matter. A paper was prepared for this meeting which assessed the possible sites on the basis of relevant criteria such as the ability to have a building fitted out by December (which would be needed if the March 1998 deadline were to be met), ease of recruitment, the likely ability to provide a quality service, ease of access to MAFF (necessary for resolving difficulties) and ability to withstand disasters. Marks had been allocated for each site and the totals were Guilford 66, Manchester 50 and Workington 36. I was astonished when Rooker announced at the start of the meeting on 30 July that there was no need for any discussion – or indeed for the meeting – since he had already concluded Workington was the correct choice. He was in any case pressed for time since he was required to speak in an adjournment debate starting in a short while. He rejected attempts by officials to discuss the drawbacks. He said that he had already told Cunningham of this decision before the meeting. Faced with decision-making processes akin to those of a third world dictatorship I said that I might wish formally to approach the Minister about it. In the meantime I advised Rooker not to mention the matter during the debate. The meeting, which had lasted barely ten minutes, ended as Rooker departed for the House of Commons. Replying to the debate Rooker volunteered without being asked:

I am pleased to announce to the House that, earlier today, I decided we were in a position to announce where the headquarters of [CMS] would be, because we are moving fast to get it up and running by the end of March next year. Some time ago [Cunningham] asked me to decide on the location, and the decision was urgent if we were to meet our deadline.

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I am pleased to announce that the headquarters of the British Cattle Movement Service…will be located in Workington… [Cunningham] has played no part in the choice of location, which is in a constituency adjoining his own. Immediately Campbell-Savours, one of the few MPs present, rose to thank Rooker for his ‘enlightened decision’. Rooker replied that it was … crucial that a decision was made on the location of the headquarters if we were to stand a chance of getting it up and running. Thus, reading the extracts quoted above together, Rooker justified the decision in favour of Workington in part by the pressure of the government’s timescale. Less than an hour previously he had attended a meeting which had before it official advice, which he had not wished to discuss, which ranked potential sites on this very quality as follows: Guildford 9: Manchester 7: Workington 1. The above Rooker quotes raise one other important point. Rooker claimed, as Cunningham did later, that responsibility for the decision on the headquarters location had been delegated to him by Cunningham. If any such formal delegation had been made one difficulty would have been that the proposal for Workington, which had been totally unexpected, had come from Rooker himself. However, no formal delegation had been made since nothing was recorded in writing. Had Cunningham told me that he wished to delegate responsibility for the decision on headquarters site I would have advised him that it should be done in writing specifying the limits of the decisions delegated, giving instructions as to the circulation of papers and the content of conversations and so on. The natural course is for a Minister to consult the Head of Department if he or she wishes to delegate decision-making to avoid a conflict of interest. I had not been consulted and nothing which stood up to scrutiny had been done. In later discussions Cunningham said he had mentioned the point at a meeting some weeks previously and enquiries confirmed this. However, it had certainly not been done in any forceful way since it had not featured in the record of the meeting. In any case this would have been an inadequate procedure. I had to take a decision rapidly. The choice was deeply unappealing. I could do nothing. This would be the way of minimal difficulty but it would be to acquiesce in decision-making procedures involving the expenditure of considerable sums of public money which fell well-below the standards the public had a right to expect. Also, if I did nothing what might happen in future? I might be taken implicitly to have accepted that the decisions in this case had been properly taken. More such might follow. I took the other course recognizing that Ministers would be deeply resentful not least because I doubted whether at heart they would feel their actions had been wise and people rarely like that to be pointed out. Accordingly with a heavy heart I fired the Permanent Secretary’s rarely used gun by asking for an Accounting Officer Direction. As explained in the Introduction this is needed when a department’s Accounting Officer considers that a decision

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falls outside an acceptable range either on grounds of propriety or value for money. The test is whether the decision falls outside an acceptable range not whether the decision is the one the Accounting Officer would recommend. In my view the way in which the decision had been taken did not look good from the point of view of propriety while, if the March 1998 deadline were to be met, the likelihood of extensive cost overruns at a site as remote as Workington was considerable. I went through all this in the note I sent to Cunningham, pointing out that unless we could resolve matters quickly I would be required to copy the papers to the Comptroller and Auditor General14 and to the Treasury. Ministers were very much taken aback, and shortly thereafter I had a tense meeting with Cunningham and Rooker. The latter appeared disorientated gasping once or twice like a fish out of water but said nothing. Rooker took a lofty view of his own integrity which he frequently contrasted favourably with that of the Tories. It may have come as an unpleasant surprise to him to find his own actions being officially viewed as being at the grubby end of the spectrum. Cunningham was a more serious proposition. He could barely conceal his anger but could appreciate that if he just rejected my position then after matters had taken their course and the detail had got into the public domain he might be in some trouble. His claims that he had formally delegated authority to Rooker did not stand up. It looked awkward that he had sought to delegate authority to the person who had first proposed Workington as the site for the headquarters. Rooker had told us on the morning of 30 July that the Minister was already aware of his decision. Why was he talking to Cunningham about a matter for which, allegedly, he had been delegated authority because the Minister had a conflict of interest? Come to that why had Cunningham allowed him to discuss the matter in such circumstances? However, the fact was that the decision had been announced to Parliament and would not, therefore, be reversed. I had to work with these Ministers whether they or I liked it. There were also potential long-term advantages to Workington because there was good reason to expect that good quality staff could be found at low cost. These advantages had not been given much weight because Ministers had insisted that speed in establishing the CMS headquarters was the vital aspect. If that were the first consideration Workington was effectively ruled out. Ministers were in effect wanting to have the advantages of two incompatible wishes – maximum speed in establishing the CMS headquarters and the choice of Workington as the site – at the same time. However, if speed was not so essential the position might look different. Speed was, of course, considered vital because the absence of full cattle-traceability might hold up a major lifting of the beef ban. I regarded that risk as very small since I regarded the hopes and aspirations on the ban prevalent within government as highly optimistic. I suggested to Cunningham that the speed criterion be downgraded on the basis that our latest exchanges with the Commission indicated the prospects for a rapid lifting of the ban were less good than they had seemed previously. On that basis I would accept that the decision in favour of Workington fell within acceptable parameters (though I would not recommend it) and I could withdraw the request for a direction.

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Cunningham accepted this route out. On the plus side Ministers, though I am sure they would never admit it, had perhaps learned a lesson. Nothing similar happened again. On the minus side relationships were damaged for the long term. There was some cynical comment about the decision in the media and some Opposition members tried to make something of it but they never got very far. The unkindest cut came the following December. A senior MAFF official working in the Cabinet Office15 came to see me to register his continued existence. He volunteered that the Prime Minister viewed me with disfavour being particularly influenced ‘by the way I had connived with Cunningham in the ridiculous decision to put [CMS] in Workington’. ‘Connived’, I reflected, was a bit harsh in the circumstances. Looking back, the difficulties I describe above would have been reduced, and might perhaps have been avoided altogether, if two things had been done differently. First, Ministers might have been more receptive to the concept of receiving advice. There was very much an attitude of ‘they can’t tell us anything we would want to know’. Senior officials have their uses, however, and the mechanism by which a Minister can delegate decision-making to a junior colleague is very much an area where they will have something to contribute. Had I been consulted I would have recommended a framework for achieving it which in the case of CMS would (whatever the underlying reality) have stood up to scrutiny. Mumbling something at a meeting which was not even recorded in the minutes was never going to be adequate. Second, it is necessary for Ministers to argue about official advice if they find it unpalatable rather than simply taking a different decision based on no clear criteria. After all the weightings in the paper before the meeting on 30 July represented the opinions of one official albeit a highly competent one. By arguing about the weightings and criteria a different perspective could have been achieved. Rooker said he wanted potential reductions in unemployment following the establishment of the headquarters to feature in the criteria. Treasury advice was that this would be ‘unusual’ so it had not been included. However it was not patently ridiculous and Rooker could reasonably have insisted it be included. By such a process a new set of weightings could have emerged which would in all probability have brought Workington within an acceptable range in a way which would provide a satisfactory audit trail. A further advantage of such an iterative process would have been to confront Ministers before a decision was taken with the reality that if speed of establishment was the most important criterion then the headquarters could not be at Workington. Rooker, and perhaps Cunningham, appeared to assume officials’ antipathy for Workington was based on prejudice probably linked to a middle-class contempt for working-class, unfashionable Northern locations. In fact it was based on Ministers’ own stated priorities and the fear that they (officials) would be criticized if deadlines were missed because the wrong site had been chosen.

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Progress on lifting the ban Meanwhile efforts were continuing unabated to secure Commission agreement to UK schemes for lifting the ban. The course followed – a sensible one – was to discuss the schemes with the Commission bilaterally seeking to persuade them of their virtues while adjusting those elements which the Commission would not accept. In this way we hoped to ensure that the Commission would be firmly on our side during the ensuing and unavoidable discussions in the various scientific, veterinary and other committees. However, the task was a laborious and, most of the time, unrewarding one. The Commission were exceptionally jumpy about BSE. The hostility with which they had been treated by the European Parliament, and especially by the Committee of Inquiry, had unnerved them. The view in the Commission was that the Parliament gave the EU the vital attribute of democratic legitimacy. Their own theology therefore compelled them to treat the Parliament with a degree of deference which seems odd to those coming from a UK perspective. The Parliament’s views about the UK were even more strongly expressed than those concerning the Commission but the low status of the Parliament in the UK meant that this fact was scarcely reported. The Commission were well-aware that most other member states had no desire to make rapid progress on lifting the ban. Accordingly they (the Commission) had to be shown to have asked of the UK all the difficult questions the others would expect them to have asked; and where appropriate to have pressed for changes to the proposed schemes. Given the imprecise terms of the Florence Agreement it could be said that in the circumstances the Commission were a lot less difficult with the UK than they could have been. This reflected the essentially reasonable character of the Commissioner, Fischler. Despite the last comment, a logical case can be made to the effect that all this pussyfooting around was absurd. This was that nearly 60 million UK, that is EU, consumers were regularly consuming UK beef products and millions more foreign visitors to the UK appeared unconcerned by the alleged risks. If the Commission and others were content for this state of affairs to continue what objection could there be to the same beef being exported elsewhere? Logically either the product was risky, in which case it should be banned, or it was not, in which case the restrictions on it should be at the least substantially reduced. However, logic is not everything. The reality is that lifting the ban in any substantial fashion was not politically possible. Nevertheless one is entitled to point out that the purported basis of the ban was a scientific one. The relevant decision had been taken by the SVC – that is a scientific committee. Scientifically the ban could not be justified whatever anyone said. There was, therefore, a lack of logic right at the heart of EU policy on BSE. After extensive bilateral technical discussions with the Commission the UK formally submitted to them in October 1997 proposals for a revised CHS and for a separate Date-Based Scheme. To help obtain a favourable outcome for the latter

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scheme it was also proposed that calves born after 1 August 1996 to cows that succumbed to BSE should be compulsorily slaughtered. This was designed to cope with the possibility of maternal transmission. There is no need for us to follow every twist in the debate on these proposals. Progress was, however, far from straightforward. It was not until 16 March 1998 that the Agriculture Council adopted the CHS, the SVC having failed to reach a decision. Exports (from Northern Ireland only) did not start until 1 June. To carry forward the story of the CHS, it operated successfully though at low volumes for a few weeks after June only for it to be discovered that exports had been made contrary to the rules. Probing showed that the vaunted Northern Ireland cattle-tracing system had not always recorded events accurately and suspicions arose that there might have been skulduggery. To overcome the problems that had been revealed the Commission insisted that the rules, already massively bureaucratic, be made more rigorous still. It became apparent that the amendments needed to the CHS to render it acceptable would be so detailed and costly that it could not be operated profitably. Reluctantly the scheme was dropped and attention turned to the DBS.

Beef on the bone However, at the end of 1997 the BSE story took another, totally unexpected, twist. Within a reducing overall budget for Research and Development MAFF had been increasing its research spend on BSE for many years. As we have seen several times a feature of BSE, indeed of TSEs in general, is the lengthy incubation period. Typically experiments only yield results after several years. Experiments started several years previously had had as their objective the identification of those bovine tissues which posed a potential threat, or in other words to check whether SBOs had been defined correctly. This represented the first direct check that the use of the sheep/scrapie model was valid. In the main the experiments found that, as expected, it was; but there was one exception. In late 1997 it was reported to Ministers that it had been found that BSE infectivity could be transmitted from bovine dorsal root ganglia. A dorsal root ganglion is an organ connected to the spinal cord; two of them are connected to each vertebra. The existing definition of SBOs did not cover them. Like I suspect many others I must confess to never having heard of dorsal root ganglia16 before the result of this experiment was reported, but it had two significant consequences. First, it provided a partial explanation of why the feed ban had not been entirely successful. It will be recalled that the 1988 feed ban had been supplemented in 1990 by an animal SBO ban under which all SBO ought to have been excluded from animal feed. The existence of BABs appeared to show that until enforcement was progressively tightened up in 1994/95/96 (i) some SBO had been included in animal feed, and (ii) there had been breaches in the feed ban, so ruminants had received feed containing ruminant protein. However the discovery of an organ outside the definition of SBO which could contain infectivity was significant in that the rules would have been less effective in protecting animal health than had

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been thought. This was because ruminant protein not containing any SBO as defined might nevertheless have contained infectivity derived from the dorsal root ganglia. In effect failure (i) above need not have occurred. There had been a loophole in the controls though this had been closed in March 1996 when the inclusion of ruminant protein in feed for any farm animal had been banned. Of much greater moment, however, was the potential risk to humans from beef cuts containing bones to which dorsal root ganglia might be attached. In practice the cuts which caused concern were rib and T-bone steak. All this caused considerable consternation in government. People had seemingly continued to have been put at risk even after March 1996 after which it had been claimed categorically by both Conservative and Labour administrations that any previous omissions in BSE controls had been put right. The public would, it was thought, react with fury to the new finding. Admittedly the risks were minute. SEAC, which was naturally consulted as a matter of urgency, advised that at the worst the chance17 of developing BSE from eating one of the suspect cuts was a matter of one in over a billion when account was taken of all relevant factors. However, everyone doubted whether the public would take much comfort from that calculation. It was thought the public’s reaction would be first to view any assertions about how low the risk was with considerable reservation. Second, they would be likely to consider the fact that Ministerial assurances about safety had again proved to be wrong as much more significant. SEAC gave advice which offered Ministers a choice. In their view it would be acceptable to take no action given the risks were so low though they recognized public opinion might not be prepared to accept that given the history of concerns over BSE. Their main other option was to ban the sale of beef on the bone, which would eliminate the risk and would not have major economic implications. This prompted the CMO to submit advice to Ministers to the effect that it would not be acceptable to him deliberately to allow possibly contaminated food to be marketed for human consumption. In other words he formally advised against the first of SEAC’s options. This was the position when MAFF and DoH led by Cunningham and Frank Dobson (Secretary of State for Health) and the Chairman of SEAC met in MAFF in late November 1997. Since attaining office Cunningham had based his policy on fully and visibly protecting consumers. This seemed a sensible political strategy deliberately designed to emphasize the difference between Labour and past ‘Tory failures’. In these circumstances Cunningham took the view that it would be difficult for him not to adopt the most precautionary option put forward by SEAC; and that in any case the nature of the CMO’s advice effectively prevented government from adopting any other option. Accordingly he supported banning the retail sale of beef on the bone. Dobson agreed and there was no dissent. Given later developments it is sensible to pause at this point and consider the situation with which Ministers were faced. Even setting aside the prominence which Cunningham had given to issues of food safety, I do not see how any Minister could have acted differently faced with the advice given by SEAC and the

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CMO. It was simply not possible to ignore the CMO’s formal advice on a matter of public health. Whether the CMO was justified in giving the advice he did is a different matter. One suspects there are a very large number of possible risks where a reasonable calculation would suggest that the possibility that death will result is at least one in a billion but no precautionary action is deemed necessary. But Cunningham and Dobson had no choice but to act as they did. It had become apparent by this time that since May Downing Street liked to be much more closely involved in routine Ministerial decisions than had previously been customary. It was, therefore, sensibly deemed expedient to alert Downing Street to what was proposed. A reply quickly came back to confirm that the Prime Minister was content. An announcement of the new ban was duly made and it came into force on 16 December 1997. Contrary to the expectation of all, the decision was strongly criticized on the grounds it was overprotective. This possibility had not occurred to anyone. A strident campaign ridiculing the decision got underway in which the London Evening Standard and its sister paper the Daily Mail were especially prominent. The truth was that this campaign struck a chord with the public and the authorities were left wrong-footed. I should perhaps have said that MAFF and DoH were left wrong-footed. When the trend of public opinion became clear Downing Street soon started agitating for the beef-on-the-bone ban to be lifted. True to form evidence soon emerged that they had briefed the media on how dissatisfied they were with MAFF and DoH Ministers and officials on the subject. They did not mention that the original decision had been explicitly approved by the Prime Minister. The same tune was sung by others with even less knowledge of the facts. Thus the Cabinet Secretary (now Richard Wilson) told me there was ‘no way’ the MAFF/DoH decision could be justified. He did not judge it necessary to explain how a decision on BSE which flatly disregarded formal advice from the CMO could be presented successfully. Looking back one can identify this incident as representing the turning of the tide on BSE. The issue had lost something of its intensity from the time of the Florence Agreement ( June 1996) and again when the backlog under the 30-months scheme had been eliminated (December 1996). The public had, I suggest, gradually come to recognize that the original reaction to the announcements of 20 March 1996, serious though they were, had been disproportionate. Several billion pounds had been spent on protecting people from something which had so far only claimed a handful of lives. Perhaps some wondered whether this was money well-spent. It had come to be recognized that in BSE like everything else it was necessary to have a sense of proportion. Unfortunately for the government it was stuck with a policy which for many failed that fundamental test. Thus very quickly the main question for government became how fast it could bail out of the beef-on-the-bone ban. This required the CMO to change his advice and government was more or less overtly hoping he would do so for months. Given his position, however, there was a limit to the pressure it was possible to exert on him directly. The first time he came formally to review his previous advice he stuck to his guns and the government was forced to announce on 4 February

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1998 that the ban would be retained – to almost universal derision. Eventually he changed his advice18 but the government was not able to announce that the ban could be lifted until 30 November 1999. The beef-on-the-bone saga was a salutary reminder to everyone that nothing continues unchanged indefinitely.19 Such had been the furore over BSE and the alleged way in which the public had been subjected to unnecessary risks by government (in)action that it had seemed impossible for government to be criticized for excessive precaution especially if they acted in conformity with a recommendation from the CMO. That had been the implicit assumption of Ministers and, probably, everyone else. Yet, less than two years after the biggest ever crisis over food safety, that is exactly what happened.

The BSE Inquiry The establishment of the BSE Inquiry was announced on 22 December 1997.20 For the next two and a half years the Inquiry gave a focus to regular speculation on who might eventually be identified as the ‘guilty men’. This was uncomfortable for those whom the media thought might qualify for this accolade. Any claim made in evidence to the Inquiry which implied any criticism was immediately reported. This was inevitable since all oral evidence was given in public and written evidence was normally placed on the internet quickly. However, any rebuttal came much later. This was because the order in which witnesses gave evidence was drawn up right at the beginning of the process. The consequence of this process – long lags between allegations being made and answered – was that the answer was often not reported in the media at all since a headline to the effect of ‘spicy allegation refuted’ was not one likely to appeal to editors. Because allegations remained unanswered for long periods some of them came, by virtue of frequent repetition, to become accepted truths. The very existence of the Inquiry gave scope for mischief-making. In summer 1998 I was surprised to be invited to breakfast by John Gummer who was, of course, by then a member of the Opposition in the House of Commons. Such invitations are potentially awkward since one’s first loyalty obviously has to be to Ministers of the day and hobnobbing with the Opposition might give rise to suspicions in the minds of the former. However, Gummer is an experienced operator and I felt confident he would have something significant to impart. It emerged at the meeting that Bernard Donoughue, the Parliamentary Secretary at MAFF, had been waxing vocal in the bars and corridors of the House of Lords to the effect that officials intended to blame past Tory Ministers for the (assumed) shortcomings in the response to BSE. Past Tory Ministers were, not unreasonably, concerned at such a suggestion even though they recognized that the source was not necessarily impartial. Donoughue will not feature prominently in these pages since his remit did not include BSE. Within MAFF he was not popular partly because he appeared to lack zeal compared to some of his predecessors. One problem was Donoughue’s surprising lack of self-confidence given that he had been at the forefront of Labour politics for 30 years. However, advising behind the

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scenes is one thing and taking decisions and publicly accounting for them is another.21 For our present purposes the important point is that Donoughue was an avid believer in conspiracy theories. From his own account this reflected his experience as a member of Harold Wilson’s ‘kitchen cabinet’. It was, therefore unsurprising that Donoughue would have gossiped in the way suggested since it assumed the existence of a conspiracy. He would have been unlikely to be deterred by the probability that such action would be likely to make past Tory Ministers uncomfortable nor that his sources must, at best, have been questionable. I was able to assure Gummer that I knew nothing of any such conspiracy and very much doubted if one existed. I was also able to make a more telling point. This was that there was no evidence on which such claims could be based. It was already apparent that, while individual decisions by individual Ministers might be challenged as a class, they were no more culpable than officials and, indeed, others such as scientific advisers.

The date-based scheme: Blair’s frustration boils over Directly the CHS was agreed in March 1998, Tony Blair made it clear that he now expected very rapid progress to be made on the much more important DBS. The latter was not limited to Northern Ireland, and by spring 1998 it was already true that a rapidly increasing proportion of UK beef came from animals which were born after August 1996 – the reference date envisaged for the scheme. It might seem, therefore, that if a scheme could be agreed quickly all UK beef would qualify for export within a relatively short period given that animals which reached 30 months of age had to be destroyed at the end of their working lives. Unfortunately the reality of the discussions with the Commission presented a rather different picture. Cunningham obviously took a close interest in these discussions and regretfully agreed. Downing Street’s pressure required a response and the senior official leading the negotiations sent him a draft letter to the Prime Minister setting out the grim reality in detail. This said that achieving agreement to the scheme under the UK Presidency, which ran from 1 January 1998 to 30 June 1998 ‘may not be achievable’. A more realistic aim would be to get the Commission to table a proposal during the UK Presidency and for agreement to be reached under the Austrian Presidency which would end on 31 December. The draft letter and an annex to it went into considerable detail explaining the reasoning behind this unwelcome judgement. Some of the points made were excruciatingly detailed but the main one was that the Florence preconditions envisaged six key stages in any proposal to lift the ban. The steps were (i) the UK puts forward a proposal; (ii) the Commission obtains formal scientific opinion on the UK proposal; (iii) the Commission draws up a formal proposal for EU legislation; (iv) the Commission puts the proposal to the Standing Veterinary Committee for decision, and if a qualified majority is not found possibly to the Council; (v) the Commission sends a mission to inspect relevant operating arrangements in the UK; and (vi) the Commission fixes a date for the resumption of exports.

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The draft went on to point out that for the DBS (and the associated offspring cull of calves of infected animals which the Commission regarded as a sine qua non) only the first two steps had been completed – twice. A proposal had been put to the Commission on 2 October 1997; the Commission’s Scientific Steering Committee had given its opinion on 9 December 1997; the UK had submitted a revised proposal to the Commission on 30 January 1998; and the Scientific Steering Committee had issued a further opinion on 21 February 1998. These facts clearly showed how drawn out the process of achieving agreement on any lifting of the ban could be. Further the following four steps were all under the control of the Commission; the UK could do nothing unilaterally to speed things up. The draft went on to add that the Commission had told the UK negotiators that they expected much more resistance among the member states to the DBS than to the CHS. The implication was that their (the Commission’s) attitude would take full account of this anticipated resistance. Among the several other points made in the draft was that a scheme would require extensive investment in IT; and that until details of the scheme were settled only a limited amount could be done without running a serious risk of nugatory expenditure. This draft was submitted to Cunningham on 19 March and I got round to looking at it a couple of days later. It met one basic Packer requirement for advice to Ministers where the latter will have strong views on what they wish to hear and which I have explained more than once in this book – namely it lay right at the optimistic end of what was possible. In general, advice pitched at this level satisfies the need for advice to be honest while minimizing the risk of Ministerial anger. However, in this case I concluded the message, even though well on the optimistic side of neutral, needed more wrapping up. Blair would clearly be unhappy with this advice and might, I suspected, be inclined to blame the UK negotiators for the lack of progress. Accordingly I asked to see Cunningham alone. I advised him to tone the draft letter down on the basis it would present the truth too starkly for Downing Street susceptibilities. Cunningham seemed surprised but said he had in any case already sent the letter, which he regarded as a good one, unchanged. The Downing Street reply dated 30 March arrived while Cunningham and I were in Brussels. Blair had clearly reacted as I had feared he would – with exasperation. Further he blamed the UK negotiators for this state of affairs. Blair was recorded as being ‘convinced that there [were] substantial tactical benefits in getting the Commission’s proposal on the table and voted on during the UK Presidency’. ‘No stone should be left unturned’ to bring about this result. Cunningham should ‘take personal responsibility for ensuring that his department attaches the highest possible priority to carrying out the work necessary to prepare for the scheme’. And so on. In other words Blair set out what he wanted to happen and made no comment at all on the explanations included in Cunningham’s letter as to why the reality was different. The letter also set out Blair’s opinions on some other issues. In response to a Downing Street request to set out a plan for exiting the over-30-months scheme

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Cunningham had suggested that SEAC might be asked to consider the matter in the second half of 1998. Blair’s firm view was that it was unnecessary to wait that long. This view may be contrasted with the fact that as I revise this paragraph in April 2005 – seven years later – the 30-months scheme remains in full effect. This response depressed Cunningham and his officials. The former did not need to be told to take ‘personal charge’ of the efforts to lift the ban. He was aware from his very first conversation with Blair that the latter attached importance to getting the ban lifted and had been striving as hard as he could to achieve just that. He had looked into the matter carefully and discussed it not only with the Commissioner but with Ministers from the other member states. The letter he had sent and to which Blair had taken exception had represented the reluctant conclusions of an experienced political operator who had looked at all the angles. It was difficult to avoid the conclusion that Cunningham’s advice had been rejected in large part not because of any defect in the logic of his position, which had if anything been set out too clearly, but rather because he was not identified as a ‘Blairite’; separately I had formed a suspicion that Blairites became such because they said what Blair wanted to hear. From the point of view of officials the incident showed that Blair would persuade himself that whatever he wanted could be delivered, and that if it was not this would be due to a failure on their part. While I was in Brussels I was told Richard Wilson, the Cabinet Secretary, wanted to see me. It was even suggested I might return early. I had no idea what he wanted but could not see that I could be justified in returning early whatever it was. Accordingly I saw him on 1 April. A certain amount of background is necessary to appreciate the inwardness of this interview. Wilson, who had previously been Permanent Secretary at the Home Office, had been appointed Cabinet Secretary by Blair late in 1997 on the retirement of Robin Butler. Blair had made it clear both before and after his arrival in Downing Street that one of his top priorities was to reform the public services and in particular to improve their delivery. Words like ‘reform’ and ‘radical’ and ‘improved delivery’ were banded about and in the main commented upon favourably in the media in the expectation that action would follow. Those of us who did not go by overall impressions, however, and read the detail of what Blair said on the subject rather doubted whether he had any idea as to how the desired improvements might be brought about. According to the accounts in the press at the time, which no doubt reflected briefings by Downing Street, Wilson had been appointed as Cabinet Secretary in preference to the other main candidate Andrew Turnbull in large part because Blair saw him as most likely to deliver on public services. This is entirely plausible. Wilson was always one to talk a good fight and Blair has always had difficulty in distinguishing words from action. Accordingly, since his appointment towards the end of 1997 Wilson had been part of the Blair inner circle often called a kitchen cabinet. However, by spring 1998 the rumours were that Blair was just beginning to suspect that Wilson could

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not or would not deliver on public service reform. He did not reach a firm conclusion that this was the case until later in the year whereupon Wilson was cast out of the inner circle. However, Wilson was probably aware by April that the mood music was changing. Dealing with failures in ‘delivery’ was important for him since they were perhaps undermining his own position. The meeting itself bore an astonishing resemblance in many ways to Geoffrey Robinson’s description of his own meeting with Wilson as described in his book of memoirs, The Unconventional Minister. The purpose of the latter meeting had been to deliver an unpleasant message – namely that Robinson had been fired as Paymaster General. Robinson records that he had reason to believe that Wilson had volunteered for the task which he regarded, understandably, as inappropriate for a civil servant and hence one that could have been easily avoided. The suggestion that I return early from Brussels indicates Wilson was looking forward to a meeting with me. As in the meeting with Robinson Wilson started with a philosophical remark very like ‘It’s a funny old world isn’t it.’ At the end as with Robinson he unconvincingly volunteered ‘I like you personally.’ Clearly Wilson relishes delivering unpleasant messages and has a set routine for doing so. There is just one other point about Wilson relevant to this meeting. He had demonstrated more than once at the weekly meetings of Permanent Secretaries that he knew very little about the EU. Wilson opened by saying how dissatisfied Blair had been with Cunningham’s letter which revealed unacceptable attitudes within MAFF. It rapidly became clear that Wilson was hoping I would admit to having drafted it or at least to having forwarded it. This, in his eyes, would enable the ‘blame’ to be pinned on me. A less good but satisfactory alternative would be to blame me for not having advised against sending it. In the words of the prayerbook I would be caught either by having done ‘things I ought not to have done’ or, failing that, by having ‘left undone things I ought to have done’. It was a setback, therefore, when I replied that I had advised Cunningham against sending the letter. Plan 1 would not work. However, I have never been someone to hide my views simply because they are unpopular and I volunteered that though the wording of Cunningham’s letter might be faulted I agreed with the judgements in it. Wilson saw a way forward. It might not be possible to blame me for what I had done or not done, but I could be blamed for what I thought. Wilson is by training an historian and he may have been inspired by knowledge of how the Inquisition got round the kind of difficulties he had encountered. The Prime Minister’s view, Wilson reported, was that the EU difficulties of which the MAFF letter made so much could be got round by ‘will’ and ‘determination’. I said that neither Cunningham nor I lacked determination. However, the realities were reflected in Cunningham’s letter and it would be dishonest to pretend otherwise. Top MAFF officials had much EU experience to bring to bear; we were not talking of something of which we had little experience. Further, Cunningham was a seasoned operator. Wilson brushed this aside. The Prime Minister had opined and it was not necessary to discuss matters further.

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It is instructive to contrast this episode with that involving John Major when he was looking to claim that the Florence Agreement could lead to a rapid lifting of the EU ban. To submit a proposal for a lifting of the ban it was clear the selective cull would have to have been started and this could not happen until the backlog of the 30-months scheme had been cleared. In June 1996 I had refused to confirm that the backlog would be cleared before November at the earliest. Roger Freeman had suggested September which was exactly what Major wanted to hear. However, he had not been satisfied with that and continued to press me as the official in the best position to take an informed view. When I refused to support an earlier date I was left in no doubt that he was displeased. But he did not conclude that he was competent to decide on the correct date and criticize those who disagreed with him. (It is true that he announced the date of October in Parliament but this reflected a political need; he did not say he had been advised this was possible and there were no recriminations.) Yet by June 1996 Major had had many years of negotiating in Europe and even more in government. By contrast, in March 1998 Blair had had less than a year in government and his experience of the EU was of the same limited duration. He felt able, however, to be so confident of his own judgement of what could be achieved in EU forums on a highly technical issue – a judgement that happened to coincide with his wishes – to conclude that those who advised differently, some of them with decades of EU experience to guide them, were culpable and merited reproof. Wilson did not distinguish himself either. Of course if the Prime Minister is angry about something and views a department’s actions as unsatisfactory he needs to pass this on, but it was foolish to pretend to believe that because the Prime Minister is frustrated then his conclusions must be objectively correct. Cunningham was not a fool and his officials had very many years of EU experience while Wilson had none. Wilson pretended to be concerned with facts but actually was only concerned to allocate blame. His whole approach showed an absence of that honest dealing which colleagues owe each other even in difficult circumstances. As someone once said, opinions are opinions but facts are facts. In due course it was shown the advice in Cunningham’s letter of 23 March 1998 had indeed been somewhat overoptimistic. The 30-months scheme remains in force seven years later. The draft DBS became ever more bureaucratic and less valuable as it was amended to meet the myriad objections raised by the Commission and other member states. After many months of sustained pressure in EU forums up to and including the Council of Ministers the scheme finally got underway on 1 August 1999, that is 18 months after the Wilson incident – only for the French and Germans to refuse to accept beef exported under its provisions. The Germans came into line reasonably soon but the French refused to do so even after the European Court ruled against them in December 2001. More important, however, is the value of the scheme which had been secured after so much effort and one might add expense. Here the evidence is clear-cut and can be given quantitatively. The value of UK exports of beef and cattle (that is excluding semen, gelatine and tallow) in 1995, before the BSE crisis and the EU ban, was £675 million p.a. In 2002 well after the DBS came into operation it was £18 million.22

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The main reasons for this very low figure were continuing reservations about UK beef among foreign consumers and the onerous conditions attached to the scheme; these in turn reflect the numerous hurdles that have to be surmounted under the Florence Agreement and the reality that progress on agreeing the scheme was in the hands of the Commission – as Cunningham had advised in his letter of 30 March 1998. Over the years since 1998 as the rate at which animals succumbed in the UK declined while the rate in other member states increased, the much stricter rules applied to exports from the UK have become progressively harder to justify until it is now an obvious anomaly. If Florence and the DBS did not exist it is likely UK beef exports would by now (2005) be subject to very limited (or even no) special restrictions, though it might still be a struggle to market the product in some places.

The cattle movement service is launched The decision to locate the CMS in Workington having been announced on 30 July 1997 the objective was to start operations on 1 April 1998. We do not need to follow the minutiae of the process, much of it related to investment in IT. After some months it became clear that we risked failure if we stuck to that date and Cunningham had to be advised that a six months postponement was necessary. Given the nature of the earlier exchanges on the subject, described above, Cunningham agreed to this with a good grace. No doubt he realized that the recommendation to delay the launch did not reflect any desire to make points, but a genuine judgement that the service could not be started successfully before the autumn. It was just as well the launch was delayed. After extensive practice runs and checking, when the service went live on 28 September 1998 it stumbled and nearly failed. However, it recovered and I was very thankful for the extra time we had allowed for training and practice. The scheme requires the births, movements and deaths of cattle to be notified to the Agency and its coverage has gradually been extended from young animals only to the whole national herd.

Worries about the possible transmission of vCJD via blood transfusions I turn now to a fascinating story which in some ways mirrors the history of government’s handling of BSE except that it all occurred after it was known that the disease was most probably transmissible to humans and yet there has been virtually no public protest. In 1997 SEAC became concerned that vCJD might be transmissible to humans if they received transfused blood donated by persons infected with vCJD but not yet showing symptoms – that is from those at the subclinical stage. They recommended on 24 October that the removal of the white blood cells from donated blood, technically known as leucodepletion, might be desirable to reduce the risk.

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This was not advice that was welcome to DoH since leucodepletion of the entire UK blood supply would be an expensive undertaking costing tens of millions a year. The Secretary of State for Health (Frank Dobson) asked DoH’s Director of Research and Development to commission an independent assessment of the risks of human to human transmission. Since SEAC was itself independent this smacks more of a delaying tactic than anything else. In any event in June 1998 SEAC confirmed and strengthened its earlier advice: On balance the Committee recommends that the Government should extend the use of leucodepletion for all blood destined for transfusion as soon as practically possible. On 17 July DoH accepted this advice in a notice which opened ‘the Government today took action’. Ignoring the delay that had already occurred, as we shall see this was an optimistic description. Interestingly the notice included a quote from the Deputy Chief Medical Officer: Blood in the UK remains very safe and leucodepletion will make it even safer. Leucodepletion was being introduced because of concerns over the safety of UK blood yet the Deputy CMO chose this moment to describe UK blood available for transfusion, not yet leucodepleted, as ‘very safe’. As we have seen, claims by CMOs and this same Deputy CMO that ‘beef was safe’, claims similar to this one, were criticized by the BSE Inquiry for being incomplete and potentially misleading. Of course DoH will have been concerned that a scare about the safety of blood transfusions could have resulted in the public refusing such treatment which could well result in many more deaths than were likely from transfusing nontreated blood. This is a real concern: but those who had spoken on the safety of beef were also motivated by the concern that public reaction to concerns over BSE could have serious and regrettable consequences. In September 2000 it was announced by the DoH that recent research results showed: BSE can be transmitted via whole blood transfusion from sheep with preclinical BSE to healthy animals. Though what is true for sheep might not necessarily be true for people, this result made it much more likely that persons might have been infected as a result of receiving blood transfusions from those at the preclinical stage of vCJD. The DoH announcement did not, however, make this point. Rather it added two others: … there remains no evidence that CJD or vCJD has ever been transmitted to humans from blood transfusion or blood products.

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… whole blood is not used for human blood transfusions in the UK. White cells are now removed from blood for transfusion (leucodepletion). The first statement was, of course, true but was virtually identical to many made about BSE until 1996 to the effect that there was no evidence that BSE could be transmitted to humans. The difference was that the result of the sheep experiment which formed the basis of this notice was significant evidence, though not proof, that such transmission might occur, while before 1996 there was no evidence that BSE posed a threat to humans. As regards the second statement, according to a later DoH announcement, discussed below: Since October 1999, white blood cells (which may carry the greatest risk of transmitting vCJD) have been removed from all blood used for transfusion. The date of October 1999 at which full leucodepletion took effect will be contrasted with the unease first expressed by SEAC in June 1997 over two years earlier. The statement also ignored the fact that people could have become infected until October 1999. This might be understandable but it will be recalled the BSE Inquiry was later critical of some who had not made clear the dangers to humans that might have existed before the slaughter/compensation scheme and the human SBO ban took effect in 1988 and 1989 respectively. In December 2003 it was announced that someone who had become infected with vCJD had received a blood transfusion from a donor who had themselves succumbed to vCJD. Statistical examination indicated that it was highly likely the two events were related. As a direct consequence on 16 March 2004 it was announced that recipients of blood donations would in future be excluded from donating blood. Years earlier the USA had excluded all who had lived in the UK for any period from donating blood. It is arguable that directly SEAC had expressed unease about the possibility of vCJD being transmitted by blood transfusions it was likely that those who had received transfusions would eventually be considered a risk; and that it was unfortunate that nearly seven years separated the two events. I do not want to make that case though precedent would suggest others might. DoH were inevitably and rightly concerned whether the cost/benefit ratio of action would be favourable when direct evidence was lacking. What has been remarkable, however, is how little public interest the above facts have elicited. Even the Opposition spokespeople in Parliament take a sympathetic line despite the uncanny analogy between public statements on BSE and on vCJD and blood transfusions. As I have said before it is very difficult to predict accurately media and public reaction to events.

EU rules to protect the public from BSE: BSE outside the UK I turn now to what was one of the most shocking aspects of the BSE story though it is rarely remarked upon. This was the prolonged attempt by some member states

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to prevent the adoption of EU rules to protect their own publics. I regret to say Germany was at the vanguard of this process though they were not the only ones. The background is that though BSE was overwhelmingly a British disease it has always been found in other countries. This is unsurprising given that substantial exports of UK breeding cattle had been made to Europe until the end of the 1980s. Also substantial exports of animal feed had been made until well into the 1990s, and as we have seen some feed undoubtedly contained BSE infectivity because of cross-contamination in feedmills. Finally some 500,000 calves were exported annually from the UK mainly to France and the Netherlands until 1995; the calves were required to be slaughtered for veal before they reached six months of age. But keeping track of millions of animals is a very difficult task. By 1998 cases of BSE had occurred mainly in those countries to which the UK had traditionally exported breeding animals, that is Ireland, France and Portugal. There had been isolated cases elsewhere but it was claimed these were directly linked to imports from the UK. There was one interesting exception to this state of affairs. This was a substantial mini-outbreak in Switzerland starting in 1990. Switzerland had not received large numbers of animals from the UK and the geographical facts suggested that it was fanciful to imagine that a large proportion of exports of animal feed from the UK had ended up in Switzerland, though that was the conclusion some, who shied away from the more obvious possibilities discussed below, tried to draw. One possibility that cannot be entirely discounted is the existence of a separate Swiss outbreak independent of that in the UK, that is that whatever had started the outbreak in the UK, probably a genetic mutation in a sheep or bovine, also occurred in Switzerland. On this hypothesis the much smaller size of the Swiss outbreak could be accounted for by the fact that they had been able to learn from UK experience. While this possibility cannot be ruled out it is theoretical and there is no direct evidence for it. It is safer to take as the starting point the assumption that the Swiss cases were linked in some way with those in the UK. On this basis one puzzling phenomenon immediately presented itself. Why were the Swiss figures so much higher than those of other countries with larger populations of dairy cattle, which were both nearer geographically and had closer trade ties with the UK, for example Germany and the Netherlands? This was not a question that most Continental interests wanted to discuss. When I appeared before the European Parliament’s Temporary Committee of Inquiry in October 1996 I drew attention to the Swiss figures and how they were difficult to understand in relation to those of other member states. I also mentioned a paper just published which had calculated that on the basis of UK experience and the number of cattle exported from the UK up to 1990 or so the number of cases of BSE elsewhere in Europe appeared low. None of the MEPs, so zealous when pursuing the perceived iniquities of the Commission and the UK, showed the slightest interest in this line of investigation. The obvious and most likely explanation was that the figures for most other countries were probably significant underestimates of the extent of infection found there.

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In some countries there were disincentives to reporting cases. In France and Ireland if BSE was discovered the entire herd was slaughtered instead of the suspect animal only as in the UK. The French were wont to represent theirs as a worthy measure more prudent than that in force in the UK. In fact, of course, it would have been a major disincentive to farmers to report a suspicious animal. There were some cynical souls in the UK administration who judged this to be precisely what was intended. The main difference between Switzerland and some other countries was, however, probably one of attitude. The Swiss veterinary authorities perhaps strove to get at the truth while others were perhaps more relaxed. As indicated above it was already clear by 1996 that the BSE figures for many Continental EU members were suspiciously low. There was obviously a real risk to consumers from BSE throughout the EU. Of course nobody doubted that the disease was still at this date much more prevalent in the UK, however in the UK extensive measures were in place which would protect consumers from risk including the slaughter/compensation scheme for clinically infected animals, the requirement to remove SBO from all cattle and the over-30-months scheme. Nobody claimed that it would be proportionate to operate the last mentioned outside the UK, but the fact was that UK vets had much more experience in judging whether animals were succumbing to BSE. Effective removal of SBO was required to protect consumers outside as well as inside the UK. Germany simply denied the validity of the above arguments. They stated in terms in the Council of Ministers that it was ‘inconceivable’ that BSE was present in Germany and that therefore extra protective measures in Germany were unnecessary; further they were opposed to introducing them. Yet the Germans knew as we did that a large number of animals and substantial quantities of feed had been exported from the UK to the Continent up to 1995. They knew also that animals could easily move between Continental member states. They also had access to the article pointing out that the number of reported cases of BSE on the Continent was suspiciously low. Despite all these factors, which led UK observers to judge that many more cases of BSE were likely to be present in Germany than was officially acknowledged, Germany worked hard to stop the adoption of a measure designed to protect their own population. All this took place not initially when the scientific situation was unclear, but after it had become known that BSE probably posed a serious threat to humans. As always the truth came out eventually. In the year 2000 simple chemical tests for BSE in dead animals became available which could be applied by technicians and did not require veterinary judgement nor expensive laboratory investigation of brains. Thus all carcasses could be tested and it was not necessary for animals to be judged by a qualified vet as a suspect and the animal slaughtered first. Testing of carcasses is designated ‘active’ surveillance while the testing of animals showing symptoms and slaughtered on veterinary advice is designated ‘passive’ surveillance. When active surveillance was made compulsory outside the UK23 the results can be seen in Table 9.1. The effects of introducing active surveillance in Great Britain are shown in Figure 9.1, which can be compared with the passive numbers included in Figure 4.1 (note the different scales).

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Country UK (including Channel Isles) France Germany Ireland Spain Switzerland Source:

Cases (up to 28 Feb. 2005)

Of which cases from 2000 onwards

185,184

4,779

957 375 1,470 530 456

878 365 1,035 530 124

Extracted from, DEFRA, Monthly Summary Statistics for March 2005.

Some caveats must be made. Since the disease originated in the UK it would be expected to occur elsewhere with something of a lag. But the way in which cases only came to light in Germany and Spain in particular when active surveillance was made compulsory do not show those countries in a good light. I have copies of very many articles on BSE which refer to the events in question as a ‘scandal’. As I hope this account has shown, most or all of these claims are misplaced. However, the attitude of the Germans to introducing controls in Germany in the late 1990s certainly deserved that description. Ironically that is one area where the media seem to have completely missed what was happening. The detail need not detain us long. A Commission proposal to introduce EU controls on SBO failed to secure a majority in the SVC on 3 December 1996. On 14 May 1997 the Commission said that the introduction of EU-wide SBO controls was essential. Their proposals could not secure a qualified majority in the SVC but were accepted by the Council of Ministers by a simple majority on 22 July 1997. However, before they could come into effect the SVC postponed implementation until 1 April 1998. On 31 March 1998 the Council of Ministers deferred implementation until 1 January 1999. On 17 December 1998 implementation was deferred again until 31 December 1999. On 14 December 1999 the Council of Ministers deferred implementation until 30 June 2000. Measures finally came into effect in July 2000 just as the implications of active surveillance were becoming apparent. Given the length of the incubation period for vCJD it will be some time before we know whether this delay will have tragic results.

The press, the government machine and the strange interest of Mr Anthony Bevins This section discusses a series of articles mainly in the Daily Express some of which are concerned with issues other than BSE. As these articles grew in number I was telephoned in 1998 by a friend of mine, close to the centre of the Labour Party for

0

10

20

30

40

50

60

70

1994

1995

1996

1997

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1999 2000 Month/year of slaughter

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Source:

DEFRA: Monthly BSE Statistics (Data valid to end of March 2005. Produced 7 July 2005 © DEFRA (2004).)

Figure 9.1 BSE cases in Great Britain confirmed by active surveillance, by month and year of slaughter

Cases

80

2003

2004

2005

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many years but no great admirer of New Labour. She said that these articles were not accidental; there was an underlying purpose. In her view the obvious explanation was that I was being deliberately set up as the ‘fall guy’ for the forthcoming Report of the BSE Inquiry. It was standard New Labour practice to decide on who should be categorized as a villain in any given circumstance and to take steps well beforehand so that their depiction in that guise rang true when the time came. I said that this all seemed a bit far-fetched. Why should New Labour pick on me? In any case I was most certainly not a major villain or, indeed, a villain at all when it came to BSE as anyone who had followed the BSE Inquiry would immediately recognize. In any case most of the bad publicity (see below) was not concerned with BSE. My friend replied that I was being uncharacteristically naïve. I underestimated the ruthlessness of New Labour. They would have no interest in whether I was or was not the villain of the BSE story. For them the important point was that for the public I would be a credible person if cast in that light. Where the truth lay would not feature in their thinking. My friend went on that she knew Bevins well and knew him to be close to the centre. He would be an obvious choice, as it were, to lay the ground. At the time I was unconvinced. It is normally unwise to imagine that one forms the focus of other people’s thoughts. An illusion of a central position is a common error of politics. However, as time passed I began to have my doubts. To skip forward in time I did eventually receive confirmation of Bevins’s closeness to the inner circle. In 2002 I was sitting next to the journalist Chris Blackhurst at a private dinner, and someone introduced the Express into the discussion. He remarked that he had worked for that paper in the late 1990s, and went on to volunteer, without any pressing, that he had shared a room with Anthony Bevins who had sat opposite him (and who had died by the date of the dinner) and that it was amazing how often the latter had had Alastair Campbell on the phone during the average day. If such plans were being made and briefings given accordingly, and readers can judge for themselves on that from what follows, they were intermingled with a different fight over the proposal to establish the Food Standards Agency. On that it is necessary to say a few words to set the background. As we have noted Labour’s manifesto for the 1997 election had promised that such a body would be created, and we had therefore planned on that basis. All those who had argued for such a body had envisaged it would report to Health Ministers. Since the whole argument for the new body was that it was unsatisfactory to have the same department responsible for the agricultural and food industries and for food safety I had expected action to be taken immediately after the Election to transfer responsibility for food safety to the Health Department. I had had work done on the necessary legislation, technically known as a Transfer of Functions Order, which could effect this more or less immediately. However, matters proceeded quite differently and much less logically due to Tony Blair’s personal intervention in a matter to which I suspect he had given little thought. First, about a month before the Election he asked Professor David James to devise a scheme for an agency. James was a well-known food scientist

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whose views were strongly held though not all of them were shared by his scientific peers. Probably one of his main credentials had been his support for the Labour party. Most people in the know were taken aback at the choice of such a contentious figure to draw up a blueprint for an agency without placing any obligation on him to consult others. In the event James delivered his report to Blair on 2 May – that is the day after the Election – who blessed it publicly straight away. Thus a decision on a complex matter was taken without any of the thought and/or consultation that normally attends decisions of this kind. Later that day as we have seen he charged Cunningham to take the proposal forward. This was odd. Since the new agency was to become a responsibility of the Department of Health the obvious course would have been to charge Health Ministers with taking the matter forward after transferring the functions (and staff ) to them. Past relevant experience in the respective Ministerial teams could not have been an issue since no Minister in either department had any in the policy areas in question. I suspect it did not even occur to Blair or his kitchen cabinet to ask themselves whether there might not be a more logical way forward than the one they assumed was inevitable. The Cabinet Office immediately tried to grab responsibility for the legislation despite Blair’s words to Cunningham and there was a not unusual but unedifying Whitehall scrap eventually won by MAFF. Not that it mattered immediately since Blair seemed to go cool on the idea of an agency24 and no space was found in the legislative programme for the bill necessary to establish the agency on a satisfactory basis for over a year. This meant that by the time authority for the bill was obtained Cunningham had been replaced by Nick Brown. Brown was easier to work for than Cunningham not least because he was a lot more appreciative of the efforts made on his behalf and was not prone to assume the existence of conspiracies among officials to thwart his wishes unless he saw some evidence to that effect. In the previous Cunningham/Rooker/Donoughue regime it had appeared to be an article of faith that such conspiracies existed. Brown was decidedly unenthusiastic about the concept of an independent Food Standards Agency as recommended by James and did his best to backtrack. The main surprise in James’s proposals had been his emphasis on independence for the agency. He appeared to envisage it acting outside the political system altogether, though it was obvious that some department, and Health was the obvious choice, would have to be responsible for its budget. Brown’s position had two aspects. First Ministers ought in his view to have responsibility for such an important area of public interest as a matter of political principle. Second Ministers would in any case be held responsible if there were a disaster so they ought to have overt responsibility if they would in reality be held accountable for the activities in question. It may also be the case that having arrived in MAFF, which was still responsible for over 90 per cent of food-safety issues, Brown had found none of the leaning towards producer interests at the expense of those of the consumer which he had been assured he would. He may have wondered whether the whole project was necessary.

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All this infuriated Rooker, still in the department and with responsibility for food safety, and Cunningham now in the Cabinet Office and who had come to view the putative agency as one of his achievements. He and Rooker mainly fought the battle not in Cabinet committees – even if they had wished to follow that path new Labour did not govern in a way which made it possible – but via leaks to the press especially the Express and Tony Bevins. They chose to do so by suggesting that Brown was unduly influenced by his scheming Permanent Secretary – me. This was quite untrue. My position was that since the establishment of the agency was a manifesto commitment and Blair had also been involved in the project personally it was pointless arguing against the concept. I advised Brown accordingly. What was true was that Brown considered advice put to him carefully even if at first he did not like it. Perhaps that was what was meant by ‘unduly influenced’. The ad hominem campaign – for that is what it amounted to – unsurprisingly did not endear Cunningham and Rooker to Brown. Nor would it have suggested to him that the case for a James-style agency was as strong as some made out. If the case was so strong why did its advocates not rely on reason instead of arguments ad hominem? There is one further aspect relevant to the following paragraphs, which is relevant to BSE. In 1996/97 I had charged a bright young civil servant to review the files on MAFF’s response to the BSE crisis – that is the actions taken after 20 March 1996 – and to write a report. The explicit objective was to inform the department’s response to an official enquiry should one be launched. The public criticism of the MAFF response had been so intense that such an inquiry seemed quite possible. In due course he produced a valuable Report on most of the events already described in Chapter 8 above which would have been very helpful had an enquiry looked into this period. When he had completed the Report the official had had a couple of weeks free before starting his next job so I asked him to look briefly into the pre-20 March situation also. He did not have time to do very much but did complete a couple of rather bitty chapters which he sent me with strong caveats about the limited nature of his investigations and hence their lack of completeness. Both parts of the Report were concerned with events under the Conservative administration that had held power until 1997. As such the standing rules meant that neither could be shown to the succeeding Labour administration. Someone in MAFF must have told Cunningham about the existence of the Report. When he asked I explained why he could not have access to it. I was not surprised when subsequently the Inquiry and the Express also asked about the Report. Having consulted departmental lawyers I took the view that (i) it had been prepared to help the department in the event of an enquiry and hence ought to be accorded the privileged status that is normally attached to papers prepared by individuals or entities for court or other investigations; (ii) the first half of the Report dealing with events within the timescale of the Inquiry’s remit was so incomplete that it did not merit the title of ‘report’ and ought not to be given status; and (iii) the second half was not within their remit. All this was a storm in a teacup since all the documents on which the official had drawn, and vastly more, were available to the Inquiry who had much more time

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than had been available to him to form their own conclusions. However, at the time it all made a bit of a wave. Just like Cunningham the Inquiry having been told they could not have something desperately wanted it and they argued that the Report did not fall within the class of document which could benefit from the kind of exemption described in (i) in the preceding paragraph. After numerous exchanges it was agreed that the Inquiry could have both halves of the Report; the first half, that is the part completed later dealing with matters before 20 March 1996, would be published unless HMG persuaded them that some sections ought not to be, while the second part dealing with events after 20 March 1996 would not be published unless they persuaded HMG to the contrary. In due course the Inquiry asked, and we agreed, that a small portion of the second part should be published. Having set the background let us look at events as they unfolded. On 19 October 1998 the Express included a major article, billed as ‘exclusive’, by Bevins starting on page 1. This described in tabloid style some of the issues before the Inquiry quoting several of the contemporary documents. The same day the Express also included another article by Bevins on page 5 entitled ‘Stench of secret government’. ‘The cover-up and the scandal continue’, he wrote and continued in the same polemical vein. One paragraph gives a flavour of the whole: John Major and senior Ministers knew that safety controls had been widely breached when the link between BSE and new variant Creutzfeldt–Jacob disease was announced on 20 March 1996. But they forgot to tell the public and Parliament. Instead they pretended the risk had ended in 1989. The fact is that all that Ministers knew about breaches of the safety controls had been speedily reported to Parliament in 1995 and later. It was SEAC that had advised that the appearance of vCJD was probably due to exposure to BSE before controls were introduced in 1989. Ministers had not ‘pretended’ anything but merely quoted the opinions of their independent advisers. Bevins went on ‘the Express has been told that one “explosive” document is still being withheld by… MAFF’. (He was referring to the official’s report described above.) Later he added ‘Someone is going to have to break Mr Packer’s fingers to get him to release that document’. On 20 October Bevins approached the Press Offices in both MAFF and Number-10 on yet another issue, namely whether there should be a ‘consumer’ representative on SEAC. His allegation is concisely summarized in a note written by Alastair Campbell that day the relevant parts of which are quoted below: 1. When JC [Cunningham] became Minister of Agriculture, he wanted to appoint a consumerist person to SEAC. 2. Richard Packer resisted. 3. Packer enlisted the support of Angus Lapsley [a Number-10 private secretary]. 4. Without reference to TB, Angus wrote to MAFF saying that the PM did not want this new person appointed. 5. JC refused to accept this…

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The most difficult part of the story obviously concerns Angus and the suggestion he took the PM’s name in vain. We have been through the papers on this, and it is clear the story is wrong. Angus did consult the PM, who was against the idea. He subsequently reluctantly went along with it because of wider BSE presentational reasons. Thus the allegation that Blair’s views had not been ascertained could be refuted. I noted, however, that the implicit suggestion in Bevins’s approach that I had sought to connive with Blair’s private secretary to circumvent my Minister’s wishes did not strike Campbell as a ‘difficult’ part of the story. I also noted that the word that came naturally to him to describe a senior official who advised his Minister against a suggestion was ‘resisted’. On 21 October the Express carried another article attacking me personally. On 23 October Nick Brown wrote to Alastair Campbell describing the recent spate of Express stories as ‘unfair, corrosive of working relationships within government… ’. Bevins was at it again in the Express on 28 October criticizing MAFF’s past opposition to the inclusion of consumer representatives on technical advisory committees. Bevins went on to make the allegation described above that I had tried to involve Blair’s private secretary to support my views. He did not mention that all concerned had explicitly denied the latter story. Indications of the source of all this were there for all to see. Bevins went on to describe how Cunningham’s ‘more persuasive argument’ had carried the day and there was a picture of him with a caption ‘the winner’. On 18 November the Express carried two further articles. On page 2, next to a picture of Cunningham, Bevins announced ‘… a concerted campaign to neuter the proposed [Food Safety] agency had been beaten off.’ ‘Richard Packer… [had] fought a rearguard action against the watchdog agency.’ Bevins went on to describe how Cunningham had arrived like Robin Hood to counter this dastardly threat. A leader on the same day went through it all again. What was so infuriating about all this was that, as already explained, there was not a word of truth in it. Later that day Lapsley from Number-10 spoke to my private secretary. He said Number-10 were extremely angry about the coverage in the Express which he described as ‘damaging to government as a whole’. They knew who the offenders were, those whom he described as the ‘old alliance’. They had already contacted Cunningham’s office to express their deep displeasure. He assumed matters were in hand in MAFF to bring the other ‘protagonist to heel’ – obviously a reference to Rooker. I wrote to the Cabinet Secretary, Richard Wilson, on 18 November setting all this out and pointing out that the doubts about the proposed agency had originated with Brown himself. Brown wrote to Wilson the following day in some detail confirming this was an accurate account. After listing his reservations about the proposals for the agency he added: These are my genuine concerns…It is unjust and entirely untrue to claim that officials have in any way tried to steer me to raise these questions… It is of great

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concern that these articles appear to have relied on briefing which has come from members of the current administration or from those close to them. (Original emphases) However, the Bevins press campaign inevitably got noticed by others in the media some of whom regurgitated the Bevins line, one suspects without doing very much to check it, while raking up every allegation previously made. It would be tedious to note every example. But the article by Andrew Rawnsley in the Observer on 22 November 1998 quoted in the introduction is a good representative of the genre. After the dust appeared to have settled, Wilson replied to my letter of 18 November on 8 December and I quote the entire letter though compressing what was four paragraphs into one: Thank you for your letter of 18 November. As you probably know your Minister, Nick Brown, wrote to me on the same subject around that time. I sympathise with the concern you feel at the articles which have appeared in the Express. It is not comfortable for any of us, least of all you. I have had a word with Alastair Campbell to consult him about what might be done. His reaction was that your department needs to be more proactive in your rebuttal of Tony Bevins. He wonders whether Nick Brown should arrange to see Bevins. I note that things have been quiet since you wrote. But you may want to keep this thought in mind. Even by his own high standards this was remarkably unhelpful of Wilson. Everyone knew, or thought they knew, from whence Bevins’s briefing had come. A Cabinet Minister, who could at least speak publicly, and his Permanent Secretary, who could not, were being attacked ad hominem by members of the administration about an important matter of public policy which deserved to be decided on its merits. The whole campaign made sensible decision making more difficult. Brown’s speaking to Bevins would achieve nothing except to keep the story running. At this point I started thinking rather more carefully about recent developments. I realized that the whole campaign would have been stopped in its tracks immediately if Campbell from his position in Number-10 had told Cunningham and Rooker he was unhappy about it. He had chosen not to do so. His advice as quoted by Wilson was close to being insulting. The temperature fell on BSE over the next few months and the arguments over the Food Standards Agency also died down as it became clear that such a body would be established. The next flurry of press comment came towards the end of 1999 when the Inquiry’s hearings came to a close. At that time their Report was expected to be published by 31 March 2000. On 17 December 1999 Michela Wrong wrote in the Financial Times: Those who have followed the inquiry predict…civil servants…will be more harshly criticised than the politicians.

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[The CVO] between 1988 and 1997 and Richard Packer, current permanent secretary at [MAFF], are two of the names expected to be singled out. Those who had ‘followed the Inquiry’ clearly did not include Wrong. By December it was obvious from the Inquiry’s hearings that the Southwood Committee potentially faced numerous criticisms, MAFF and DoH Ministers faced potential criticisms, while several officials, including not only the CVO mentioned in her article but also two CMOs, potentially faced several criticisms while I only faced one which was also faced by many others including the CMO at the time (who also faced other potential criticisms). From where, therefore, had Wrong got the idea that I would be ‘singled out’ for criticism? There are two possibilities. Either she just sloppily reported tea room gossip without making any attempt to check it or someone to whom she gave credence had suggested it to her. She could not have conducted any research into the Inquiry’s hearings and as a result come to the view included in her article since all the evidence suggested differently. I telephoned Wrong to make these points and left a message on her answermachine. She never got back to me. I left the civil service on 17 February 2000. On 24 February the Express included an article by Tony Bevins on page 2 headed ‘Guilty Secret in mad cow scandal’. A second heading ran ‘Agriculture chief accused of turning blind eye’. The article went on to claim I had made a ‘classic example of a Whitehall non-denial denial’ of certain serious allegations made to the Inquiry by the CMO for Scotland at the time of the incident in question in 1995. The allegation as summarized by Bevins and described as a ‘damning admission’ was that I had ‘confessed at a private meeting in 1995 that it was impossible to guarantee official precautions to keep infected meat out of the human food chain’ and had, moreover, been unconcerned, indeed somewhat jaunty about the fact. The implication was that I had known about this state of affairs all along and done nothing about it. Bevins’s reporting on this occasion was highly partial even for him. He was taking as his texts evidence given to the Inquiry by Dr Howard Kendall, the CMO for Scotland in the mid-1990s on 15 July 1999 and my written comments on Kendall’s claims. Kendall’s evidence was given at the second stage of hearings – that is when those giving evidence faced potential criticisms. The impression given by the transcript of the hearing is that Kendall was taken aback to find himself in that position having like many others in the Health establishment anticipated that only those connected with agriculture would be so situated. He was asked, inter alia, about a meeting I was recorded as having had with the CMO and another on 25 October 1995. Kendall replied that he had been present – that is he had been the other – and that he had ‘a very vivid memory of it’. He was clear that it had been held in Richmond House, that is in the main DoH building. It had been ‘a somewhat heated meeting’ because of the way I had reacted with what amounted to nonchalance to the recently discovered evidence of breaches in the SBO controls. The CMO (for England) had been concerned and annoyed at the MAFF attitude as evinced by me. I came across this evidence by chance when the transcript crossed my desk and at once resolved to contradict it since it seemed only too likely to provoke hostile

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comment and was entirely untrue. I pointed out to the Inquiry numerous flaws in Kendall’s evidence including that: (a) I had sent an account of the meeting to the Minister (Hogg) that very day (25 October 1995) in which I referred to its taking place in MAFF. The phrase I had used had been ‘The CMO… came to see me’; (b) My diary confirmed a meeting with the CMO in my room on 25 October. (Though on legal advice I did not make the point my diary was an electronic one which I lacked the expertise to alter even if I had wanted to); (c) The tone of my report to Hogg bore no relation to the heated occasion claimed by Kendall; (d) Kendall did not claim to have made any contemporaneous notes of the meeting despite claiming to have regarded it as highly significant; (e) Kendall had not mentioned the meeting in his original witness statement despite the importance he now attached to it; (f) In fact the first reference Kendall had made to the meeting had been to the Inquiry on 15 July 1999 – that is four years later; (g) No other contemporaneous document suggested DoH/MAFF tensions in October/November 1995 of the sort now claimed. For example the CMO met Hogg on 7 November and is recorded as saying ‘co-operation between the two Departments at all levels had been consistently very good’. I suggest any neutral observer would conclude that Kendall’s claim to have a ‘very vivid’ memory of the 25 October meeting had been shown to be inaccurate by his clearly having misremembered the location and that there was no other evidence to support his contention of what had taken place. Bevins’s account on the other hand, given prominence in the Express on page 2, made no mention of the circumstantial evidence to which I had drawn attention and which so strongly indicated that Kendall was at best confused and certainly did not remember accurately important details of the 25 October meeting. Bevins implied that I had no answer to Kendall’s accusations other than to say that I ‘did not recollect’ having said what was claimed. I call reporting of that kind dishonest. Bevins had an agenda and was by omission twisting the facts to suit his purposes. With hindsight we can see another fact offering strong support for my contentions. The Inquiry’s system was such that they would have asked the CMO (for England) to give his views on this dispute about a meeting at which he had been present and had, allegedly, taken a strong line. Yet there is nothing from him on the subject in the evidence collected by the Inquiry. Clearly he declined to comment. Yet he could have helped Kendall whose position looked awkward after the submission of my comments. After all Kendall was the Scottish CMO – as the CMO (for England) had been before he landed the bigger job. He would not have had to support Kendall’s claims in full, which might perhaps have raised questions about why he had not mentioned the matter himself. He could, for example, have said that at the meeting he had not interpreted my attitude in the way Kendall had, perhaps because he had known me for some time, but he could understand

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that others less familiar with Packer directness might do so – or the like. His silence speaks volumes. I also suspect that the CMO’s diary when checked had confirmed that the meeting on 25 October 1995 had been in my room. Also in February 2000 I was surprised to be invited to lunch by two senior BBC executives in the News Department. They said that the BBC was especially concerned to get its treatment of the Inquiry’s Report (still expected by 31 March) right. The tone was likely to be set by the initial coverage and there was a danger that injustice might be done if they gave too much weight to preconceptions rather than the actual conclusions of the Inquiry which might be significantly different. Timing pressures were likely to be such that this would be difficult to avoid. As the discussion continued it became apparent to me that these executives had been told that after the CVO I was likely to be the person most prominently criticized. In other words they had been spun the line probably spun to Michela Wrong which had been naïvely included in her Financial Times article on 17 December 1999. However, they had come to regard such unofficial briefings from the centre of government with suspicion. Although they did not quite say as much it was clear that since New Labour came to power they had accepted past briefings from that source at face value and only appreciated afterwards that they had been misled. I explained how matters lay and in particular how the Inquiry’s procedures operated. These showed clearly that I only faced one fairly minor draft criticism which was also faced by several other Ministers and officials from MAFF and probably several from DoH also. I hoped to avoid even that since it was badly based for the reasons set out above in Chapter 7. Other people potentially faced several criticisms. The BBC executives were taken aback. They asked me twice whether I was really claiming that I only faced one criticism at most. Was it really true that I would not face any criticisms directed at me only? I replied that not merely was that true but if they read the transcripts of the Inquiry’s hearings against the background of the Inquiry’s explanations of how they would conduct themselves they would see for themselves that it was quite certain. The BBC executives clearly did not know what to think. I interpreted this as meaning that, following awkward experiences, they had come to view unofficial briefings from the centre of government as prone to involve distortion and exaggeration. If what I had said was true they would have involved outright invention also which would take government’s deception and attempted manipulation to new levels. I hope they remembered all this when the eventual Report of the Inquiry showed that what I had said at the lunch had indeed been entirely accurate. Shortly after this lunch the Inquiry was extended for another six months and I have no evidence of any further central briefing – save one snippet. Jonathon Leake, a Sunday Times journalist, kindly arranged for me to examine the extensive cuttings on BSE kept by the News Corporation library. Discussing this he told me that at the time the Report was published, ‘government’ had let it be known quietly that since I had left the civil service there was no more need to look for a culprit for BSE. This was interesting given the facts. In contrast to me, several people,

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including at least one serving civil servant, faced multiple criticisms including ones directed at them only. I have discussed with several political insiders with varying sympathies whether evidence like that quoted above shows that I was deliberately chosen by elements of the government machine as a target on BSE as my friend had originally suggested and even though this would have no factual justification. The most interesting fact is that none of them, including Labour supporters, said that it was ridiculous to imagine that the present government would behave in such a way. That would, I suggest, have been the natural reaction if similar suggestions had been made about any of its predecessors. Perhaps this encapsulates the contribution which New Labour has made to the political life of the nation.25 Notes 1 He once said that towards the end of the 1983 Election campaign the flow towards the Conservatives was so strong that if it had continued for another week he doubted whether 100 Labour MPs would have survived, and that he would not have been among the survivors. 2 Considering all factors not just financial ones. 3 Questioned in summer 1997 I replied to an academic from Essex University who regularly interviewed Permanent Secretaries on a confidential basis that in my view politics had not changed in any fundamental sense and that the current enthusiasm for Blair/Labour would prove temporary, like all previous such enthusiasms. He commented that some of my Permanent Secretary colleagues took the view that a paradigm shift had occurred and UK politics would never be the same again. In my view it is not the job of top civil servants to be taken by enthusiasms however strongly or widely they might be manifested at any given time. 4 Of course Cunningham was expected to approach this task bearing in mind the steer he had already been given. 5 IGCs are established to discuss changes to the EU Treaties; since these treaties reflect agreements between states only those states can agree changes to them. The point is the discussions are outside the formal EU framework. 6 Who it will be recalled was chef de cabinet to the Agriculture Commissioner, Franz Fischler. 7 That is now an overtly Europhile UK administration had been elected with a large majority. 8 Blair spent a significant proportion of his time on the ban in his first few months in office. 9 Under both schemes reducing payments greatly would provide incentives for avoidance. For example if compensation for animals submitted under the over-30 months scheme were very low, an incentive would be provided to pass off older animals as being under 30 months which could be used for human consumption for which higher prices were available. Experience showed some would respond to such incentives. 10 For a typical example (relating to postgraduate grants) see Peter Cotgreave, Science for Survival, British Library, 2003, pp. 93–4. 11 For example John Prescott who reacted to a MAFF Press announcement that grants for investment in safety equipment for fishing vessels would cease by telling Nick Brown (who had succeeded Cunningham) that as Deputy Prime Minister he could not allow it and our announcement would have to be withdrawn. We replied by pointing out that (a) we had no money to do so and (b) formally the expenditure settlement was a collective decision which bound Prescott as much as it did MAFF. Prescott continued to huff and puff for a bit but eventually gave up.

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12 One result of having no money was that pay increases were severely curtailed and inevitably the worst-paid suffered most. When MAFF and part of the Environment Department merged in 2001 discontent led to industrial action because the junior grades in the former MAFF were so much worse paid than their ex-Environment colleagues. 13 The terminology may be confusing. It may be asked that if no legislation existed how were exports illegal? However the ban was set out in an EU instrument of a kind which is directly applicable in all member states including the UK so it is correct to refer to exports made in contravention of the ban as ‘illegal’. 14 The official who heads the National Audit Office and reports to Parliament on government expenditure. 15 Hence officially placed on MAFF seniority lists. 16 I should record here for the sake of completeness that one of the consumer representatives who gave evidence to the BSE Inquiry on 30 October 1998 and who features none too well in my description of that session had earlier queried whether dorsal root ganglia might not pose a risk. 17 That is the contemporary chance in December 1998. Chances at earlier dates would have been higher though still very low. 18 On the basis that the risk had diminished over time as progressively fewer animals harboured infection. 19 Or, as Heraclitus put it over two thousand years previously, ‘we never step into the same river twice’. 20 See Chapter 5. 21 For completeness I should add that I feature as something of an evil genius in Donoughue’s book of memoirs. Those who like a dash of romance, gossip and style in political comment and are not overconcerned with the facts will find these congenial. 22 Figures supplied by Food from Britain. 23 Full active surveillance was not required initially in the UK because the 30-months scheme provided extra protection for consumers not available elsewhere. 24 An official spokesman (Campbell (?)) was quoted as describing the concept as ‘dead in the water’. 25 New Labour’s preoccupation with ‘spin’ and lack of truthfulness as understood by ordinary people is well-documented but even now has not been fully taken on board by the general public. Among a host of analyses, that by Nicholas Jones remains among the best (The Control Freaks: How New Labour Gets Its Own Way, Politicos, 2002).

10 Conclusions

Conclusions as regards BSE It is not my intention here to rehearse again the evidence set out above, but rather to draw out the main conclusions to which it clearly points: ●

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My first conclusion is that the advent of BSE was nobody’s fault and that nothing anybody could reasonably have been expected to do would have prevented it. Second, given the length of the incubation period for BSE a substantial epidemic was inevitable however quickly the disease was discovered and action taken. Third, for the same reason it was inevitable that the human population would be exposed to progressively greater amounts of BSE until the disease manifested itself clinically and preventative measures were taken. It is quite possible that all of those who have succumbed to vCJD were infected before controls were introduced. Fourth, there is no ‘smoking gun’ to be discovered. There was no unwise action taken nor any major step left untaken which, had they been avoided or taken respectively, would have resulted in a radically different outcome. Similarly, while in some cases actions could have been taken more quickly, this would not have produced a radically different result.

Though the evidence for these four propositions is overwhelming, such neutral judgements might disappoint some. However, while it might be a natural, if unattractive, human reaction to assume that if something dreadful has happened someone must be to blame, it is not always the case and is in fact not the case for BSE: ●

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Fifth, government correctly took early steps to ensure it had access to distinguished, independent scientific advice on the disease. Sixth, the correct measures – notably the slaughter/compensation scheme and the human SBO ban – were adopted to protect human health. As a result of 245

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good sense in MAFF the human SBO ban was adopted earlier than it would have been otherwise. Seventh, the ban on using protein derived from ruminants in ruminant feed was the correct policy for protecting animal health. Eighth, errors were made. As regards risks to human health the manufacture of MRM from spinal columns ought to have been banned well-before 1995; MAFF and SEAC must accept responsibility for this lapse. DoH should have acted more quickly to require leucodepletion of UK blood destined for transfusions. As regards animal health the animal SBO ban adopted in 1990 was a mess for which MAFF was responsible. This resulted in more BSE cases in animals born after 1990 than need have occurred. Some would consider that the decision not to have a feed-recall scheme in 1988 when the ruminant ban was first introduced was another error by MAFF but this is less clear-cut. Ninth, some slaughterhouses and animal feedmills had an irresponsible attitude towards their obligations, with management sanctioning actions that they must have known would put animal and perhaps human health at risk. Tenth, the system of local-authority control in slaughterhouses in place until 1995 was highly unsatisfactory. MAFF correctly advocated a national control service and robustly drove the concept forward against strong opposition from all quarters and even from within government. This resulted in a major improvement in standards, and hence in protecting human and animal health from BSE from 1995 onwards. This benefit would have occurred earlier in the absence of opposition much of which was based on considerations unrelated to meat hygiene.

Conclusions as regards politics BSE demonstrated many attributes which the public inevitably found troubling; hence a strong public and media reaction was inevitable. These factors included the invisible nature of the threat, its being linked to food, the spectacular way in which afflicted animals lost control of their movements, the seemingly constant emergence of new facts about the disease over a prolonged period culminating in an official acknowledgement that BSE had caused disease in humans and the grisly way in which CJD sufferers declined. This inevitable strong public and media reaction was exacerbated by three further factors. The first was the extent of public suspicions of government policy on food, especially food safety, which had grown up from about 1970 as the consumer movement gained influence and consolidated itself. Government attempts to counter this trend were generally unsuccessful. Second, the rows with the EU, especially at the time of the beef ban and non-cooperation in spring 1996, increased the salience of the disease even more. This was, arguably, in part self-inflicted. Third, having witnessed matters at first hand, I am sure that comments on BSE up to the Election of May 1997 increasingly reflected the exasperation a substantial number of people felt with the long-running Conservative government. BSE was a useful peg on which to hang complaints based on a wider dissatisfaction.

Conclusions 247

All these factors reinforced each other resulting in one of the most explosive public and media reactions of the last fifty years, especially in the weeks following the announcements of 20 March 1996. The account in the above chapters also demonstrates the ethos of the government machine which varies over time and with different administrations. Until March 1996 the Conservative administration broadly operated by traditional methods while at the same time struggling (with limited success) to adapt to the more reasonable demands of the growing consumer lobby, notably the demands for greater openness. After the announcements of March 1996 and the imposition of the EU beef-ban policy became increasingly based on the need to unite the governing party which was deeply split on policy towards ‘Europe’. This concentration on the demands of party management to the detriment of good organization and, arguably, policy reflected in part the small government majority and in part, one suspects, the predispositions of John Major himself. However, in general debate was open; indeed in spring 1996 some contributions at the many Ministerial meetings were not obviously based on departmental responsibility or personal knowledge. Nevertheless real attempts were made to obtain a Ministerial consensus on the way ahead. After May 1997 Labour approached matters differently. Collective responsibility in the sense that all Ministers could contribute to the development of policy was abandoned; the doctrine remained valid only as a matter of discipline. Significant policies were determined in Downing Street. All Ministers were very well-aware of this and the implications were also felt by officials who increasingly were expected to work with and indeed under those from Number-10. While saying something which ran against the grain of government inclinations even in internal discussions has never been popular the pressures not to do so increased significantly. Allied to this were ruthless media campaigns on specific issues – ‘spin’ – sometimes directed at individuals. All those near the centre of events knew that this was how government operated though they never openly acknowledged as much; they simply looked the other way professing distaste only to their closest intimates. This rigid regime of central control allied with media manipulation, often cynical, obviously represents the preferred working method of Blair himself. It sits oddly with the open, caring persona he projects at the wider public. Is it utopian to wonder if a more open and honest approach which avoids the near anarchy of the later Major period might be possible?

Long-term effects of the BSE crisis and lessons to be learned When BSE comes up in conversation I am often asked by sympathetic acquaintances what, with the benefit of hindsight, have in my view been the long-term effects of the BSE saga and what lessons can be learned. These questions rest on the entirely reasonable proposition that such a convulsion in the political life of the nation must have had profound effects of one sort or another. This proposition is closely linked to another one, also apparently reasonable, which is that it ‘must

248

The Politics of BSE

surely’ – I use quotes because these are the words most often used – have been possible to avoid or at least to reduce in scale the hostile reactions which fuelled the crisis. These reasonable propositions are, however, largely fallacious. Outside the beef sector the effects of the BSE crisis or crises have been limited and such lessons as might be drawn from them are rather obvious. Equally, it is highly doubtful whether any action that the authorities could have taken would in practice have lessened the scale of the crisis.1 I say this because since the consumer and environmental movements got properly underway in the 1970s virtually all policies connected with food have been subject to sustained criticism. The targets vary over time – for example there was a strong campaign against food additives before BSE was even discovered. There have been several similar campaigns subsequently, all having as a prominent feature criticism of the regulations established by government often allied with equal criticism of parts of the food industry. Not infrequently claims are made to support these criticisms which bear a strong resemblance to those made about BSE – ‘cover-ups’, ‘lies’, ‘secrecy’ and the like. At the same time some foods, organic produce and foods with vitamin additives being the most obvious examples, have vociferous supporters. Both criticism and support are more passionate than a careful examination of the scientific evidence could justify. The fact appears to be that many in Western society are uneasy about modern life as it affects the environment and diet. These concerns cannot be fully explained by reference to established scientific truths. There is not time to discuss here in detail why this phenomenon might have emerged. But BSE did not create it nor in my view has it done much to magnify it save in the very short term. Thus I am doubtful about claims that the credibility of government has been more than marginally damaged by BSE. As Francis Fukuyama has pointed out,2 trust in government across a wide range of issues has apparently been declining in the West for some time for no apparent, objective reason. Likewise everyone now accepts that being entirely open about the facts is the best way forward in almost all instances.3 However, this is not something that has been deduced from the experience of BSE. As we have already noted, though there was a widespread belief to the contrary, the facts about BSE were almost always put into the public domain promptly. Rather it reflects the expectations of the public which is no longer prepared to defer to the views of those in authority. Against this background there was little the authorities could have done to reduce the scale of criticism at the height of the crisis in March 1996. BSE was a natural disaster which occurred in an area where much of the public were already uneasy. It is true, as we have seen, that many of the claims about official actions were inaccurate and that at the time these claims were not refuted successfully. But this does not mean that if the specific claims had been successfully refuted at the time the volume of criticism would have been less. I suggest that what would have happened then is that attention would have focused on some other criticisms instead. My thesis is that the overall volume of criticism of the authorities did not reflect the sum of the specific criticisms made. Rather the overall volume of

Conclusions 249

criticism reflected the level of general unease which was then put forward by reference to specific points or criticisms which were not really crucial to the argument or, indeed, properly evaluated. The article by Andrew Rawnsley I quoted in the introduction is a good example of this tendency. The specific claims he made were incidental and in fact wrong; however what was important was his overall attitude which probably reflected reasonably accurately how many people felt. Evidence for this perhaps surprising thesis is given by the fact that though many of the more important criticisms made of the authorities were shown to be wrong by the BSE Inquiry, assuming we accept their verdict, this has had no discernible effect on media or public opinion. The findings in question have just been ignored. The truth is that the precise nature of the criticisms made was only marginally relevant to the unease and anger that people felt at the time. I hope this book will contribute towards building a more balanced assessment which will obtain majority support and which, while rightly taking full account of the errors made, also recognizes that some things were well-done. Notes 1 Though the advice to stop digging when in a hole has much to commend it. The Major government arguably ignored this ancient wisdom when opting for non-cooperation. 2 The Great Disruption, Profile Books, 2000. 3 Security matters are the obvious exception.

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Index Accounting Officer Directions 5, 95, 177, 214–15 Acheson, Sir Donald 118 Agriculture – scientific revolution in 7 Anderson, Professor Roy 193–4, 206 (note 77) Andrews, Sir Derek 116 Animal feed sector 8–9 Arable farming – importance of geographically 7 Attack rate experiment 70–1, 77, 79 BABs (cattle born after the feed ban of July 1988) 71–3, 77–8, 90, 121 Baldry, Tony 95–6, 163, 175 BBC 87, 242 Beef ban see EU export rules Beef on the bone 218–21 Beef production and consumption 7–8, 160–1, 164, 168 Beef safety 63–4, 87, 88, 90, 91, 143, 194 Bevins, Anthony 234, 235, 237–8, 239, 240, 241 Blair, Rt Hon Tony 100–1, 209, 210–11, 216, 220, 222–3, 234–5, 237, 243 (notes 3 and 8), 247 Blood transfusions 227–9 Bridgeman, Mrs 102 British Cattle Movement Service (BCMS) see CMS British Medical Journal 105 Brown, Rt Hon Gordon 210–11 Brown, Rt Hon Nick 235–6, 238–9 BSE and sheep see Sheep BSE as a notifiable disease 37, 38 BSE epidemic 1, 33–4, 67, 68, 69, 232, 233, 245 BSE Eradication Plan 178, 183, 184, 185 BSE Inquiry 1, 2, 30, 92, 98, 100–7, 108–28, 129–157, 221–2, 237, 249 criticisms by 103–4, 108–28 Draft Factual Accounts 104 BSE outside the UK 229–32 Butchers 12

Butler, Sir Robin 97, 100, 184, 187, 188, 203 (note 34), 205 (note 61), 206 (note 79) Cabinet procedure 158–9, 171–2, 173, 236 Calman, Sir Kenneth 125 Campbell, Alistair 234, 237, 238, 239 Campbell-Savours, Dale 213, 214 Cannibalism in cattle 8–9 and kuru 18 Cat SE 61–2, 121 Cattle identification and traceability 61, 197 see also CMS Cattle industry 7–8 economics of 7–8, 57 output, value of 7 population 7 CHS (Certified Herd Scheme) 194–5, 200, 212, 217–18 CJD 1, 14, 16–17, 20–1 and farmers 75, 86, 90, 148 and medical practices 19 in young people 86, 90–8, 148 CJD surveillance unit (CJDSU) 49–50, 77, 152 Clarke, Rt Hon Ken 117, 204 (note 49) Cloos, Jim 168 CMO (Chief Medical Officer) 37–9, 63–4, 75, 76–7, 84, 86, 87, 94, 95, 96, 97, 124, 138, 143, 147, 219, 220–1, 240–2 CMS ((British) Cattle Movement Service) 212–16, 227 see also Cattle identification and traceability Collinge, John 86, 145, 147, 200 Common Agricultural Policy of the EU 7, 91, 156 Concentrates – in feed 8 Consumers (including Consumer Groups) 12, 31, 56, 133–4, 164, 169, 173, 196, 244 (note 16), 246, 247, 248 251

252

Index

Contingency planning 91, 125–6, 146–53 Cunningham, Rt Hon Jack 100, 101, 208–9, 210–11, 213–16, 219–20, 222–3, 227, 235, 236, 238, 239, 243 (note 1) Currie, Edwina 98, 138 CVL 33, 34, 115, 136 CVO 34, 35, 39, 67, 72, 80, 96, 117, 240 Daily Express 234, 235 Daily Mail 186, 220 Daily Mirror 96 Daily Telegraph 186 Darling, Rt Hon Alistair 210 Date Based Scheme (DBS) 212, 217–18, 222–7 Department of Health (DoH) 27, 38, 39, 50, 63, 86, 117, 125–6, 137–8, 138–9, 147, 149, 220, 228–9 Deregulation 26, 29, 30, 83, 123 of rendering 10, 109–10 Dobson, Rt Hon Frank 100, 219–20, 228 Donoughue, Bernard 221, 235, 244 (note 21) Dorrell, Rt Hon Stephen 87, 97, 98, 126, 147, 151, 160, 201 Dorsal root ganglia 78, 218 Dose required to cause infection with BSE 40, 64, 67–71, 77, 110–11, 130–1 ELISA test 74, 80 Elk – TSE in 19 Enquiries (Public) 95–6, 99–100 see also BSE Inquiry Environmental Health Officers (EHOs) 24, 25 see also Meat Inspectors European Commission 59–60, 165–7, 182, 199, 212, 221–2 European Court 180 European Parliament 198–9, 217 European Union (EU) 1, 4, 25–6, 91, 158, 164, 167, 246 export rules 59–61, 100, 164–7, 173, 178–87, 200, 211–12, 217–18 treaties, effect of 7 Evening Standard 159, 220

Express

see Daily Express

Farms, family 8 FCO (Foreign and Commonwealth Office) 178, 179, 194 Feed ban 39–40, 115, 135–7, 218–19, 246 Feed recall scheme 195 Ferguson-Smith, Professor 102 Fischler, Commissioner 165, 166, 170, 179, 217 Florence Agreement 178, 183–6, 194–5, 209–10, 226 Food Standards Agency 208, 234, 238, 239 Forsyth, Rt Hon Michael 180, 194, 199, 200 Franklin, Sir Michael 37 Freeman, Rt Hon Roger 171–2, 185, 186, 187–8, 226 Gelatine 11, 181–3 Guardian 94 Gummer, Rt Hon John 25, 26, 27, 28, 31, 47, 48, 55, 60, 62, 123, 221–2 daughter and beefburger 62 Hadlow, Bill 17 Harman, Rt Hon Harriet 97–8 Headboning 10 Herod Premium 161 Heseltine, Rt Hon Michael 158, 180 Hogg, Rt Hon Douglas 82, 84, 87, 89, 91, 94, 95–6, 97, 98, 99, 125–6 147, 149, 151, 157 (note 9), 159, 161, 163, 164, 165, 167, 170–2, 177, 180, 182, 184, 186, 187–8, 193, 194, 198, 201, 205 (note 61), 206 (note 73), 241 Home Office 2–3 House of Commons Agriculture Committee 55, 62–3 Human growth hormone 14, 19 Hunt kennels 11–12 IBEA (Intervention Board Executive Agency) 174, 203 (note 34) IEHO (Institute of EHOs) 55 Incubation period of BSE 33, 37, 91, 109, 131, 245 of CJD 18, 148, 245 of kuru 18 Independent 88, 144

Index 253

James, Professor David 234–5 Kendall, Howard 240–1 Kimberlin, Richard 41, 42, 47, 51, 117 Klug, Sir Aaron 105, 207 (note 77) Knackers 11 Kuru 17–18 similarity to scrapie 17 Labour manifesto 99, 208, 234 Lacey, Richard 63, 76 Lamming Report 73 Lang, Rt Hon Ian 29 Leake, Jonathon 242–3 Leaks to the media 92–3, 96, 151–2, 159 Leather 12, 164 Leucodepletion 227–9, 246 Local authority enforcement 25, 54, 73–5, 79, 82–4, 120–1, 121–2, 141–2, 246 MacGregor, Rt Hon John 37–9, 51, 116, 117–18, 137, 138 MAFF 2, 27, 38, 39, 49, 50, 51, 52, 63, 65, 82, 85, 86, 87, 90–2, 117, 120–1, 125–6, 137–9, 140–1, 147, 149, 178, 201, 203 (note 67), 220, 235 monitoring by 74, 81–4, 120, 141–2 Major, Rt Hon John 26, 27, 28, 96, 158, 165–6, 167, 170–1, 173, 178, 179, 180, 181, 182, 184, 185, 186, 187, 189, 194, 226, 247 May, Sir Robert 206 (notes 77 and 79) McDonald’s 161 McKechnie, Sheila 133–4 McNeil, Johnston 29 Meat and bonemeal (MBM) 8, 11, 36, 109, 195 Meat and Livestock Commission (MLC) 51, 56, 87 Meat hygiene see Slaughterhouses, standards Meat Hygiene Service (MHS) 27–30, 30–2, 74, 80–2, 120–1, 121–2, 123, 141 Meat Inspectors 24, 25–6, 28, 30, 82–3 Mechanically Recovered meat (MRM) 11, 53, 84–6, 89–90, 118–20, 140–1, 246

Medicines and BSE 42 Morris, Professor Roger 40 Naish, Sir David 176 National Audit Office (NAO) 5, 192 Nature 18, 193–4 Newton, Rt Hon Tony 158 NFU (National Farmers’ Union) 162, 177, 180, 189 Non-cooperation 1, 167, 182–7 NPU 36, 67, 71 Nyala 34 Observer 2 Openness 106–7, 132–3, 145–6, 248 Organophosphates 36, 110 Pattison, Sir John 85, 87–9, 94, 95, 96, 97, 102, 144, 199–200 Pedigree Petfoods 51, 55, 114, 117 Phillips, Sir Nicholas 101, 106, 134 Pirzio-Baroli, Corado 168–9, 184, 209 Plumb, Lord 198 Portillo, Rt Hon Michael 28 Prescott, Rt Hon John 243 (note 11) Preston Report 25 Prion theory 19–21 Prosper de Mulder 79, 81, 114 PrP gene 20, 21, 108, 130 Public Accounts Committee 5 Rawnsley, Andrew 1–2, 239, 249 Recycling of animal waste 8–9, 44 Redwood, Rt Hon John 28 Rendering 10, 109–10, 162, 175, 189–90, 191 process 10, 36 Retailers 12, 161, 162, 163, 174 Ridley, Rosalind 22 (note 7) Rifkind, Rt Hon Malcolm 180, 182, 188 Rimmer, Vicky 76 Risk, communication of 123–5, 143–6 Robinson, Geoffrey 225 Rooker, Jeff 213–16, 235, 236, 238, 239 Santer, Commissioner 166, 179 SBO ban animal 55–8, 64–6, 77–80, 90, 121–3, 130, 142, 246 human 50–5, 90, 94, 117–18, 120–1, 138–40, 141–2, 152, 245–6

254

Index

School dinners 61 Scientific Veterinary Committee (ScVC) 59, 119, 212 Scrapie 14–16, 36, 132 SEAC 48–9, 55, 61, 64, 65, 72, 75, 76–7, 85, 86, 88, 92, 93–6, 126, 140–1, 143–4, 151, 160, 196, 219, 227–8 Secrecy, culture of 1, 2–3, 35, 113, 146 Selective cull 168–9, 180–1, 186, 193, 194–5 Sheep, BSE and 125, 195–6 Shephard, Rt Hon Gillian 28, 29, 30, 31, 77, 156 Slaughter/compensation scheme 36–9, 116–17, 137–8, 245 Slaughterhouses 9–10, 23–32 enforcement of controls in 24, 120 licensing of 24 standards in UK 23–5, 31, 123, 141 subsidy 163 Soames, Nicholas 25, 29 Southwood Committee 38, 41–6, 111–13, 131–3, 138–9 Southwood Report 42–6, 111–13, 131–3 Southwood, Sir Richard 13 (note 8), 41, 44–5, 51–2, 139, 206 (note 77) Spongiform Encephalopathy Advisory Committee see SEAC Standing Veterinary Committee (SVC) 165–6, 167, 169, 180, 182, 184, 203 (note 21), 217, 218, 232 Strang, Rt Hon Gavin 97–8, 208 Suckler herds 8 Suddeutscher Zeitung 199 Sun 186

Tallow 10, 181–3 Targeted slaughtering see Selective cull (Thirty) 30 months scheme 95, 96, 97, 149–50, 152, 160, 161, 168, 171, 174–7, 188–92 Thompson, Sir Donald 35, 51, 117 Times, The 36, 87, 141, 144, 187 Today 76 Tomlinson, Sir Bernard 87 Transmissible Mink Encephalopathy (TME) 19 Transmissible Spongiform Encephalopathies 14–22 Treasury 5, 29, 91, 100, 149, 163, 177, 190, 191, 210–11 Tyrrell Committee and Report 46–8, 49 Tyrrell, Dr David 47, 48, 144 UKASTA

55–6, 72, 80

Vaccines 15, 36 vCJD 1–2, 90–8, 165, 199–200, 201, 229, 245 Veterinary Record 35, 36, 38, 72 Waldegrave, Rt Hon William 27, 30, 31, 79, 156, 180, 194 Wilesmith, John 36, 39, 43, 46, 156 (note 2), 168 Will, Robert 47, 48, 49, 87–9, 95, 144 Williamson, David 168 Wilson, Sir Richard 100, 220, 224–7, 238, 239 Witness statements 102–3 Wrong, Michela 239–40, 242