THE ROYAL SOCIETY OF EDINBURGH ENQUIRY
INTO THE FOOT AND MOUTH DISEASE OUTBREAK IN SCOTLAND IN 2001.
Roger S. Windsor
MBE. MA. BSc. BVM&S. MRCVS
My views are put to the committee in the form of a series of questions to be asked:
A. QUESTIONS OF A POLITICAL NATURE
1. Why had successive governments failed to invest in veterinary education, veterinary research and the State Veterinary Service ?
The number of veterinary surgeons working for MAFF was reduced from 570 in 1968 to 270 in 2002.
2. Why had successive governments failed to invest in the BBSRC Laboratory at Pirbright?
This laboratory is the World Reference Centre for foot and mouth disease (FMD) and in 1967 employed 19 veterinary surgeons. At the start of the 2001 FMD outbreak there were only 3 veterinary surgeons working at Pirbright - there are now only two ! This laboratory now does almost no veterinary research work and most work is of a molecular nature.
3. Why had successive governments failed to invest in Customs Services, to prevent the illegal importation of animal products ?
Much has been made of the legal importation of animal products as being the likely cause of the importation of the virus. Given the veterinary controls that are in place, this is unlikely. There is a possibility of animal products entering countries such as Italy and Greece from the Balkans and further east. Once in the EU, with a minimum of processing, they can then be shipped on to other countries as being of Italian or Greek origin with no disclosure of their actual country of origin: this anomaly must be addressed. However, much the greater risk is the illegal importation of "bush meats" and other processed or unprocessed animal products from Asia and Africa. Customs officers and dogs are required to check all containers coming from outside the EU.
4. Why was the control of the outbreak taken out of the hands of the Chief Veterinary Officer and put into the hands of:
Prof. John Krebs - No veterinary training,
Prof. John King - No biological training,
Prof. Roy Anderson - No veterinary training ?
5. Why is the government no longer supporting teaching at the Centre for Tropical Veterinary Medicine ?
The CTVM was set up by the University of Edinburgh in conjunction with what is now the Department for International Development, to train British and foreign veterinary surgeons and animal scientists in husbandry and tropical diseases, and to carry out research into these topics. This is the only such institute in Britain and in the future should play a much greater part in the training of British and overseas veterinary surgeons in the epidemiology, diagnosis and control of epizootic diseases including FMD, which could be introduced into Britain.
6. Have ministers and officials acted illegally in requiring veterinary surgeons in their pay, both salaried and fee-earning, to practice veterinary surgery below the normal professional standards, to the detriment of animal welfare?
The case for this is argued below under D 1.
7. Why did the Government permit the social destruction of the country in the name of animal disease control ?
Decent honest people were turned into criminals because they loved their pets. The police invariably sided with the authorities and some of their actions would have been normal in a police state: doors were broken down, deception was used to gain entry so that animals could be slaughtered, young girls were taken to police stations in handcuffs, and road blocks were set up before dawn. Farmers were blackmailed by SERAD officers and members of the State Veterinary Service: they were told that if they did not permit the slaughter of their sheep then their cattle also would be slaughtered. Farmers were known to issue "death threats" to other farmers and a livestock dealer had to be imprisoned for his own safety.
B. QUESTIONS FOR SERAD
1) Why was the contingency plan for Dumfries and Galloway not used ?
Among the items recommended in the plan was that the Centre should be set up at the Crichton Estate, using the Easterbrook Hall. Had this been done, all staff could have been on one site not in two buildings 70 miles apart, with all the decision makers on one site and all the workers on the second. There is plenty of parking and office space and all the other Government Departments would not have been inconvenienced. Do not accept the argument about it being difficult to instal computers. The use of computers in Scotland was a sick joke (see below).
2) When and why were MAFF's contingency exercises stopped ?
When I was a DVO (1978-9) at Tolworth (fore-runner of Page Street) contingency plan war-games were held on Saturday mornings.
3) Why was the outbreak in Dumfries and Galloway controlled from Ayr ?
Was it because people did not want to leave home ? Did not want to travel ? The official answer was that it was too difficult to set up the computers !
4) Why was the centre directed by a man who was only of acting Divisional Veterinary Manager rank ?
In 1967/8 each centre was head by a Regional Veterinary Officer.
5) Why was the man in charge of the Dumfries Office only of Veterinary Officer rank (the lowest grade that exists for a veterinary surgeon) ? Please note that this is not a criticism of the man who ran the Dumfries Office, who did a fine job in difficult circumstances,
This is a serious criticism of the Management of the Veterinary arm of Scottish Environment and Rural Affairs Department (SERAD).
6) Why were the ACVO and the RVO almost never seen in Dumfries ?
Were they concerned about personal survival rather than taking responsibility ?
7) Why were veterinary surgeons with experience of foot and mouth disease both in Britain and overseas (Minor, Richardson, Windsor and many others) used as foot soldiers, when the management of the outbreak was put into the hands of inexperienced veterinary surgeons with no knowledge of the disease or its control, and even less knowledge of management ?
The same could be said of the control room in London (SVS, Page Street) where the veterinary surgeons taking the telephonic reports from the field and making decisions, were often people who had never seen the disease.
8) Within the Dumfries Office why were the staff not divided into teams under an experienced leader ? This did happen after six weeks or so but only after regular requests to the Edinburgh managers. When it did happen why did the teams shift and change so that no team spirit developed ?
The real answer is that there was nobody in charge who had any idea how to organise a large team of professional staff. In England it was noticeable that the management improved when the army were brought in. In Scotland the army was only involved with the cull.
9) Why was the computer system such a disaster ? Why were no attempts made to remedy the problems when the Edinburgh managers were asked time and again ?
7 Why was the Scottish computer system incompatible with the English system ?
7 Why was the IACS map system not compatible with any other system used in Scotland ?
7 Why were staff not issued with farm maps ?
7 Why were Visit Report Requests not issued as a computer print-out containing the results of previous visits ?
Because of this nonsense, thousands of hours of veterinary time were spent filling in pages and pages of forms which then took more veterinary time to examine in Ayr and more thousands of hours of support staff time entering the results into the computer, only for these results to be ignored.
10) Why were there no briefing meetings to inform staff what was going on ?
In 1967/8 at every centre there were meetings morning and evening so that it was usually possible for staff to attend one or other. In Dumfries there were occasional briefing meetings, usually at 7:00pm.
11) Why were staff given no explanation about the daily aims, national aims, or the overall picture ?
The opinion of the staff was that the Management had no idea themselves.
12)Why did the senior staff have no idea about the computer model that was being used to orchestrate the contiguous and three kilometre cull ?
When questioned about this at a meeting in Dumfries the RVO stated that he had gleaned information about the computer model from the internet, but did not know which one was being used!
13) When the widespread killing was introduced why did SERAD not bring new legislation to ensure that what they were doing was legal ? Why did they instruct veterinary surgeons to sign the Form A (the Form that is used when a farm is known to be infected), after having first examined the animals to ensure that they were all healthy ?
This has been referred to the Royal College of Veterinary Surgeons because there is a strong body of opinion in the profession that what these TVIs did amounted to "false certification". The hastily introduced "Animal Health Bill" with its poorly thought out regulations is an attempt to make good the deficiencies of last year.
14) Why did senior SERAD staff tell lies to the TVIs ?
The worst example of this was when TVIs were informed that if they did not sign the Forms A, the animals would be slaughtered anyway, but the farmer would receive no compensation.
15) Why did SERAD find it necessary to resort to police state tactics ?
There can never be any excuse, in the name of disease control, to make criminals of decent people. It was totally unnecessary to employ these high-handed tactics -
7 smashing down doors, arresting teen-age girls and taking them to the police station in handcuffs,
7 prosecuting people who objected to their pets being slaughtered,
7 arranging with the police to set up road blocks in the night.
7 threatening farmers that if they complained about the slaughter of their sheep, their cattle would killed as well
This is perhaps the most distressing part of this whole sorry mess.
16) Why were SERAD responsible for the appalling lapses in animal welfare ?
The rigid and often illogical imposition of movement controls affecting animals, food and bedding resulted in some of the most distressing lapses in animal welfare that the authors have ever seen: animals standing up to their bellies in dung; animals crowded into pens so that they could hardly move; animals giving birth unattended because the farmers were prohibited from bringing the flock or herd home; the list is endless. And this was done in the name of disease control !
The answers to questions 1 to 13 all demonstrate that there was NO LEADERSHIP.
C. QUESTIONS FOR THE FARMING COMMUNITY
1. Why did the farmers and in particular the Scottish NFU reject the use of vaccines ?
There are good effective vaccines now available against FMD viruses. Even if the vaccinated animals were slaughtered at a later date (although there is no scientific evidence that such a policy is necessary), it would have been cheaper, more effective and have caused far less suffering and social damage than the contiguous and 3 Km cull policies.
D. LEGAL AND ETHICAL ISSUES FOR THE ROYAL COLLEGE OF VETERINARY SURGEONS (RCVS). (This Section is based on the evaluation by Dr Alan Richardson PhD. BVetMed. MRCVS. and is not put in the form of questions)
1. The duties of care towards animals are defined in several statutes, for example the Protection of Animals Act (1911). These statutes bind the veterinary surgeon, like any other citizen, but the Veterinary Surgeons Act (1966) confers upon him certain privileges, by restricting the practice of veterinary surgery to members of the profession. To quote from the Royal College of Veterinary Surgeons (RCVS) Guide to Professional Conduct (2000, p30):
"The Veterinary Surgeons Act (1966) provides, subject to a number of exceptions, that only registered members of the Royal College of Veterinary Surgeons may practice veterinary surgery. "Veterinary surgery" is defined within the Act as encompassing the "art and science of veterinary surgery and medicine" which includes the diagnosis of disease and injuries in animals, tests performed on animals for diagnostic purposes, advice based upon diagnosis and surgical operations which may not necessarily form part of a treatment. These restrictions are in the interests of ensuring that animals are treated only by people qualified to do so." (Author's underlining)
2. RCVS jurisdiction applies to all veterinary surgeons (Guide to Professional Conduct, 2000 p 43).
3. The diagnosis of Foot and Mouth Disease (FMD) and its treatment, namely euthanasia of affected and contact animals, is the practice of veterinary surgery, as defined in the Veterinary Surgeons Act and so is the responsibility of a veterinary surgeon from initial clinical examination until the animals' deaths.
4. A veterinary surgeon is obliged to practise according to the highest professional standards and undertakes continuing professional development (CPD) to meet that obligation. If he fails to practice to a reasonable standard, he may face a civil action for negligence. A veterinary surgeon losing a civil case may also be punished by the RCVS.
5. The RCVS may also rule on clinical standards even where there has not been a civil action, so clinical standards regarding FMD diagnosis are subject to RCVS jurisdiction.
6. A veterinary surgeon who lowers his clinical standards to co-operate with a layman to practice veterinary surgery cannot absolve himself from the responsibility for any unfortunate outcome on the grounds that he was meeting his client's wishes. Indeed, it is likely a court would hold him fully responsible and the RCVS would deem him to have acted unprofessionally. A veterinary surgeon would probably have no defence from pleading that he co-operated against his will and judgment, to please his client and earn his fee.
7. The diagnosis of FMD is largely based upon clinical findings and usually (apart from the disease in sheep) offers no serious problem. Sometimes it is not possible to confirm the disease at once because the presenting lesions are not typical. But it may not be possible to rule it out either. In such cases laboratory investigations of tissues are indicated. However, such is the nature of the disease, that when the first affected animals do not show typical lesions, it is often only a matter of hours before typical lesions do appear in the first affected or the contact animals. The best practice requires laboratory tests and/or keeping the animals under close observation. In positive cases the lesions soon appear; in negative cases they do not. This simple protocol, used in all previous FMD outbreaks, may be regarded as representing the state of the veterinary art. Anything less than the application of this standard, to the detriment of the animals, is probably unethical behaviour as defined in the Guide (p 42) being "a departure from that standard of behaviour accepted as the norm."
8. In early March 2001, Temporary Veterinary Inspectors (TVIs) were presented with animals with clinical histories and lesions typical of FMD. In many, if not all, instances, the veterinarians at HQ declined to accept the diagnosis and required laboratory confirmation. This was not best practice and appears to have been a general policy, rather than a response to individual cases. The effect was to prolong the suffering of the affected animals, the development of disease in more animals and the generation of more virus challenge to neighbouring farms.
9. As the outbreak progressed, there was a change of policy and far from demanding laboratory confirmation of all clinical cases, the veterinarians at HQ began to refuse testing in doubtful cases; they also refused to allow a period of observation. Instead they required the TVI to choose between declaring the animals FMD free, or advising "slaughter on suspicion". There is a significant difference between not being able to rule out the presence of the disease and suspecting that it is present. The option offered to the TVI did not admit of this difference and placed him in a dilemma. Because opting for the negative diagnosis carried the onerous responsibility for mis-diagnosing a positive case, with frightful consequences, a TVI invariably opted for the "slaughter on suspicion." He did not arrive at a diagnosis by due state of the art process, but made a guess. The correct diagnostic procedure (state of the art) was not implemented. The result was that perfectly healthy animals committed to his care, (see above) or the CVO's care, were often slaughtered in very unsatisfactory conditions. In obliging the CVO, the TVI, arguably, could not but fail to breach his duty to the animals committed to his, or their, joint care.
10. Killing all the susceptible livestock within three km of an FMD infected place, irrespective of local circumstances, extended the notion of slaughtering on suspicion to the extent that animals were suspected of suffering FMD merely on account of their geographical location, without reference to particular local circumstances. This was a further departure from "best practice".
11. The withholding of laboratory tests from animals that might have benefited from them was a breach of duty to animals committed to my/our care.
12. After slaughter, animals killed "on suspicion," having been refused the benefit of laboratory tests when alive, were then subjected to tests with the results given to the farmer. These often cast doubt on the diagnostic, or rather guessing, competence of the TVI. This practice also served to bring the profession into disrepute and arguably the CVO was culpable in that regard.
13. There are grounds for believing that the debasement of the diagnostic protocol was dictated by the government's electoral concerns. As early as April 26th 2001, Valerie Elliot wrote in The Times, "There will be no new FMD cases by the time of the election date of June 7th , the government's Chief Scientific Officer has predicted. David King told the Agriculture Select Committee that epidemiologists believed that the number of new cases would drop to zero in the days before June 7th." Clearly this date was significant to the epidemiological modellers, presumably because they were asked about it. It had no significance from a disease control point of view. This provides the reason for suspecting that that the drastic culling was instituted to validate the model's prediction and to eradicate the disease in time for the election, even though it required debasing the diagnostic criteria and killing far more animals than was strictly necessary for disease control.
This disaster must never be allowed to happen again. The basic cause was that successive governments have failed to invest in public services. They have failed to invest particularly in Customs Services and in veterinary training, research and the State Veterinary Service: indeed they have slashed the numbers of veterinary surgeons in the SVS, particularly in those at the higher ranks. The training budget for SVS staff has almost disappeared and as a result the university departments that provided the training have closed the courses (in particular Edinburgh University has been seriously affected). As our society grows more complex and as people travel round the globe more freely it becomes ever more important to invest in surveillance services.
Political considerations resulted in the removal of the control of the outbreak from the hands of the Chief Veterinary Officer and his usurpation by the Prime Minister, the Chief Scientist and the assorted mathematical modellers round Britain. As a result there was no single, simple, line of command and policy was implemented in different ways in different parts of Britain. This resulted in confusion, and loss of public confidence in the government policy. The massive slaughter of millions of healthy animals (when there was a perfectly good vaccine available) has led to serious social disruption, hardship, unrest and damage to the fabric of the country. There is also evidence that the 3 km cull was totally unnecessary. The numbers of new outbreaks had already reached the peak and were beginning to fall when the policy of mass slaughter commenced. The Government panicked because they wanted to hold a General Election, they took the control of the outbreak from the veterinary profession and put it in the hands of scientists who had no conception of the social implications of what they were doing and no professional organisation to control their actions.
The author believes that there is need for an independent, national, public enquiry to look at all aspects of the outbreak to restore confidence in the public services.
Roger S. Windsor