Lessons for food-safety policy from the Aberdeen typhoid outbreak
David Smith |
- Over 500 people were hospitalised by an outbreak of typhoid in Aberdeen in May/June 1964.
- The official enquiry that followed (the Milne report) concluded that a 6 pound can of corned beef had been contaminated by cooling water during manufacture in Argentina. The infection had spread to other produce at a supermarket, via implements, surfaces, and hands. A series of recommendations were made which aimed to prevent the re-occurrence of these circumstances.
- Detailed analysis of events surrounding the Aberdeen typhoid outbreak makes it possible to draw a series of broader lessons from the affair concerning the nature of food-safety policy-making.
- Food-safety policy-making during the 1960s was a complex process. Decisions were normally taken by civil servants but ministers, including the Prime Minister, became involved in crisis situations.
- Thus the link between scientific advice and the decisions made was often tenuous because of the intervening effects of a large number of political and commercial considerations.
- While the Aberdeen typhoid outbreak did not lead to any decisive shift in the nature of food-safety policy-making, a concentrated series of episodes in the 1980s and 1990s led to the creation of the Food Standards Agency, which aimed to restore public confidence in the government's food-safety machinery.
- To date, openness has been the watchword of the Agency but as the organisation becomes more complex, its work more routine and public interest diminished, insights into the 1960s policy-making process may alert interested parties to the kind of problems which may yet re-emerge.
Typhoid and corned beef in 1963
The Aberdeen outbreak was preceded by three much smaller typhoid outbreaks in England - in Harlow, South Shields and Bedford, between May and October 1963. These were all associated with corned beef from the same canning plant in Argentina, known as Establishment 25, and it was realised, soon after the first outbreak, that the plant had been using untreated cooling water, and that a typhoid outbreak had occurred in the vicinity. It was not until some five months later, however, that corned beef in circulation in Britain from Establishment 25 was withdrawn on the advice of the Ministry of Health.
The subsequent Milne report accepted the explanation that it was not until the third outbreak that the evidence was sufficient to justify action, but examination of the original documents suggests that there were also other factors involved. The officials of both the Ministry of Health and the Ministry of Agriculture, Fisheries and Food (or MAFF) were very concerned to avoid publicity, and in the case of MAFF especially, this was because they feared offending the Argentine government. This was in view of other on-going delicate negotiations about the volume of Argentine chilled beef imports. Since the spring of 1963, after a sudden increase in such imports, which depressed prices and increased subsidies to British farmers, MAFF had been trying to persuade Argentina to limit their chilled beef exports to Britain. Public accusations against Argentine corned beef were likely to upset these negotiations.
Such considerations were of less concern to the Ministry of Health, but they also acted as quietly as possible: this was the preferred method of the civil service. When they finally decided to withdraw the corned beef, the ministries arranged for the operation to be carried out by the company concerned. Local medical officers of health were kept in the dark, and the problem with untreated cooling water was not publicised in South America. So among the factors which conditioned decision-making in this example, were concern with international trade relations, and civil service secrecy culture.
The Aberdeen outbreak
In view of the 1963 outbreaks, MAFF's chief technical adviser on meat inspection, a veterinarian, was sent to South America to inspect the canning factories. Establishment 25 was now satisfactory, but two others, Argentine 1A and Uruguay 5 had been using untreated water. Several consignments of 1A corned beef in transit were stopped, but others already in Britain were left in circulation, later causing the Aberdeen outbreak.
The explosive nature of the Aberdeen outbreak during the last week of May 1964, along with a mistaken allegation by Aberdeen's medical officer of health that thirteen-year-old corned beef released from the government's nuclear stockpile might be the cause of the outbreak, created intense press interest and vigorous questioning of ministers. The uproar led to the formation of the Milne committee, and the creation of a special committee of ministers to oversee the handling of the outbreak. The Ministers of Health and Agriculture, and the Secretary of State for Scotland were members, but two senior cabinet members, Christopher Soames and William Deedes also played key roles. These political heavyweights were involved because of the impending general election, and the Conservative administration in power was flagging. The political stakes were high and decisive action was called for if public confidence was to be regained.
From 2 to 22 June the ministers' committee approved recommendations by expert advisers for the withdrawal of successive batches of canned meat, and local medical officers of health supervised the exercise. The first withdrawal was of Argentine 1A and Uruguay 5 corned beef. Later corned beef from another factory, Argentine 1819 was withdrawn, following the discovery of a food-poisoning organism (not typhoid) in a can in Edinburgh.
Compared to decision-making in 1963, these decisions were made rapidly, stimulated by domestic political considerations, the intense public, press and parliamentary interest, and the sense of crisis that prevailed.
Decision-making on the Milne Committee recommendations
Overseas meat inspection
One recommendation concerned the mechanism for approving meat exports to Britain. According to the established system, permission was granted subject to a satisfactory inspection of the foreign country's meat plants and meat-inspection service by one of MAFF's technical advisers on meat inspection.The Milne report recommended, however, that in future a Ministry of Health medical officer should also be involved. This recommendation was received with indignation and resisted by MAFF veterinarians, the background to this being that the overseas meat-inspection responsibility was the only small public-health role monopolised by the British veterinary profession. Meat inspection in Britain was supervised by medical officers of health, whereas in most other countries there was a state meat-inspection service controlled by veterinarians.
The debate between the Ministry of Health and MAFF on this recommendation became strongly intertwined with other policy processes. Firstly, negotiations on the recommendations of a Treasury working party report which aimed to establish a clearer demarcation of duties with regard to food and nutrition. Secondly, negotiations arising from the recommendations of the Verdon-Smith committee on fatstock marketing, that proposed the establishment of a centralised-meat inspection service. This was eventually precluded by a Treasury ruling.
These other decision-making processes, as well as the opposition of MAFF veterinarians, delayed the implementation of the Milne committee recommendation. And it was also implemented half-heartedly, largely just to make it possible for the government to claim it had implemented the recommendation. The key factors involved here, then, were inter-departmental and inter-professional rivalries and wider pre-existing policy agendas, as well as political considerations.
Reprocessing and release of 'suspect' corned beef
Given the commerical value of the meat involved, efforts were made to see whether it was technically possible to make safe the suspect meat. A working party considering means of reprocessing the suspect corned beef was completing its work by the time the Milne committee reported. The Milne committee recommended that once the method was finalised, the suspect corned beef could be reprocessed and then distributed in the normal way.
The importers and others who held suspect stock were anxious to press ahead. Foley Brothers Ltd, the main importers and holders of the Establishment 1819 stock, carried out reprocessing trials, and the Ministry of Health was satisfied that the product posed no health risk. Foleys then pressed for permission to begin distribution. At this stage, however, other sections of the food trade, especially the retailers, began to object to reprocessing on the grounds that consumer reaction would damage the canned-meat market, which was only just recovering from the Aberdeen typhoid outbreak. Some consumers' representatives also expressed concern, and a new wave of press coverage began. In the light of this, Prime Minister Harold Wilson intervened, and told the Ministers of Health and Agriculture that he wanted the reprocessed as well as the suspect corned beef to be permanently withheld. Wilson was governing with a very slim majority and feared the public reaction.
Sorting out the mess fell to MAFF, who struck a deal with the large producers and importers, whereby MAFF would permanently withhold their suspect nuclear stockpile stock if the firms undertook to do likewise. The big firms subsequently re-exported their suspect stock to South America. But Foley Brothers and other holders of the 1819 stock had no connection with the producer in Argentina and refused to be bound by the same undertaking. Compensation was ruled out by the Treasury, and just before Christmas 1965, Foley Brothers began to distribute their reprocessed stock. There were no legal powers to prevent this because no health risk was involved.
A further round of publicity, a chorus of protest from trade organisations, and further interventions from the Prime Minister followed. After meetings with the Minister of Agriculture the 1819 stock holders then agreed not to market their stock in Britain, in the expectation that MAFF would help them to find export markets. In the end, however, MAFF did little to help and the 1819 stock was eventually disposed of abroad on the initiative of the stockholders - and most of it was eaten without reprocessing. A few years later, most of the suspect stockpile stock was shipped to Gibraltar for reprocessing, on condition that it would not be returned to Britain.
Here then, we have an example of intervention of one section of the food trade against another, along with the press, public, and parliamentary interest, as well as the intervention of the Prime Minister, preventing the implementation of scientific advice. The consequence (in the case of the 1819 stock) was increased health risk - but this risk was ultimately exported (and probably without the risk-receivers knowing of it) to inhabitants of foreign countries.
Argentine meat-plant hygiene and meat inspection
When the chief technical adviser on meat inspection visited Argentina in Spring 1964, he was shocked by the poor state of hygiene throughout the meat industry, and the disorganisation of the Argentine Veterinary Service.
As Argentina was known to resent being singled out, an aide memoire was transmitted to 54 governments, asking for assurances that in meat plants exporting to Britain meat inspection was carried out according to procedures outlined in appendices, which also included specifications for water quality. The aide memoire asked governments to produce, by the end of September, a list of meat plants at which the specified principles would be observed, but Argentina failed to respond despite repeated reminders, and within MAFF possible actions were debated. The MAFF division responsible for meat hygiene favoured a ban on Argentine meat imports until the Argentines put their house in order. They were opposed, however, by the division of MAFF responsible for managing meat supplies, which feared meat shortages and high prices. This emphasises the role of intra- as well as inter-departmental conflict in the generation of food-safety policy decisions. MAFF's external relations division, and the Foreign Office also resisted strong action.
The ambassador in Buenos Aires was asked to put pressure upon the Argentine authorities, but after much fruitless effort, MAFF drew up their own list of acceptable establishments in August 1965. Over the next eighteen months, on the recommendations of the veterinary attach to the embassy, some of the worst establishments were removed from the list because of deteriorating standards.
In view of the veterinary attach's reports, and reports about contaminated Argentine meat from port health authorities, in 1967 the chief technical inspector on meat inspection again visited Argentina. Little had changed since 1964 but at least, following the publicity given to the Aberdeen outbreak, in no plant was there a potentially dangerous water supply. But the Argentine meat inspection service played no part in monitoring water, and the service had deteriorated further and received the strongest criticism. The inspector told the Argentine Minister of Agriculture that the UK could not tolerate a situation which 'left them open to unnecessary health risks'.
A new round of policy-making followed and a note was prepared giving notice to Argentina that, unless they cleaned up their meat industry, exports to Britain would be banned. In November 1967, however, the ambassador in Buenos Aires argued that the delivery of the note should be delayed because there was currently a 'great opportunity' to increase British exports to Argentina in view of the recent devaluation of sterling. He was also negotiating for Argentine support in the UN over Middle East issues, and there were repercussions of a foot-and-mouth epidemic in Britain, which had begun on 25 October.
The ambassador warned that the Argentines were sensitive about accusations in the British press that their meat had caused the epidemic and argued that in the circumstances 'peremptory admonitions against the Argentine' on the public-health issues should be delayed. Nevertheless, sufficient momentum had at last built up, and the ambassador was instructed to proceed. The note called for assurances that remedial measures were in hand, and set a deadline for making improvements of 1 June 1968. This determination finally to take decisive action was short-lived, however, and complicated by the temporary ban on Argentine meat imports imposed in view of the foot-and-mouth outbreak. In retaliation, Argentina threatened not to proceed with the purchase of British military equipment and other orders, and, as a result, the public-health issues were again sidelined.
Following the 1 June 1968 deadline, the Argentine meat plants were inspected and of 17 only three passed without qualification. At four, which normally accounted for about half of British supplies from Argentina, no improvement had taken place. MAFF officials recommended to their minister that unless they were removed from the approved list British consumers would be exposed to risks of 'typhoid, paratyphoid, botulism and staphlococcal toxin'. However, in view of fears of further trade retaliation, no action was taken.
Despite the easing of pressure, when the chief technical advisor on meat inspection revisited Argentina in early 1969 he reported that while the meat-inspection service remained inadequate, there had been a remarkable transformation in most of the meat plants. But the improvements had come about largely independent of any British or Argentine government activity specifically concerned with the public-health dimensions of meat hygiene. Of greater significance were impending policy changes in connection with animal-health precautions. In view of the foot-and mouth epidemic, in future only boned Argentine meat would be permitted into Britain, but this could not be produced reliably and profitably in run down, unhygienic meat plants. It was therefore commercial interests rather than public-health considerations which finally forced the owners to make the necessary investments in their premises and equipment.
In this example, as in our first one, considerations of international trade and politics again conditioned decision-making. Intra-departmental interactions were also important. In addition, we also see food-safety improvements being made, not because of pressure upon industry to comply with public-health regulations, but because of the commercial implications of new animal-health regulations
Food-safety policy-making then and now
There were other factors involved in the policy-making process in the 1960s besides those outlined here, and there are many differences between the 1960s and the current situation. In particular, the Food Standards Agency (FSA) began work on 1 April 2000, operating principles of transparency and disclosure intended to restore the faith of the public in the government's food-safety machinery following the BSE/vCJD affair and other food-safety problems. The creation of the FSA streamlined policy-making but MAFF retained responsibility for a number of issues including on-farm strategy with regard to control of food-borne zoonoses. The Department for Environment, Food and Rural Affairs (DEFRA) retained these responsibilities when MAFF was abolished in June 2001. The Meat Hygiene Service, which was established in 1995 and finally created a centralised meat inspection under veterinary control, is now an executive agency of the FSA. However, the chief veterinary officer, on the staff of DEFRA, is head of profession for the veterinarians employed by the service. The Food Standards Agency itself, not only has national offices, but has an internal structure consisting of a Food Safety Policy Group, Enforcement and Food Standards Group and Corporate Resources and Strategy Group. Local authorities retain the responsibility for the enforcement of food standards regulations.
While there have been important changes, the system for the making and application of food policy inevitably remains complex. There is certainly continuing potential for the kind of inter-departmental, intra-departmental, and inter-professional tensions and conflicts which sometimes made decision-making and action difficult during the 1960s. As the work of the FSA develops and become more routine, the historical insights into food-policy making and action provided by this paper may sensitise participants and commentators to the kind of problems which may well re-emerge.
- Keir Waddington, Safe meat and healthy animals: BSE and bovine TB, History and Policy, 2002
- Eileen Rubery, Medical science and public policy: handling uncertainty, managing transparency, History and Policy, 2003
Diack, L., T. H. Pennington, E. Russell, D. F. Smith, 'Departmental and professional agendas in the implementation of the recommendations of a food crisis enquiry: the Milne report and inspection of overseas meat plants', in D. F. Smith and J. Phillips (eds), Food, Science, Policy and Regulation in the Twentieth Century: International and Comparative Perspectives, London, 2000, pp. 189-206.
D. F. Smith and H. L. Diack, with T. H. Pennington and E. M. Russell, Food Poisoning, Policy and Politics: Typhoid And Corned Beef In The 1960s, London: Boydell Press, July 2005.
Scottish Home and Health Department, The Aberdeen Typhoid Outbreak (the Milne Report), Edinburgh, 1964.
About the author
David Smith is lecturer in the history of medicine, Aberdeen University. He is editor of Nutrition in Britain: Science, Scientists and Politics in the Twentieth Century (Routledge, 1997) and joint-editor (with Jim Phillips) of Food, Science, Policy and Regulation in the Twentieth Century: International and Comparative Perspectives (Routledge, 2000). email@example.com.