The British population was in the 1990s involved in a real time experiment to see the extent to which BSE ('mad cow disease') had been transmitted to humans and so caused vCJD. (CJD is a rare disease which was identified many years ago. New variant CJD (vCJD) is relatively recent variant, clearly linked to the consumption of BSE-infected beef.)
There were interesting lessons to be learned concerning the interpretation of statistics, and concerning the way in which the crisis was handled by the government machine. The science/statistics issue is considered in a separate note. This web page summarises and comments on the Phillips report on the Government's handling of the BSE crisis which was published in October 2000.
See also a separate note which gives advice to officials on the preparation of advice to Ministers on risks to health and safety.
The Inquiry's key conclusions that affect the civil service are:
- In the years up to March 1996 most of those responsible for responding to the challenge posed by BSE emerge with credit. However, there were a number of shortcomings in the way things were done.
- At the heart of the BSE story lie questions of how to handle hazard - a known hazard to cattle and an unknown hazard to humans. The Government took measures to address both hazards. They were sensible measures, but they were not always timely nor adequately implemented and enforced.
- The Government was anxious to act in the best interests of human and animal health. To this end it sought and followed the advice of independent experts - sometimes when decisions could have been reached more swiftly and satisfactorily within government.
- In dealing with BSE, it was not MAFF's policy to lean in favour of the agricultural producers to the detriment of the consumer.
- At times officials showed a lack of rigour in considering how policy should be turned into practice, to the detriment of the efficacy of the measures taken.
- At times bureaucratic processes resulted in unacceptable delay in giving effect to policy.
- The Government introduced measures to guard against the risk that BSE might be a matter of life and death not merely for cattle but also for humans, but the possibility of a risk to humans was not communicated to the public or to those whose job it was to implement and enforce the precautionary measures.
- The Government did not lie to the public about BSE. It believed that the risks posed by BSE to humans were remote. The Government was preoccupied with preventing an alarmist over- reaction to BSE because it believed that the risk was remote. It is now clear that this campaign of reassurance was a mistake. When on 20 March 1996 the Government announced that BSE had probably been transmitted to humans, the public felt that they had been betrayed. Confidence in government pronouncements about risk was a further casualty of BSE.
In short, the Government was well intentioned but far too secretive. Greater and earlier openness might have caused problems, not least for the farming industry, but the long term consequences would probably have been been less damaging.
The report's introductory comments on the performance of individual civil servants are worth repeating in full:
- Should offal of sheep be removed from human food?
- Should tripe and rennet from the abomasum be included in the SBO ban?
- Should tissues from calves under the age of 6 months be excluded from the SBO ban?
- Was MRM a risk to humans?
- He recommended that there should be no exclusion from the SBO ban of intestines that had been procured to produce sausage skin.
- In 1990 he raised concerns in relation to peripheral nervous tissue going into MRM
- In 1994 he raised the suggestion of banning recovery of MRM from the spinal column.
"It is inevitable that an Inquiry such as ours focuses on what went wrong. The main point of having the Inquiry is to find out what went wrong and to see what lessons can be learned from this. This can be harsh for individuals. Their shortcomings are put under the spotlight. The overall value of the contributions that they have made is lost from view. We do not wish our Report to produce this result. Yet we cannot set out in detail the workload over the years of each of those who has received - at one point or another - a criticism in our Report. We must make some general comments.
The more senior posts in the civil service are seldom sinecures. Ministerial office never is. We have limited our consideration of individual responsibility to those who occupied such positions. The shortcomings that we have criticised have not been the product of indolence; they have for the most part been mistakes made under pressure of work ñ pressure made the greater by the imposition on already busy lives of the considerable additional burdens of handling BSE.
The day- to- day demands made by BSE on MAFF, and particularly on the State Veterinary Service, were considerable. By way simply of example, in the period with which we are concerned approximately 200,000 suspect cattle had to be inspected, slaughtered and autopsied by histopathology. The carcasses had to be collected and destroyed. Compensation had to be assessed and paid.
Between 1988 and 1995 about 30 Statutory Instruments in Great Britain alone were brought into force making or amending Regulations dealing with BSE. Some of these involved a great deal of work, but more significantly they evidence the ongoing attention being focused on addressing the implications of BSE for both animal and human health during a period when it was considered unlikely that BSE was in fact a threat to humans. Thus the individual criticisms that we have made must be read in the context of participation in a positive response to BSE, which on the one hand brought the animal disease under control, and on the other resulted in the removal from human food and from medicines of a very high proportion of the material that might have had the capacity to infect.
There are aspects of the response to BSE that stemmed from broader government policies, or from particular ways of handling the problem. Again, these may not be matters that give rise to individual criticism, but they may well highlight lessons for the future. For example, we have noted that Ministers often sought policy advice from SEAC during most of the period. A lesson we have drawn from this is that where the policy decision involves the balancing of considerations which fall outside the expertise of the committee, it will normally not be appropriate to ask the committee to advise which policy option to adopt. It is not our job to examine broad government policies, for example the deregulation initiative. Where relevant, we have examined their implications for the BSE story. For example, our consideration of the impact of the deregulation initiative for slaughterhouses is in Volume 6.
Those who were most active in addressing the challenges of BSE are those who are most likely to have made mistakes. As was observed in the course of the Inquiry, if you do not put a foot forward you do not put a foot wrongí. In this context we think it right to single out for mention Mr Meldrum. Mr Meldrum was Chief Veterinary Officer in Great Britain for almost the whole of the period with which we are concerned. He involved himself personally in almost every aspect of the response to BSE. He placed himself at the front of the firing line so far as risk of criticism is concerned.
Mr Meldrum impressed us as a particularly dedicated and hard- working civil servant. We are aware that many consider that he epitomises an approach on the part of MAFF that placed more weight on the interests of the farmer than on the safety of the consumer. We do not consider such an accusation to be fair.
Mr Meldrum was at all times concerned that the livestock industry should not be damaged by a public reaction to BSE for which there was, in his opinion, no scientific justification. That is not an approach for which Mr Meldrum can be criticised. On the contrary, we consider that it was a proper approach for the Chief Veterinary Officer to adopt.
In the BSE story there were a number of issues on which Mr Meldrum advanced the view that the possibility of risk to humans was too insignificant to warrant precautionary measures:
We do not doubt that the views which Mr Meldrum advanced reflected his own beliefs.
When Mr Meldrum had concerns about risks to humans, he acted on them. Thus:
We are satisfied that where Mr Meldrum perceived the possibility of a significant risk to human health he gave this precedence over consideration of the interests of the livestock industry.
Pressures on busy people go some way to mitigate a number of other criticisms that we have made ñ for example, the failures to review the Southwood Report , and failures to give rigorous consideration to the form of the animal SBO ban.
We have criticised the restrictions on dissemination of information about BSE in the early stages of the story, which were motivated in part by concern for the export market. We suspect that this may have reflected a culture of secrecy within MAFF, which Mr Gummer sought to end with his policy of openness. If those we have criticised were misguided, they were nonetheless acting in accordance with what they conceived to be the proper performance of their duties.
For all these reasons, while we have identified a number of grounds for individual criticism, we suggest that any who have come to our Report hoping to find villains or scapegoats should go away disappointed."
The Government's interim response to the report seemed to accept all its key conclusions and recommendations. Its weakness, which to some extent it shares with the wider Modernising Government Initiative, appeared to be that it promised change in some but not all of the principal characteristics of the organisation that is the modern UK government. As long as other characteristics remain the same, it seemed all to likely that the organisation would remain in its original risk-averse and uncommunicative shape.
Whilst one must applaud the fair-minded approach displayed in Phillips' comments, and the sensible nature of the Government's interim response, it will nevertheless remain difficult truly to change Whitehall's current culture. Indeed, there must now be a real danger that senior officials will, with some relief, mentally file away the BSE report and fail to learn and act on the wise advice that it contains.
It is also worth noting that the inquiry team, like the earlier Scott Inquiry into "Arms to Iraq" felt it right to comment on the work and performance of individual civil servants. I think that this was inevitable and right, but it is a small breach of the principle that officials advice to Ministers is private. I suspect that this breach could in fact be made a little larger without greatly damaging the relationship between officials and Ministers, and maybe there should be more frequent inquiries into the effectiveness of civil servants' handling of major issues. But I believe that the wholesale publication of policy advice would greatly inhibit the freedom of Ministers. I know that some think that this would be a good thing, but I instinctively doubt it, and fear for the power that would inevitably be handed to officials as a result of such openness.
Finally, the scientific conclusions are also interesting. Scientists originally thought that BSE was probably transmitted to cattle from sheep with scrapie (e.g. in recycled animal protein used in cattle feed). And this led some scientists to suggest that it was therefore possible that the disease could also cross the further species barrier into man, whilst others pointed out that scrapie had never crossed from sheep to man, so it was unlikely that BSE would do so.
However, the inquiry concluded that the disease probably originated as a gene mutation in cattle in the 1970s. This means that scrapie did not cross any species barrier from sheep. The new disease was therefore not derived from scrapie and, unlike scrapie, it was able to cross the species barrier into man and so cause new variant CJD.