An inquiry into Britain's most serious food poisoning outbreak found that the dishonesty of a butcher and the incompetence of Environmental Health Officers were crucial factors. The poisoning killed 21 elderly people, hospitalised hundreds, and left some permanently affected.
The E.coli 0157 outbreak began in November 1996 in Lanarkshire, Scotland with the infection of meat and gravy served at a church lunch for pensioners. It raged for several months. Sheriff Principal Graham Cox, who headed the inquiry, found that butcher John Barr had concealed the full extent of his business from health officials. Cox said six lives might have been saved if Barr had been more honest about his supply of cold meats.
He criticised Barr's training and supervision of staff, failure to use proper temperature probes while cooking raw meat, the absence of cleaning schedules, and the failure to separate processes, knives and equipment for raw and cooked meat. As a result of Barr's 'lack of frankness' about the extent of his business, which supplied meat to a far wider number of outlets than had been suspected, officials had exempted him from registration and other rules for the supply of cooked meat. Cox said environmental health officials had shown a 'total lack of initiative', had been slow in obtaining information and then 'did not react competently'.
However, a criminal prosecution against the butcher was thrown out last year because of lack of 'corroborative evidence'. In a separate case Barr's company was later fined £2,250 for breaching food safety laws.
The inquiry criticised the authorities for taking six days to confirm E.coli in the food supplied by the butcher due to the lack of equipment. Though valid, these criticisms relate only to the distribution of infected meat to consumers and the handling of the crisis by the local authorities once it had become apparent.
The inquiry was silent on the central problems of temperature-controlled storage, the underfunding of the environmental health departments and the lack of public accountability of these services. Like an earlier inquiry led by Professor Pennington, it did not address how the meat had become infected in the first place and how the disease might be eradicated. It did not examine the source of the E.coli infection, the transmission agent, the infectivity of animal feeds, the practices of the livestock, slaughtering and food industries or the regulation of the meat industry.
To do so would impose extra costs on an industry already suffering as a result of the BSE (mad cow disease) crisis, and interfere with its right to make a profit. That is of much greater concern to the authorities than the lives and health of consumers.
There are hundreds of cases of E.coli every year and a fivefold increase in reported food poisoning in England and Wales between 1980 and 1994. Food poisoning is on the increase all over the world. Just 12 months ago, the US Department of Agriculture warned that as many as five million hamburgers could be contaminated with the E.coli bacteria. While it named the factory that had supplied them, it did not name the fast-food restaurants that purchased most of the hamburgers, in order to protect their business.
The source of E.coli 0157 is in the infected guts of livestock. If these are allowed to fall onto meat during processing at the abattoirs, the contamination may infect humans.
It was known well before this tragedy occurred that E.coli 0157 is a serious and growing problem. It is thought to have emerged as a result of the indiscriminate use of antibiotics that has given rise to resistant bacteria.
A government research programme into its incidence and causes found that 5 percent of carcasses were infected with the bacteria. Yet the response of a scientific officer at one of the Veterinary Inspection Centres carrying out the research was, 'This showed that it really wasn't much of a problem'.
This complacent interpretation horrified Dr Stephen Dealler, a microbiologist at Burnley General Hospital. He commented: 'That was a lot. They should find none. The amount needed to infect humans is low. It has become a resident bacteria.'
The infection, now found in sheep as well as cattle, is spread by a variety of means. The search for cheap high-protein feeds led to cattle being fed with 'cake' based on faecal material from cattle and contaminated animal-based compound feedstuffs, the same feedstuffs which lay at the heart of the BSE tragedy. Again the Veterinary Inspection Centre could only say, 'animal based feedstuffs are sterile compounds,' which they manifestly are not, as the BSE crisis testifies.
The practice by the water companies of spreading untreated or inadequately treated sewage sludge on agricultural land has exacerbated the problem. This is set to increase as, after 1998, sludge can no longer be dumped at sea. It is known to contain the E.coli bacteria. Researchers recently reported that sewage washed up on the beaches in North West England has contaminated the sand.
The inquiry did not address the slaughtering practices that lead to cross-contamination, even though new procedures known as rodding and bagging can minimise the risk. Nor did it investigate the lack of lairage facilities (the accommodation and cleaning of cattle waiting to be slaughtered), or the disgraceful state of the abattoirs. There was no criticism of the lack of bacteria testing at the slaughtering plants, despite the fact that a fluorometer, costing a mere £3-4,000, will give an immediate bacteria count. There was no mention of the persistent underfunding of the government's meat inspection service, which is required to make a profit by charging the meat industry for its services.
Once the infected meat gets into human food, it is absolutely vital that bacteria are killed by cooking and, once cooked, are not allowed to multiply. The government's own advisory committee recommended that cooked meat should be kept below 3 degrees Centigrade. However, the Department of Health introduced regulations in September 1995 which raised the temperature at which food could be stored from 5 to 8 degrees, saving the industry £40 million a year in refrigeration costs.
In 1990, an Audit Commission study of over 5,000 food premises in England and Wales inspected by Environmental Health Officers found that almost one in eight presented a significant or imminent health risk and one third of these should be prosecuted or closed down. Nearly half the food premises had not been inspected within the last year; a quarter of these had not been inspected within the last three years and five percent had never been visited.
The factors most commonly assessed as high health risks were ineffective monitoring of temperatures, cross-contamination resulting from poor food-handling practices, inadequate hand-washing facilities and lack of hygiene awareness among management and staff. It noted, 'the high risk in food manufacturers is of particular concern given that a failure in food hygiene at a food manufacturer could have widespread consequences.' Nearly 20 percent of food manufacturers were deemed to be of high risk.
Since then, the micro biological contamination of meat has risen 4 percent to 13 percent of fresh meat samples tested, and from 9 percent to 11 percent of cooked meat. Yet prosecutions have fallen from 10 percent to less than 1 percent of unsatisfactory samples. Enforcement agencies have been ordered to take a 'less zealous' approach.
Local authorities' environmental health departments are underfunded and short of staff and resources. They are not required to make their findings public and data on food contamination is only made available on request.
None of these facts are unknown to those connected with monitoring the food industry. Numerous committees in the last 10 years have made recommendations to improve the situation, but these have never been acted upon.
The explanation is very simple. The Ministry of Agriculture, Fisheries and Food (MAFF) is the government department responsible for the food industry. MAFF's role as 'the sponsoring department for the food industry' is to ensure the financial viability, and profitability, of the industry. Food poisoning is the price paid by the public to ensure the healthy profits of agribusiness.
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