Warmwell's Lessons Learned session. 23 May 2002


Full notes of the meeting may be read here (From the Lessons Learned CD)
The Lessons Learned Inquiry have been aware of the warmwell website for several months and they have been directed to many of the most important files.

This was a face to face meeting to give an overview.

We spent quite a lot of the session trying to get through to the three men (Rupert Cazelet, Dr Iain Anderson and Alan Evans) that the disease was in the DECLINE stage by the time Prof Roy Anderson took over the leading of policy at the instigation of Prof King. Our explanation was of necessity complex. We left room for doubt - after all this cannot be proved to others until a proper analysis is done and published of the test results and locations of those first 800+ outbreaks. But it is an investigation that can and should be done.

Everyone seems to have looked at the graph for Late Feb and early March that rises steeply up until - apparently - Prof Anderson arrives with his model in one hand and scythe in the other - and the graph curve starts to "come down".

But...was the sharp upward curve "new" cases showing that the disease was rising unaccountably out of control? Or were Nick Brown and Jim Scudamore actually right in the EFRA committee of 21 March when they said "..One uncertainty is how much infectivity is out there; the other is what is incubating but has not yet shown itself. ..... In as much as we have imposed blanket movement restrictions across the whole of Great Britain, all movements are controlled. In other words, we are not spreading the disease by the movement of animals. That is also what I mean by "under control".

In spite of this, and the assurances of Alex Donaldson that this was a disease that could be correctly handled by tried and trusted methods ( slaughter the IP within 24 hours then monitor neighbouring farms and DCs unless they were high risk) the modellers convinced all and sundry that this graph shooting upwards meant that far more draconian methods were necessary.

But the graph was very probably showing, as can be resolved once and for all by the existing but unpublished data, not new outbreaks from farm to farm spread, but discovered "old" cases. "New" outbreaks were not popping up unaccountably or spreading farm to farm out of control; they were incubating already and appearing as a result of their pre ban links with source infection. As a result of the great delays in slaughter that Nick Brown admitted were a real problem, some may have been being infected by a large amount of virus appearing where infected animals were able to spread the virus - a problem that would have been solved by using manpower properly and slaughtering within 24 hours.

When delays allow cattle to develop full blown FMD the lesions produce 100,000 to 500,000 times more virus.

We explained that we need a proper analysis of what this "rising graph" actually conveys. Was it a disease going out of control because of new ways of spreading? Or was it classic FMD incubating, showing itself as a result of known links to infected sources or spreading as a result of delays in slaughter?

The modellers must have assumed the former; their plan of "bearing down on the disease" is at least understandable - given that vaccination was so absurdly ruled out and given that they had such a sketchy idea about transmission.

But if - as is now widely believed - it was the latter, i.e. previously undiscovered disease or disease spreading as a result of delays on IPs, most of which were not being dealt with quickly, then the contiguous cull just made things far, far worse. Tragically so.

This is difficult to convey for the first time to those not conversant with it. Poor Dr Anderson returned to the graph again and again. Although of course he did not say so in so many words, he appeared convinced that - leaving aside what happened after the end of March in terms of poor management - the decision to instigate the contiguous cull was reasonable and proportionate.

It was not reasonable if one remembers that there were experts on hand who were telling them that it was not. Paul Kitching was called a Neanderthal for his pains. Professor Fred Brown, one of the most straightforward and kindly men it has been our privilege to meet, was derided and accused of having commercial interests. The same sort of mud slinging was directed at Simon Barteling - a world-renowned expert who was offering the most generous and disinterested advice. Pirbright was sidelined. Gloss and Image won the day over quietly spoken expertise. This is not excusable. It is not reasonable and proportionate. Our words here fell on stony ground.

On the question of how good were the contingency plans, we discovered that the team had never, apparently, heard of the 1993 EU recommendations for contingency plans - It seems MAFF too were unaware of it since their own attempt had been so pitiful.

The point was made that when the EU made the extraordinary statement in answer to a question by the Temporary Committee, that DEFRA's plan "had no major flaws" it was not that it didn't indeed have very many major flaws. It was rather because NOT to say so would make the Commission look irresponsible for accepting it as sound. At this, Anderson looked highly sceptical. The fact remains however that this whole catastrophe has been made worse by human failings - destructive behaviour caused by those with power over people's lives. They behaved, whether they realised it at the time or not, in ways that hurt others. Ignorance, fear , arrogance and intimidation characterise this episode.

Centralisation led to scenes of horrific cruelty and utterly indefensible situations; lambs dying in mud, animals starving because of mad regulations, inexperienced slaughtermen killing brutally and messily, animals in extreme terror. This was safe ground for the team. They had heard it all before.

It was also mentioned that Alan Richardson, Roger Windsor, Ken Tyrell and co had found it impossible to operate as the experts they are in the circumstances imposed. All that expertise wasted. I made the point that proper funding and genuine management skills (not jargon and "targets") would have made a difference - but years and years of "Buggins' turn" does not make for common sense or grasp of logistics.

The really terrible aspect of the situation was the "little-nazi" attitude of the local MAFF officials. It seemed that in a sort of way they were obsessed with the virus as if it had been a malevolent spirit that must be eradicated from their patch at any cost - animal or human. It was like a witch hunt. Like bad officialdom anywhere, they couldn't cope with anyone "disobeying" or questioning their rules. And since they had no reasonable arguments to offer (not their fault - they were "obeying orders" the poor mutts) they simply fell back on bullying and intimidation. A sorry tale of centralisation gone mad.

Any future plan must use the local expertise available.

Dr Anderson nodded when we talked about local authority services having the right to take initiative, experienced private vets being listened to, expert teams being recruited well in advance of any emergency, and junior members of it trained in advance.

However, when we strayed into the area of vaccination we found, to our amazement, that it was too hot a potato to be passed across the table, while the subject of "sidelined FMD scientific experts" led us onto even stonier ground.

All that we felt so passionately about the tragic refusal to use "ring" vaccination or on farm tests such as the USDA/Tetracore rapid diagnosis machine (and the sorry tales of in-fighting and wrong reagents) was rather impatiently swept aside. Nor did Dr Anderson wish to hear of David Shannon's opinion of the "scientific group" brought in by Professor King, none of whom except Prof Donaldson had the faintest notion of FMD any more than he did himself.

Stephen Smith QC had written us a new letter about the legality of the contiguous cull. Although there was no time to talk about this I left a copy with the team, wondering whether it would be read, with all the relevant bits not only underlined but summarised in the margin. Let us hope it makes someone think about the fact that no judge at any point gave a judgement that can be construed as recognising any legality to the blanket culling of healthy animals. The two judgements clung to by Lord Whitty - Winslade and Westerhall in Scotland - were given on the grounds of safety margins. Had the real nature of virus transmission been disclosed - as they were in the Grunty case - these judgements would have been seen to be wrong.

The letter is vitally important, showing as it does that neither Winslade nor Westerhall were a judgement that could be construed as giving legal sanction to the contiguoous cull. The Upton case came later, took two days and considered the disclosed scientific evidence that had been missing in the others - and therefore the Winslade case can hardly be considered a precedent. That disclosure was not made in the earlier cases - and had it been, the judges would certainly not been likely to interpret margin of safety as they did - and that even though Upton was a DC case the Scientific evidence was highly relevant because the judge realised that even had the animals become infected there would be no risk to outlying farms.
The fact that a DC case - considered as they were as MORE dangerous - was given this judgement and DEFRA required to pay costs, makes it even more unlikely that had DEFRA had the nerve to test the courts again, any judgement would have been given in their favour.


Full notes of the meeting may be read here (From the Lessons Learned CD)

We felt less than optimistic after the meeting - but grateful at least for the time made available to us. They had actually made another session available to us the same day since we had been so late ( wrong sort of car on the railway line) and since Dr Anderson evidently felt there was some substance in what we were saying. This made a very long day for the team.

Meanwhile we shall continue to conduct our own public enquiry on these pages.

One interesting and cheering piece of information received today concerns the evidence of Professor Anderson, appearing in Brussels on 21 May. A smooth performer, he went through his urbane and confident explanations. However, he did not find the usual "Emperor's New Clothes" reaction. Dr Simon Barteling, who followed him, began by saying, "I do not agree with one single word of what Professor Anderson has said." And we are told that the Committee Members were inclined to agree.


There has been a lot to say on warmwell today on the scrapie issue. We can't help feeling that there is something really quite underhand - indeed sinister - going on. The SEAC/FSA activity and spin is too blatant to be ignored. What is their game? If their main concern were the real safety of food they would NOT be stifling the research efforts of rival scientists into BSE.

Their arrogant pronouncements about older sheep, beef and goat meat from other countries is infuriating Africa. There is little doubt that they have been softening up public opinion and sheep societies (semen banks!) for a mass cull. But why?

Over the past year we have become far more wary of conspiracy theory and far more aware of just how easy it is for human beings to make dreadful and far-reaching errors. But this seems different.

It's hard to escape the speculation that they want to be able to boast of a completely scrapie free national flock.

The argument that to allow genotypes susceptible to scrapie to go on breeding is "irresponsible" is persuasive (although only of any value if the link with CJD were established which it is not) It is so persuasive that they used it to get through their nasty little SI 843. Yet the slaughter of susceptible animals is NOT required in Europe. It's no good their denying that this was Animal Health Bill by the back door. It was.

We get worried every time we remember that there is such a close link between Roy "FMD"Anderson and John"GMOs" Krebs (SEAC/FSA) and that it is their pronouncements that are so fuelling the irrational fear that CJD could be caught from sheep. I very much fear that David Byrne is on the same "net".

The influence of the NFU was behind the conservative party's abstention. Why? How can legislation capable of such a shameful and unnecessary waste of life and money be driven from such quarters? How could the vaccination issue have been so lied about? Is this a sordid gambit for huge gain? Dizzy incompetence that, once begun must be pursued for fear of lost face? Could the FMD policy and the scrapie/BSE/CJD fiasco have been genuine attempts to do good? If so, whose good? Who can possibly gain from any of the measures imposed on farmers and their livestock over the past terrible months? What do others think?


Answers
1. From Delaine on how prepared was the UK in reality?

2. From Janet on scrapie and the ignorance of relevant legislation among those it most concerns

3. From Alan Beat extract from a letter to Lessons Learned pointing out that "if the new culling policies were to make any impact on the course of the epidemic, this would show as a marked decline in daily case numbers commencing on or around 9th April. That did not happen, in fact there is no significant change in the pattern of decline at any point that can be attributed to the new culling policies."

4. From Mark Purdey's article about why the scrapie theory is so useful to the government.