Case Study
Strategic Risk Management & Crisis Communications
Mad Cow (BSE & vCJD) Issue Incubation
Lessons for Crisis Managers & Policy-Makers
Dr. J. Brian Morrissey

Excerpts from Chapter 7: Value Incubation
Harnessing the Power of Intelligence, Counterintelligence & Surprise Events,
Alain Paul Martin, ISBN: 0-86502-924-5. Executive.org Press. Cambridge MA
The book is available from Amazon.com and Chapters Booktores
© Alain Paul Martin, December 2002. All rights reserved.
Publication of any part of this document in electronic or printed
form without the written permission of the author is prohibited.

Related Documents:

1. Bovine Spongiform Encephalopathy Diagnostics
2. BSE Prevention Update: Comparing France and California
3. BSE: Science & Research - Diagnosis of BSE
4. Emergency Preparedness & Risk Management
5. Japan-United States BSE Working Group Final Report July 22, 2004

Isolated event phase: Several isolated events form the embryo of the issue in Great Britain. Citing J.W. Wilesmith, the FDA states that there are indications that the first clinical case of the disease was observed as early as April 1985. i] The New Scientist reports "the first confirmed victim of BSE: Cow number 133 on the Stent farm in Sussex develops head tremors and a loss of coordination" on Dec. 22, 1984, to die on Feb. 11, 1985. "Other cows show similar symptoms the next year... Government pathologist finds Cow 133 died from spongiform encephalopathy (SE) on Sept. 19, 1985." ii]

Surprise event phase: UK laboratory identifies the first clinical case of Mad Cow in November 1986.

Quarantine phase: new scientific information progressively becomes available starting in 1987, and gradually reduces uncertainty. A milestone in the Quarantine phase was reached when the EU made BSE a "notifiable" disease for animals in March 1990. It meant that EU farmers and veterinarians must notify government of animals suspected of Mad Cow disease. It did not imply any links with the human disease vCJD. That link was not established until 1996.

Critical-mass phase: While the UK Minister for Health, Stephen Dorrell, maintained the status quo as late as December 1995, stating that there was "no conceivable risk of BSE being transmitted from cows to people", the CJD Surveillance Unit dropped a bombshell, in March 1996 by announcing that the "most likely explanation for vCJD]"was "exposure to BSE." John Darnton of The New York Times wrote about "a total lack of confidence in what the Government or its scientific experts were saying. The suspicions that had been building up for six years suddenly reached a critical mass and the result was a spontaneous boycott." iii]

Issue rider phase: Opposition leader Tony Blair orchestrated a smart move of the Labour Party to the political center away from the trade-union base. The move resulted in a surge in popularity. On March 7, 1997, Tony Blair commissioned Professor Philip James, Director of the Rowett Research Institute, to study the need for reform to eradicate BSE. Riding on the issue, he accused the government on March 25, 1997 "of appalling delays and incompetence in dealing with BSE." iv]

Constituency phase: Opinion polls reflected the need for a major government reform in dealing with BSE and signaled the presence of powerful constituencies.

Decision phase: While decisions on technical matters were made from 1986 onwards, reflecting the gradual unfolding of new knowledge, organizational restructuring decisions at the national level were only made after Tony Blair became Prime Minster on May 1, 1997. Proposed by Professor Philip James eight days later and voted by Parliament in November 1999, the UK Food Standards Agency was established in the year 2000 as an independent watchdog led by 12 commissioners. MAFF was subsequently disbanded and its duties assigned elsewhere in June 2001.

An unusual feature of this case was the long duration of the "quarantine phase". This is explained by the fact that Mad Cow disease was a new disease. As such, virtually nothing was known about it. There was little specific scientific knowledge on which to base informed decisions. Consequently, as new intelligence on the disease became available, the uncertainty associated with this phase was gradually removed.

By contrast, the 2001 outbreak of “Foot and Mouth” disease (FMD) in cattle that also occurred in the UK had a well-known body of science on which to base decisions. Thus, in the FMD case, the “quarantine phase” associated with uncertainty was much shorter. Within a year after the first FMD case was diagnosed, the UK was declared officially FMD-free. The cost to the British economy (tourism and farming) was over $10 billion. For links to FMD chronology of events, policy decisions and lessons learned, visit: www.executive.org/FMD

2. Lessons Learned

The following lessons may be noted from the Mad-Cow experience in the UK. Some are drawn from this book, some from Lord Justice Phillips’ inquiry report on BSE, and others from personal experience in dealing with surprise events.

1. Focus on leading. Neither the crisis nor the long term developments can wait. Both must be addressed simultaneously. At least one senior leader must devote all her/his attention to managing the crisis. That person must dramatically prune her/his remaining workload and promptly delegate what can be done by others.

2. Scan the Environment regularly. Scan the whole value chain, in this case from the farm to the consumer table. Focus on high-risk issues. Build, an informal early warning system with the help of sister organizations and other global allies. Train everyone to collect and submit intelligence. Validate data. Prepare a weekly roll-up of information to be shared upwards and downwards in the organization.

3. Anticipate possible surprise events. In Agriculture and Agri-Food Canada (AAFC), we frequently run simulated models of disease outbreaks.  

4. Communicate with experts and policy makers. In AAFC, we held "High Visibility Meetings" twice daily in the early phases of dealing with a surprise event, and as required thereafter. For example, in the Canadian context, a surprise event involving a serious animal disease would bring together representatives from:

– The Privy Council Office for government-wide coordination,
– Health Canada (Department of Health),
– Agriculture and Agri-Food Canada (AAFC) including the Canadian Food Inspection Agency,
    the Minister’s and Deputy Minister’s offices, legal and field staff,
– The Department of Finance to explore compensation (for animals slaughtered),
– The Treasury Board,
– The Department of Foreign Affairs and International Trade (international impact),
– The Department of Justice (for quick passage of new regulations), and
– Provincial governments and other organizations, as required.

5. Foster transparency. Communicate with other stakeholders and the public at large. Base public statements on evidence. Act as a single government, not as a collection of independent departments. Citizens don’t care about government’s internal structure. This is especially true in the food chain. Provide regular public briefings with written support material (Lord Phillip’s Inquiry) v].

6. Be particularly careful to brief issue riders. Attempt to ethically move stakeholders along the Factional Scale^™ from "foes" towards "friends" by listening and addressing the questions and concerns within your domain (see Chapter 10).

7. Avoid absolute statements such as “there is no conceivable risk of BSE being transmitted from cows to people.” In the early stages, put emphasis on collecting evidence and facts. Information is incomplete in the early phases of a surprise event. It is important to be able to confront opinion with facts.

8. Be candid with the media. Misleading the media and the public is unethical and irresponsible. In this case, the Phillips’ inquiry tells us the "government did not lie to the public about BSE. It believed that the risk was remote". But, the public felt betrayed when, in March 1996, the Creutzfeldt-Jacob Disease (CJD) Surveillance Unit declared that the "most likely explanation for vCJD]" was "exposure to BSE."

9. Value prompt decision-making. Disease can spread geographically with great rapidity; thus a short, fast decision cycle is of paramount importance. In overlapping legal jurisdictions, federal, state, or provincial controls must be synchronized. Act on the suspicion of disease. Protecting human health is the first priority. Control the spread first; fight adversity afterwards. The alternative can be much worse. Armed with comprehensive intelligence about the causes and the stakeholders, AAFC has produced new regulations in a day in a crisis situation.

10. Proceed with caution. Based on Maslow hierarchy of needs, health and safety are fundamental human priorities. The precautionary principle should be used where a serious animal or human disease is suspected. This principle has been used since biblical times in disease control, e.g., the principle of quarantining suspected disease carriers.

11. Marshall adequate resources. Draw, if necessary, on all the country’s resources to deal with a national crisis. Call on universities, contract employees, retired professionals and resources from other agencies and governments.

12. Consider the benefits and costs of advisory bodies. Consultative boards provide access to knowledge, a different point of view, a sense of public participation, and create a perception of openness to public participation. However, they may slow decision-making, as observed in Lord Phillips’ Inquiry Report. In addition, rejecting the advice of an advisory body can lead to a serious loss of credibility.

13. Adjudicate competing priorities. The customer comes first! For government, the citizen is the customer. A farming crisis is a serious economic crisis. A food-safety crisis is a matter of grave concern. Both issues must be addressed. But, human health must be given priority over farm economics.

14. Reach out to credible authorities worldwide. Be careful not to be contradicted by an authoritative body. Although both the UK and EU ruled on BSE, the EU can be seen as more credible if considered to be less captive to local or special interests.

i] U.S. Food and Drug Administration: BSE Contingency Plan, Version 1.0 – February 15, 2001
quoting J.W. Wilesmith et al.: Bovine Spongiform Encephalopathy:
Epidemiologic Features 1985 to 1990. Veterinary Record 130:90-94. 1992.
www.fda.gov/oc/bse/contingency.html#background

ii] New Scientist: Timeline: The Rise and Rise of BSE, undated. Consulted August 25, 2002.
www.newscientist.com/hottopics/bse/bsetimeline.jsp

iii] John Darnton: The Logic of the "Mad Cow" Scare, The New York Times, March 30, 1996.
www.mad-cow.org/96mar.html

iv] Reuters Newsmedia.
www.ita.suite.dk/alreuter.htm

v] BBC News: BSE Report: The Main Points, BBC, October 26, 2000.
https://news.bbc.co.uk/1/hi/uk_politics/992435.stm