Following that Whitehall herd instinct

How culpable were scientists in the BSE fiasco? Steve Farrar and Caroline Davis dissect the Phillips report

Close to the beginning of the BSE inquiry's 4,000-page report, it is noted: "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."

In Lord Phillips's script, the leading players - the scientists, policy-makers and civil servants - spent a decade wrestling with this conundrum.

The lengthy incubation period before Stephen Dorrell, then secretary of state for health, could announce a possible link between BSE and variant Creutzfeldt-Jakob disease was born of the considerable difficulties scientists had unravelling how these initially intractable new diseases probably emerged. It cruelly reflected the frustratingly long incubation period of prion infections themselves.

Yet the gradual understanding of the epidemic - still far from complete - is only one facet of the story. The glue that connected science and political action was advice.

The government constantly sought advice from scientific experts in a bid to project the likely future course of events and act accordingly.

The BSE inquiry was charged with establishing and reviewing the history of the emergence and identification of BSE and vCJD in the United Kingdom, and analysing the action taken in response to it, up to the day of Dorrell's announcement.

In the course of doing so, it names and shames nearly 30 senior civil servants and eight former government ministers. After a decade in which scientists have borne much of the public blame for the debacle, it is widely acknowledged that the Phillips report lets them off very lightly, while civil servants fare much worse. Generally, Lord Phillips is full of praise for the efforts of scientists in pursuing research into aspects of the epidemic.

The decision to set up the CJD Surveillance Unit in Edinburgh in 1990 was singled out as being vindicated by the prompt detection of the emergence of vCJD.

Referring to the detection of the first cases of BSE, Lord Phillips remarks: "It is to the credit of the system of passive veterinary surveillance and the skill of the Central Veterinary Laboratory pathologists that the disease was identified at a relatively early stage of the epidemic."

However, preliminary conclusions reached in those early days, when little was known of the new disease and projections were made simply on its similarity to the sheep disease scrapie, shaped scientific thought on the matter for a considerable time.

It was posited that as scrapie had clearly not infected humans, despite 200 years of exposure, it was probable that BSE would likewise prove not to be a threat to mankind.

This theory, although now widely rejected, allowed the message to be repeated that BSE was probably incapable of infecting people, to the relief of those who wanted to protect the British beef industry.

Along with the scientific advances, the inquiry catalogued delays and instances of poor communication between civil servants in the Ministry of Agriculture, Fisheries and Food, the Department of Health and the scientific advisers.

The report notes, for instance, that it took two-and-a-half years after scientific experts warned of the danger for official advice to be issued to schools about the risks from dissecting bovine eyeballs.

A prime example of poor communications came in 1990. Maff officials had stated that it was inevitable there would be a degree of contamination of the beef-cattle spinal column, still a source of meat, with spinal cord identified as a possible source of infection. But members of the Spongiform Encephalopathy Advisory Committee believed clean removal of the spinal cord was easy, having witnessed a demonstration at a slaughterhouse. When Seac then advised there was no need for further action to stop contamination - because they believed there was none - Maff officials interpreted this as meaning instead that the contamination they knew to be present was no cause for concern.

The amount of work being handled by Seac, a body of independent scientific experts set up in 1990 to advise Maff and the DoH, is criticised.

The report also notes: "Contrary to the expectations, and to some extent the wishes, of its members, Seac found itself given the role of providing policy advice on almost every decision that the government was faced with in handling BSE."

In addition, a number of times, assumptions were made that should have been questioned, such as what the minimum quantity of material that could transmit the disease might be. This had significant implications for subsequent advice and actions.

Between 1987 and 1996, the government spent more than £60 million on research into BSE, CJD and related diseases, of which £37.9 million came from Maff and £.4 million from the research councils. Nevertheless, the report says: "We have identified, with hindsight, areas where research could profitably have been started earlier or been pursued with more vigour. Also, an attempt might have been made, with advantage, to recruit expertise from the wider scientific community."

By September 1994, advances in knowledge had significantly altered the scientific evaluation of the risk that BSE might be transmissible to humans.

Indeed, Lord Phillips says that at least some of those responsible for public pronouncements were aware of the possibility humans might have become infected before the slaughter policy and the ban on specified bovine offal from human consumption.

Yet the public was not informed of this change. Instead, there were repeated public assurances that it was safe to eat beef, sometimes without any qualification. This was seen as an attempt to balance alarmist media coverage, "leaning into the wind," as one witness described it.

Those actions that were taken often appeared to be simply in response to public concerns rather than changing scientific views, sending out the wrong message to those charged with upholding new regulations.

"The impression thus given to the public that BSE was not transmissible to humans was a significant factor leading to the public feeling of betrayal when it was announced on March 20 1996 that BSE was likely to have been transmitted to people."

Among those singled out by the report for individual criticism are:

* William Watson, director of the Central Veterinary Laboratory (CVL) at Weybridge until 1990 and a member of Seac. He should have sought the assistance of the neuropathogenesis unit in Edinburgh, the acknowledged experts in transmissible spongiform encephalopathies (TSEs), from the beginning instead of delaying until June. He should also have urged the merits of publishing information about BSE sooner.

* William Rees, chief veterinary officer 1980-88. He should have permitted the publication of a proposed article in the Veterinary Record by Gerald Wells, head of neuropathology at the CVL, comparing BSE with scrapie. This would have resulted in a higher rate of referral of suspected cases. He should also, with Dr Watson, have sought to involve the DoH in consideration of risk to human health from BSE before March 1988.

* Keith Meldrum, chief veterinary officer, 1988-97, should have considered the impact of ruminated feed getting contaminated in feed mills, later pinpointed as a major problem. He should not have given the minister the impression that there was no likely connection between a cat found to be suffering a feline TSE in 1990 and BSE. He should also have anticipated serious problems in enforcing the ban on specified bovine offal in animal feed.

* The Southwood Working Party, an expert group, chaired by Sir Richard Southwood, professor of zoology at Oxford University, set up in 1988 to advise on the implications of BSE. The group advised that cattle showing signs of BSE should be slaughtered and destroyed, while concluding: "It is most unlikely that BSE would have any implications for human health."

The working party should have made clear the basis for its risk assessment - that BSE was probably derived from scrapie (now known to be incorrect) and that recommended precautionary measures should be adhered to. It did not and, despite all the uncertainty it noted, an unqualified reassuring message was drawn from its report: a message that was repeatedly cited over the following years. Another shortcoming of the report was that it did not recommend that the possible risks from eating animals incubating BSE but not yet showing signs of the disease called for any precautions. An inadequate review of the report by Maff and DoH allowed these faults to pass unnoticed.

* Sir Donald Acheson, chief medical officer 1983-91. He should have questioned the Southwood report's statement that offal was safe for adults but not for babies. He should have appreciated that his public statement about the cat was likely to give a false reassurance about the possibility that BSE might be transmissible to humans.

* Sir Kenneth Calman, chief medical officer, 1991-98. He should not have made unqualified statements in 1993 and 1995 that eating beef was safe. He should also have alerted the health minister, Mr Dorrell, when he was first informed of concerns about CJD cases among young people in February, 1996.

* Richard Kimberlin, scientist at the neuropathogenesis unit, Edinburgh, independent TSE consultant since 1988, member of Seac. He should have told members of Seac that questions he put to the committee had been drawn up by the Meat and Livestock Commission, for which he was acting as a consultant.

* Sir John Pattison, professor of medical microbiology and chair of Seac from 1995. He should not, along with Robert Will, director of the CJD Surveillance Unit, have issued reassurances on the safety of British beef at a press conference in December, 1995, on behalf of Seac, as it endangered the public credibility of a body whose job was to issue advice to the government.

SCIENTISTS WHO DARED TO CHALLENGE OFFICIAL FINDINGS

The Phillips report also looks at how the government responded to unsolicited independent views. It chronicles three cases of scientists attempting to challenge government scientific findings.

Two Leeds University microbiologists, Richard Lacey and Stephen Dealler, embarked on a media campaign to expose the risks of BSE. In 1990, they said the possibility that it could be transferred to humans should not be dismissed and two years later told newspapers that an epidemic of BSE was "likely to hit the human race by the end of the century".

The Ministry of Agriculture, Fisheries and Food dismissed their claims as alarmist and not supported by science. However, the Phillips report said Professor Lacey and Dr Dealler were serious scientists. It concluded: "The public concerns raised by media coverage of views expressed by Professor Lacey were unwelcome to the Maff. With hindsight, it seems to us they were beneficial."

The report examines whether Maff was at fault in failing to support Harash Narang, a Public Health Laboratory Service microbiologist who specialised in spongiform encephalopathies. He had developed tests that he believed could be of use in diagnosing BSE or CJD. In 1989, he contacted the CVL to discuss funding for collaborative work. The report found that although the CVL initially proclaimed Dr Narang's proposals "too good an opportunity to miss", he experienced repeated delays in his dealings with Maff in terms of securing funding, accessing research samples and the publication of his results.

The report says this led to allegations that Maff was afraid to develop such a test because it could expose the extent of BSE.

Mark Purdey, an organic farmer, had been looking into the use of organophosphorus compounds in the treatment of cattle for warble fly infection. He suggested a link between BSE and these compounds. He wrote to Maff with his theory in 1992, but was told that there was no evidence to support his claims. However, extensive media coverage forced Maff to take notice. In 1995, the Medical Research Council toxicology unit began some experiments that proved inconclusive. The Phillips report commended Mr Purdey for his tenacity in pursuing his theories in the public interest. Although it said the government had given them fair consideration, it concluded that organophosphorus compounds may yet be proved to make cattle susceptible to BSE.